Pursuing Perfection - Overview
Organization Overview
The medical community serving Whatcom County, Washington,
includes more than 300 physicians, St. Joseph Hospital - PeaceHealth, and
several other health care providers. Together,
the hospital and medical community provide care to Whatcom County's population
of approximately 170,000. St.
Joseph Hospital is one of six hospitals in the PeaceHealth not-for-profit
system serving Southeast Alaska, Washington, and Oregon. The 253-bed hospital is the only
hospital in Whatcom County.
Phase I Project Results
During the first phase of Pursuing Perfection,
a community wide team of patients, physicians, and hospital staff identified how
to improve care to diabetic and congestive heart failure patients and their
families through the development of a shared care plan, creation of care teams,
and the redesign of services in the hospital, clinics and community. The team developed a preliminary financial model that will inform policymakers about the impact of changes to
health care services across a community. A
cross-organizational leadership board of physician groups, payers, consumers,
and hospital administrators was created to ensure cross-organizational alignment of
services to support patient choice and evidence-based care.
Description of Phase II Pilots
Family Care Network, Sea Mar Community Health Center, North Cascade
Cardiology and the Center for Senior Health will be piloting the changes in the
next two years. They will be
working with adults with diabetes and/or congestive heart failure to improve
access to care, improve communication across health care organizations and
support patients in being full members of the care team. These sites are members of the Community Health Improvement Consortium
(CHIC) of Whatcom County. CHIC’s
mission is to improve health care outcomes by working together and, as such, will
share results with other community partners and physician groups as changes are
implemented. These two conditions -– diabetes and congestive heart failure
--
have a high prevalence in Whatcom County. The
changes planned will build on significant work already in place with community
physicians. In 2000, St.
Joseph Hospital had almost 700 admissions related to diabetes and almost 900
admissions related to congestive heart failure. The intent of the project is to reduce admissions and re-admissions to
the hospital through innovative chronic care services focused on strengthening
patients’ ability to manage their own care, and to create a more effective
health care system.
Both the diabetes and the congestive heart failure service delivery changes will focus on key issues: evidence-based protocols to support continuum-based care; disease registry functionality for providers and patients; using leading-edge technology to improve the flow of information between patients and providers; and patients self-managing their care in collaboration with virtual care teams that are based throughout the care continuum. Additionally, improving the safety of the medication-management process between providers and patients will be a targeted area of emphasis. This model is built on the work of the W.A. (Sandy) MacColl Institute for Healthcare Innovation. These pilots will be an opportunity to closely evaluate the economic costs and benefits of a community-based continuum of care model.
Potential Results
This community effort plans to achieve breakthrough improvement in the
health of people with diabetes and those with congestive heart failure by
dramatically improving continuum-based disease management care. The program is expected to enhance and improve existing collaboration
between physician groups, health plans, patients, the hospital and a host of
community agencies. Additionally,
an infrastructure will be established that will implement the chronic-care model
and will be expanded to other chronic conditions. This infrastructure will be supported by information technology focused
on a disease registry, medication management across a continuum, seamless
information management, and management of chronic disease supported by
evidence-based protocol.
The project plans to demonstrate improved access to care, increased patient self-management and satisfaction, and a decrease in medication errors associated with care at different points in the health care system. Areas for improvement include increased monitoring of critical factors such as glucose levels for patients with diabetes, and weight fluctuations for patients with congestive heart failure. For example, one goal is that 100% of diabetes patients will meet their personal goal for glycohemaglobin. Overall it is expected that hospitalization, re-hospitalization, and inpatient mortality rates will significantly decrease. More important, by creating programs which effectively assure patients and providers are working together using the latest evidence to manage their conditions, the overall costs to the patient and the community in lost productivity, decreased optimal health, and well-being will be decreased.
Contact
For more information, please contact Judy Smith at St. Joseph Hospital
at (360) 738-6760.
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