Nine public hospital clinics came together in 2004-2005 to transform care for patients with diabetes. The teams of doctors, nurses and other medical staff successfully changed the way they help diabetic patients stay healthy. They used the Chronic Care Model to keep patients healthier and more engaged in managing their disease:

• Technology – patient registries identify chronically ill patients and ensure they get needed care using a database.
• Patient empowerment: Patients set realistic goals for the day-to-day management of their disease.
• Team-based approach: Clinic teams use educators, social workers, and medical assistants to ensure that patients receive across-the-board care.

Patients being treated by these public hospital clinics are now doing significantly better than other diabetics around the country. For example, nearly 60 percent of CCLC patients have healthy cholesterol levels versus 11 percent of diabetics across the country. Public hospital patients also have lower risk of cardiovascular complications because of better controlled blood pressure and cholesterol. They’re also more likely to get preventive care. The team-based approach has also helped ensure that all diabetic patients receive a foot check, which prevents subsequent amputations by catching early infections.

Future SNI work includes attention to spreading the Chronic Care Model throughout public hospital systems. Also, SNI will address policy issues around chronic care delivery, including reimbursement.

SNI chronic care projects are funded by the California HealthCare Foundation and receive additional support from Kaiser Permanente.

CCLC Collaborative team, Chinatown Public Health Center, with their award for being chronic care pioneers