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Self-management Support for Community Health Centers . West Central Cluster. Connie Sixta, MSN, MBA Consultant for TACHC. Background:. In 1999, Community Health Centers began implementing the Care Model (BPHC Health Disparity Collaboratives).

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Self management support for community health centers l.jpg

Self-management Support for Community Health Centers

West Central Cluster

Connie Sixta, MSN, MBA

Consultant for TACHC


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Background:

  • In 1999, Community Health Centers began implementing the Care Model (BPHC Health Disparity Collaboratives).

  • Patient self-management is a key component of the Care Model, and the key to chronic disease management.

  • The average percentage of patients with self-management goals has been low (30% through mid 2004).


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WCC Plan for Supporting Self-management at CHCs

STEP 1. Identified problems related to self-management implementation at CHCs (Staff, Provider, Management Questionnaires).


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Problems with implementing Self-management

  • Self-management process has not been taught at Phase II Learning Sessions.

  • Phase II teams (staff and providers) have not had self-management training-----Providers and staff want it.

  • Diabetic patient education is done almost exclusively on a 1:1 basis and in over 50% of the cases by a provider.


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Problems (con’t)

  • Hospital-based diabetic education programs are accessible for many CHC patients but are cost-prohibitive.

  • All CHCs are trying to set behavioral goals with patients, but are not discussing barriers or assisting patients with problem solving.

  • Goal follow-up is done every three to four months.


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Problems (con’t)

  • Documentation of patient self-management is inconsistent.

  • Many patient self-management tools do not meet the patients’ needs.

  • Most CHCs do not have a infrastructure to support self-management (Promotora, Case-management, Health Educator, CDE)--- Providers and staff want it.


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Problems (con’t)

  • Professional staff for support of a self-management program are in short supply.


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WCC Plan

STEP 2. Convened a group of CHC self-management experts to design change packages for self-management (Providers and Staff).


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WCC Plan

STEP 3: Developed the change package and tools.

  • Videos (Provider and Staff)

  • Self-management Manual

  • Provider-specific Tools


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Next Steps

  • Survey WCC CHCs to determine interest in testing/building a self-management infrastructures (Promotora, Case-management, etc.)


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