About the Program

Overview
Approach
Measures

Overview

This collaborative is focused on improving care for patients with chronic conditions - specifically diabetes and heart disease - but strategies to improve care can be applied to other populations of patients.

Enrollment is limited to 10 organizations serving at least 500,000 patients. Over the course of the 15-month program, participating organizations will implement systems to identify, track, and support patients in managing their care. The focus will be developing the skills and tools to engage practices in population management and patients in self-management. Activities include 4 onsite learning sessions and monthly teleconferences. Each organization will receive additional individualized support.

Approach

The collaborative is scheduled over 15 months. Organizations first set their own goals based on diagnosis of current reporting of heart and diabetes metrics with analysis by practice (if data is available) and patient characteristics. Participating teams select approaches used successfully by other physician groups and test and adapt for their practices and patients. Training in engaging physicians and practices in change is an essential element of the curriculum and training in patient self-management techniques (motifvational interviweing) is available to anyone in the group working directly with patients.

Measures

Participants report measures from their registry quarterly. Collaborative measure specifications align with Pay for Performance and HEDIS clinical measures.

Measures:

• Diabetes Care: HbA1c Screening
• Diabetes Care: HbA1c Control < 8.0%
• Diabetes Care: HbA1c Control > 9%
• Cholesterol Management: LDL-C Screening
• Cholesterol Management: LDL-C Control < 100mg/dL