CSSI projects address variety, quality of patient-care issues
By Maileen Hamto, CareOregon Communications Writer
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Focusing on enhancing processes and implementing innovative system design, project leaders for CareOregon’s Care Support and System Innovation (CSSI) program are at the forefront of lasting systems change.
Now in its third year, CSSI is bringing together fresh new ideas and process enhancements in various areas of care, from chronic disease management to chemical dependency treatment, to addressing challenges to prenatal care access.
CareOregon provided $3 million to provider-led strategies designed to making health care more safe, effective, patient-centered, timely, efficient and equitable. "This year’s CSSI projects are grounded in the Institute of Medicine’s call to action to improve health care delivery system in the United States," said Diana Wolford, CSSI Program Coordinator.
"Our goal for the program is to foster a culture of evidence-based practice and continuous improvement among our providers,” she says. “Over time, we’d like to help empower our providers with the skills, knowledge and resources to create necessary and substantial change to deliver high quality health care for our members.”
While primary care renewal is one of the focus areas for the CSSI program (click here to read), a greater percentage of CSSI projects focus on specific areas of improvement chosen by provider-led teams.
Thus far, the teams have gathered several times at the CareOregon office for process improvement training sessions. In October, providers will convene at a daylong conference to discuss success stories, lessons learned and way forward for CSSI projects.
A sampling of 2007 CSSI projects are described below:
Yakima Valley Farmworkers Clinic. Four clinics in Oregon will implement Tomando Control de su Salad Chronic Disease Self-Management Program, an evidence-based practice designed for patients with diabetes, who will learn about self-management. The project will recruit, train and mentor lay health leaders who will teach the classes. The clinics will develop the infrastructure to sustain the program by building capacity through a designated program coordinator and a group of master trainers.
Allied Health Services. Allied’s Strategies To Enhance Patient Success (STEPS) program focuses on immediate access to treatment, treatment engagement through patient incentives and treatment retention. Patients will receive more direct care through increased contact with a nurse practitioner, intake worker and counselor.
The four-week patient orientation process will be expanded to include a weekly 90-minute Medical Services Group presented by a nurse practitioner focusing on Hepatitis C and sexually transmitted diseases. The program manager will monitor and track all new patients and will measure outcomes after 30 days, 6 months, and 12 months of treatment.
Kim Sanderson, regional director, is proud of the progress of the project. “We have already reviewed, revamped, and streamlined our intake process to shorten the time between initial clinic contact – by phone or walk-in – and admission to the program. Our goal is to admit patients within 24 hours – one business day – from the initial appointment,” she said.
“We also now have a full-time nurse practitioner to help speed the intake process and to provide increased access to medical personnel for advice and medical orders at the clinics by supplementing the time spent at each clinic by the medical director and/or attending physician."
OHSU. A project led by a team at Oregon Health and Science University addresses discharge care for patients with congestive heart failure. The purpose of the project is to deliver discharge instructions and smoking cessation information to all patients with congestive heart failure (CHF) who are discharged to home. The goal is to verify that patients and families understand what is expected of them following discharge, said Christy Marchant, Care Management Specialist.
“Detailed evidence-based discharge instructions have been developed and will be reviewed in detail with both patients and their families. Project nurses will telephone all patients with CHF who are discharged to home 24 to 48 hours post discharge to confirm that patients are able to comply discharge instructions once patients and families are home,” she said.
Lifeworks NW. Joe Hromco, PhD, is leading a team that is focused on medical integration into mental health care for persons with serious and persistent mental illness. Clients with severe mental illness typically are unable to build a lasting relationship with a primary care provider (PCP) due to symptoms of paranoia, isolation or depression. To reach clients with psychotic disorders or major mood disorders, the project will bring physical health services to a mental health clinic.
A registered nurse will work with clients who are CareOregon members and their identified primary care providers to coordinate primary care needs. The RN will conduct basic health evaluations, provide health education, explain the purpose of the medications prescribed by the PCP, and coordinate care between the PCP and mental health provider.
“People with severe mental illnesses, such as schizophrenia, have high medical risks. Often, they have difficulty accessing and effectively utilizing medical care. This pilot is providing us an opportunity to address these issues,” said Hromco.
These and other CSSI projects address areas of importance to CareOregon members: complex care management, chronic care management, reducing health disparities, improving access to care and office efficiency, and increasing patient safety.
For more information about the CSSI program, contact Diana Wolford at 503-416-1725 or e-mail wolfordd@careoregon.org.
