Cynthia T. Schaefer

Improving and sustaining diabetes care in community health centers with the health disparities collaboratives.

Background:In 1998, the Health Resources and Services Administration’s Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions. Objectives:To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further. Subjects:Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively. Measures:American Diabetes Association standards. Research Design:We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1–2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers. Results:Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [−0.45%; 95% confidence interval (CI), −0.72 to −0.17] and low-density lipoprotein cholesterol (−19.7 mg/dL; 95% CI, −25.8 to −13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07–2.01] and aspirin (OR, 2.20; 95% CI, 1.28–3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08–0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15–0.75). Conclusions:Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.

Insurance Status and Quality of Diabetes Care in Community Health Centers

OBJECTIVES We sought to compare quality of diabetes care by insurance type in federally funded community health centers. Method. We categorized 2018 diabetes patients, randomly selected from 27 community health centers in 17 states in 2002, into 6 mutually exclusive insurance groups. We used multivariate logistic regression analyses to compare quality of diabetes care according to 6 National Committee for Quality Assurance Health Plan Employer Data and Information Set diabetes processes of care and outcome measures. RESULTS Thirty-three percent of patients had no health insurance, 24% had Medicare only, 15% had Medicaid only, 7% had both Medicare and Medicaid, 14% had private insurance, and 7% had another insurance type. Those without insurance were the least likely to meet the quality-of-care measures; those with Medicaid had a quality of care similar to those with no insurance. CONCLUSIONS Research is needed to identify the major mediators of differences in quality of care by insurance status among safety-net providers such as community health centers. Such research is needed for policy interventions at Medicaid benefit design and as an incentive to improve quality of care.

The Cost Consequences of Improving Diabetes Care: The Community Health Center Experience

BACKGROUND Despite significant interest in the business case for quality improvement (QI), there are few evaluations of the impact of QI programs on outpatient organizations. The financial impact of the Health Disparities Collaboratives (HDC), a national QI program conducted in community health centers (HCs), was examined. METHODS Chief executive officers (CEOs) from health centers in two U.S. regions that participated in the Diabetes HDC (N = 74) were surveyed. In case studies of five selected centers, program costs/revenues, clinical costs/revenues, overall center financial health, and indirect costs/benefits were assessed. RESULTS CEOs were divided on the HDCs overall effect on finances (38%, worsened; 48%, no change; 14%, improved). Case studies showed that the HDC represented a new administrative cost (

Improving the Effectiveness of Health Care Innovation Implementation: Middle Managers as Change Agents

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Sustaining quality improvement in community health centers: perceptions of leaders and staff.

22/patient, year 1) without a regular revenue source. In centers with billing data, the balance of diabetes-related clinical costs/revenues and payor mix did not clearly worsen or improve with the programs start. The most commonly mentioned indirect benefits were improved chronic illness care and enhanced staff morale. DISCUSSION CEO perceptions of the overall financial impact of the HDC vary widely; the case studies illustrate the numerous factors that may influence these perceptions. Whether the identified balance of costs and benefits is generalizable or sustainable will have to be addressed to optimally design financial reimbursement and incentives.

Predicting Changes in Staff Morale and Burnout at Community Health Centers Participating in the Health Disparities Collaboratives

The rate of successful health care innovation implementation is dismal. Middle managers have a potentially important yet poorly understood role in health care innovation implementation. This study used self-administered surveys and interviews of middle managers in health centers that implemented an innovation to reduce health disparities to address the questions: Does middle managers’ commitment to health care innovation implementation influence implementation effectiveness? If so, in what ways does their commitment influence implementation effectiveness? Although quantitative survey data analysis results suggest a weak relationship, qualitative interview data analysis results indicate that middle managers’ commitment influences implementation effectiveness when middle managers are proactive. Scholars should account for middle managers’ influence in implementation research, and health care executives may promote implementation effectiveness by hiring proactive middle managers and creating climates in which proactivity is rewarded, supported, and expected.

Positive and Negative Spillovers of the Health Disparities Collaboratives in Federally Qualified Health Centers: Staff Perceptions

The Health Disparities Collaboratives are the largest national quality improvement (QI) initiatives in community health centers. This article identifies the incentives and assistance personnel believe are necessary to sustain QI. In 2004, 1006 survey respondents (response rate 67%) at 165 centers cited lack of resources, time, and staff burnout as common barriers. Release time was the most desired personal incentive. The highest funding priorities were direct patient care services (44% ranked no. 1), data entry (34%), and staff time for QI (26%). Participants also needed help with patient self-management (73%), information systems (77%), and getting providers to follow guidelines (64%).

The perceived financial impact of quality improvement efforts in community health centers.

OBJECTIVE To identify predictors of changes in staff morale and burnout associated with participation in a quality improvement (QI) initiative at community health centers (HCs). DATA SOURCES Surveys of staff at 145 HCs participating in the Health Disparities Collaboratives (HDC) program in 2004. DATA COLLECTION AND STUDY DESIGN: Self-administered questionnaire data collected from 622 HC staff (68 percent response rate) were analyzed to identify predictors of reported change in staff morale and burnout. Predictive categories included outcomes of the QI initiative, levels of HDC integration, institutional support, the use of incentives, and demographic characteristics of respondents and centers. PRINCIPAL FINDINGS Perceived improvements in staff morale and reduced likelihood of staff burnout were associated with receiving personal recognition, career promotion, and skill development opportunities. Similar outcomes were associated with sufficient funding and personnel, fair distribution of work, effective training of new hires, and consistent provider participation. CONCLUSIONS Having sufficient personnel available to administer the HDC was found to be the strongest predictor of team member satisfaction. However, a number of low-cost, reasonably modifiable, organizational and leadership characteristics were also identified, which may facilitate improvements in staff morale and reduce the likelihood of staff burnout at HCs participating in the HDC.

Community Health Center Provider and Staff's Spanish Language Ability and Cultural Awareness

Introduction:Quality improvement (QI) interventions are usually evaluated for their intended effect; little is known about whether they generate significant positive or negative spillovers. Methods:We mailed a 39-item self-administered survey to the 1256 staff at 135 federally qualified health centers (FQHC) implementing the Health Disparities Collaboratives (HDC), a large-scale QI collaborative intervention. We asked about the extent to which the HDC yielded improvements or detriments beyond its condition(s) of focus, particularly for non-HDC aspects of patient care and FQHC function. Results:Response rate was 68.7%. The HDC was perceived to improve non-HDC patient care and general FQHC functioning more often than it was regarded as diminishing them. In all, 45% of respondents indicated that the HDC improved the quality of care for chronic conditions not being emphasized by the HDC; 5% responded that the HDC diminished that quality. Seventy-five percent stated that the HDC improved care provided to patients with multiple chronic conditions; 4% signified that the HDC diminished it. Fifty-five percent of respondents indicated that the HDC improved their FQHCs ability to move patients through their center, and 80% indicated that the HDC improved their FQHCs QI plan as a whole; 8% and 2% indicated that the HDC diminished these, respectively. Discussion:On balance, the HDC was perceived to yield more positive spillovers than negative ones. This QI intervention appears to have generated effects beyond its condition of focus; QIs unintended effects should be included in evaluations to develop a better understanding of QIs net impact.

Development and Testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey

We administered surveys to 100 chief executive officers (CEOs) of community health centers to determine their perceptions of the financial impact of the Health Disparities Collaboratives, a national quality improvement initiative. One third of the CEOs believed that the HDC had a negative financial impact on their health center, and this perception was significantly correlated with centers having a higher proportion of uninsured patients. Performance-based payment incentives may improve care but may also add new financial burdens to facilities that treat the uninsured population. As such, a providers payer mix may need to be considered in the design of QI programs if they are to be sustainable.