Phase 2 Narrative Report
Health Disparities Collaborative
Date: February 1, 2006
Center Name: Beaufort Jasper Hampton Comprehensive Health Service Cluster: Southeast State: SC Total # Provider Sites: 8
Organizational Aim: To sustain and spread the redesign of the agency’s diabetes care delivery system to improve patient self-management skills, decision support, information system, community relationships, and leadership. We will spread our improvement efforts by expanding our population of focus as described below. See our Key Measures descriptions (also below) for specific goals.
Initial Population of Focus (POF) and Site: Sheldon Health Center was initial POF with 200+ known diabetics. We have now expanded the changes to all eight (8) of our clinic sites.
Progress on Spread of Care Model:
| Site Name | Initial Condition of Focus | Spreading to the Following Condition | Number of Spread Providers | Registry Size |
| Site 1: Sheldon (SHC) [POF] | Diabetes | Cardiovascular | 2 | 98 |
| Site 2: Chelsea (CHC) | Diabetes | Cardiovascular | 2 | 85 |
| Site 3: Estill (EHC) | Diabetes | Cardiovascular | 2 | 205 |
| Site 4: Hampton (HamHC) | Diabetes | Cardiovascular | 1 | 129 |
| Site 5: Hardeeville (HHC) | Diabetes | Cardiovascular | 1 | 145 |
| Site 6: Port Royal (PRMC) | Diabetes | Cardiovascular | 2 | 294 |
| Site 7: Ridgeland (RHC) | Diabetes | Cardiovascular | 1 | 154 |
| Site 8: St. Helena (StHHC) | Diabetes | Cardiovascular | 2 | 100 |
Type of Registry Being Used [ X ] PECS [] CVDEMS [ ] DEMS [ ] Other, Specify :
Key Measures:
|
Measures (Nationally Shared Core Measures* and any additional) |
Goal |
SHC (POF) |
CHC |
EHC |
HamHC |
HHC |
PRMC |
RHC |
StHHC |
|
1. *Average HbA1c for Diabetes Mellitus Patients |
7.0% |
7.2% |
8.0% |
8.1% |
7.4% |
8.2% |
7.6% |
9.1% |
7.7% |
|
2. *DM patients w/2 (or more) HbA1c in last 12 months (>90 days apart) |
90% |
49.0% |
16.5% |
11.7% |
19.4% |
11.1% |
29.9% |
22.7% |
20.0% |
|
3. *DM patients w/ SM goal setting last 12 months |
70% |
68.4% |
30.6% |
48.3% |
69.8% |
60.0% |
43.2% |
23.4% |
24.0% |
|
4. *Patients w/ BP < 130/80 |
70% |
33.3% |
35.0% |
38.4% |
40.9% |
23.6% |
41.6% |
36.2% |
30.6% |
|
5. Dilated eye exam in last year |
70% |
31.6% |
12.9% |
3.4% |
0.8% |
7.6% |
15.3% |
1.9% |
7.0% |
|
6. Foot exam in last year |
90% |
75.5% |
22.4% |
13.7% |
6.2% |
27.6% |
39.1% |
5.8% |
22.0% |
|
7. Influenza vaccine |
90% |
8.2% |
1.2% |
1.5% |
0.0% |
1.4% |
3.7% |
0.0% |
1.0% |
|
8. Pneumonia vaccine |
90% |
74.5% |
41.2% |
6.3% |
3.9% |
19.3% |
36.7% |
4.5% |
14.0% |
|
9. *DM patients w/Microalbuminuria screening |
50% |
54.1% |
16.5% |
7.3% |
3.1% |
9.0% |
37.2% |
3.2% |
9.0% |
|
10. Microalbuminuria screening (not on ACEI or ARB) |
<25% |
27.3% |
16.1% |
1.7% |
0.0% |
10.5% |
21.5% |
3.9% |
11.1% |