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The Health Disparity Collaboratives
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Fundamental changes have been underway in American medicine for some time.
Technology is offering us new ways to understand the health of our patients. In response to increasing demands on the system of care,
we must aggressively pursue greater efficiencies. As professionals, we must seek new clinical strategies to improve patient outcomes.
All this must be accomplished while upholding the highest standards of care for our patients,
a diverse population disproportionately affected by health disparities.
The Collaboratives
In order to sustain its success as a healthcare learning organization, MCHC takes advantage of the unique opportunities
offered by the Health Resources and Services Administration (HRSA) and the Bureau of Primary Health Care (BPHC).
Participating in BPHC's Collaboratives has increased our knowledge about qualitative measures regarding the diseases
affecting our patients. This has enhanced our ability to quickly improve processes as data demonstrates more
successful treatment methods. Participating in the Collaboratives has helped us transform our practice.
MCHC has joined with the Collaboratives' mission to identify innovative and rapid responses for the chronic diseases
increasingly affecting our patients, and to actively engage our population in disease prevention.
In an on-going way, MCHC participates in the following projects:
The HIV/AIDS Collaborative
In 2000, MCHC began to reengineer its treatment of HIV-infected patients through its participation in HRSA's HIV/AIDS Bureau HIV
Collaborative. During this training process, we learned to employ two new models: the Chronic Care Model and
the Change Model.
These trainings transformed our practice in significant ways: We collect and monitor clinical results through the use of a
confidential patient registry, we co-locate a case manager within every medical provider team, we ensure patient input into our program
planning processes, and we invest significant resources into educating our providers and staff about HIV/AIDS.
Today, our clinical outcomes are excellent: Over 93% of our patients having a clinic visit in the last three months;
80% of our patients on anti-viral treatment having a viral load of <75 copies; 93% of our patients on anti-viral treatment
having a CD4 count of > 200.
The Diabetes Collaborative
In all three of our rural communities, we began seeing the rising number of diabetic patients often reported in the press.
We realized that we were in a unique position to move from a practice that focused on reacting to the symptoms of diabetes to
becoming a strong and knowledgeable agent of change for our patients.
We began participation in the Diabetes Collaborative in 2001. We learned to track HbA1c levels, improve application of our clinical
guidelines and keep a patient registry to create a data set that will enable us to continue to refine treatment based on evidence.
Additionally, we continue to employ case management staff as educators to improve outcomes for our diabetic patients.
The Cancer Collaborative
In 2003, MCHC was invited by the Institute for Healthcare Improvement (IHI) and the Bureau of Primary Health Care (BPHC) to
participate as one of 12 pilot teams in the Cancer Collaborative. We have developed and deployed a registry to manage over 5000 patients.
We have increased use of FOBT and continue to work on ways to reduce health disparities in cancer screening.
Innovation Community
In 2005, we were invited to become a BPHC-sponsored participant in the Institute for Healthcare Improvement's (IHI)
newest initiative called Innovation Community for Planned Care. The goal of this project was to "raise the bar" by engendering
a new clinical ethic that moves a practice beyond "doing well" at treatment protocols and care management, encouraging us to reach
for excellence. At MCHC, this translates to a commitment to identify and implement best practices for planned care in our patient population.
INSIGHT: Understanding the Collaborative Model
The models on which the Collaboratives are based facilitate an
interactive process-improvement approach with rapid clinical change. These models are drawn from the experience of the
BPHC's National Health Disparities Collaboratives. The Collaboratives models encourages data-driven and organization-wide
positive results and MCHC's participation has transformed the way we measure and evaluate success in our practice.
For more information about the Collaboratives process, click here.
To learn more about the Chronic Care model,
click here.
(Adobe Acrobat PDF, file size: 129K)
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