Health Disparities

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%