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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

Self-management Support for Community Health Centers

West Central Cluster

Connie Sixta, MSN, MBA

Consultant for TACHC

background
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).
wcc plan for supporting self management at chcs
WCC Plan for Supporting Self-management at CHCs

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

problems with implementing self management
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.
problems con t
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.
problems con t6
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.
problems con t7
Problems (con’t)
  • Professional staff for support of a self-management program are in short supply.
wcc plan
WCC Plan

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

wcc plan9
WCC Plan

STEP 3: Developed the change package and tools.

  • Videos (Provider and Staff)
  • Self-management Manual
  • Provider-specific Tools
next steps
Next Steps
  • Survey WCC CHCs to determine interest in testing/building a self-management infrastructures (Promotora, Case-management, etc.)
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