- Overview
- Adult Immunizations
- Alcohol and Substance Use (SBIRT)
- Asthma
- Appropriate Use of Antibiotics for ARI
- Colorectal Cancer Screening
- Cardiovascular Disease (CVD) and Stroke Prevention
- Depression
- Diabetes in Adult Patients
- Gestational Diabetes
- Hepatitis B and C
- Immunizations
- Motivational Interviewing
- Obesity
- Pediatric Immunizations
- Pneumococcal & Influenza Standing Orders
- Preconception & Interconception Care
- Prevention
- Tobacco Cessation and Secondhand Smoke Exposure
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Health Care Reform: a Reality or a Dream? At the end of the day, it makes it even clearer that “healthcare is local”. It will take all of us working together at a grassroots level to change the way healthcare is delivered and how it is paid for to improve quality, reduce costs, and improve experience for patients and their healthcare teams - bringing back the joy of practicing medicine. Last weekend over 175 physicians, midlevel providers, nurses, medical assistants, office administrators and others from the Improving Performance in Practice (IPIP) and Patient Centered Medical Home (PCMH) initiatives came together for a Learning Session in Lakewood, CO. The purpose was to hear from local and national experts and share ideas about the various methods they were working on to redesign their practices. These included topics such as team based care to improve office efficiency; implementation of registries to track patients and use data regularly to improve and demonstrate care; coordination of care with the medical neighborhood; motivational interviewing techniques to engage patients in their care; practice leadership and culture issues; integrating mental and behavior health into practice; and many other subjects. We are so proud of the work these practices have done! Whether they are just beginning the journey or have been active for awhile, we are seeing significant transformations in system implementation, leadership and culture. And they are not alone! Similar activities are going on all around the country as providers, employers, health plans and others realize that we can no longer sustain the status quo. This will be important work to leverage all of the changes flooding the environment such as payment reform, incentives for “meaningful use” of technology, accreditation for board certification and CME, and many other initiatives. And there is help out there for those willing to jump in. This is our time to make meaningful changes in our practices and communities to improve communication, coordination of care, quality, safety, efficiency, and experience for patients and their healthcare teams. Hopefully, if we continue to work from the ground up, things will also change from the top down and we can meet somewhere in the middle to create the kind of health and healthcare system we want for ourselves, our families and generations to come!
New Guideline for Preconception and Interconception Care; Hepatitis B and C Guideline Underway Why should women, menarche to menopause, have preconception screening?
This new guideline is intended for the screening of all women of childbearing age and to assist in the assessment of specific health conditions and contraception choices. Each and every encounter a woman has with the health care system becomes an opportunity to incorporate steps to improve her health as well as the health of the next generation. Despite efforts to improve prenatal care and advances in medical science and technology, maternal and infant health in the U.S. has improved very little in the last few decades. However, there is mounting evidence that improving a woman’s health before pregnancy can optimize future pregnancy outcomes. This would be easy to institute if all women came in for information and treatment before they chose to get pregnant. Unfortunately, only 50% of pregnancies in the U.S. are planned. This is why we are enlisting your involvement. Much if not all of the information presented in this guideline is part of what is collected at a standard health exam. Some information can potentially be gathered by medical assistants. In the near future, we are hoping to include screening tools which should further streamline this process. The front page offers brief explanations as to the value of screening for certain risk factors and the recommended interventions for all women who can potentially become pregnant, whether they are actively trying to or not. The back page discusses certain medical conditions in which additional counseling and/or testing should take place. Finally, we have added some information about what types of contraception are safe in specific situations.
In January, the Institute of Medicine (IOM) issued a report finding: a lack of knowledge and awareness among health care and social-service providers about chronic viral hepatitis; lack of awareness among patients who do not know they are infected, and inadequate funding for public-health resources related to prevention, control and surveillance programs. Chronic viral hepatitis B and C are among the leading causes of preventable deaths worldwide. As many as 1 in 50 Americans are afflicted with viral hepatitis with African Americans and Asian Americans being disproportionately afflicted. The diseases infect all walks of life in American society. A new CCGC guideline on hepatitis B and C is being developed to help primary care providers identify infected patients and provide the ongoing care needed to prevent complications caused by these infections. It can be used to monitor, treat or refer. In addition to the guideline—hepatitis B on one side of guideline and hepatitis C on the other--supplemental materials are being developed including a Flow Sheet for Treatment of HCV Infection, Medications List, Adverse Event Monitoring List, Counseling Messages/scripts, map or list of endemic countries and posters and flyers. As with all guidelines, links to additional references will be provided on the CCGC website.
Tobacco Team Focused on Low Income and Prenatal Practices The tobacco team has received approval on a scaled back work plan for this fiscal year (July 1, 2009-June 30, 2010) that focuses on low income patients and pregnant women. We have successfully partnered with Medicaid (Department of Health Care Policy and Financing), Local Health Agencies, and the Colorado Department of Public Health and Environment (CDPHE) to target appropriate providers. At this point, halfway through our grant year, we have reached a large number of providers through our interventions. We continue to make our one hour in-office Tobacco Rapid Improvement Activity (TRIA) intervention available to low income and prenatal practices in Colorado. If your practice falls into either of these categories and you would like a TRIA please call Emily Gingerich at 303-962-8981. With the threat of further reduced funding, we are relying on other CCGC programs to create sustainable tobacco interventions that are not dependent on state health department funding. As many tobacco control programs are discovering nationally, CCGC’s tobacco team believes that sustainability depends upon integration of tools, techniques and messages into ongoing programs. Tobacco is addressed in eight other CCGC guidelines, and tobacco screening and advice are also included in CCGC’s Improving Performance in Practice (IPIP), Medical Home and Reach My Doctor (RMD) activities.
IPIP experienced an amazing overflow of innovation, creativity and energy at its most recent Learning Collaborative, which took place January 22nd and 23rd at the Sheraton Hotel in Lakewood, Colorado. It was exciting to participate with over 50 practices and organizations for the sole purpose of improving systems, patient health, and organizational health! The 2 day collaborative learning session left many people energized and passionate about the amazing year to come. We thank those of you who participated and cannot wait to see you again in June. 2010 holds many new and exciting projects, prospects and advancements! We look forward to working with you all, and eagerly await to hear your creative and innovative ideas as we move forward into a new decade. By simply participating in the IPIP Program, you have demonstrated that your practice is forward thinking and ready to embrace the healthcare challenges that are yet to come. Don’t be afraid to pat yourselves on the back! As your IPIP coaches, and collaborative partners in your practice, we are left with one burning question: What are you going to accomplish by next Tuesday?
PCMH Pilot Update
The hospital sub-group also created a list of mutually agreed upon information that will be included when the ER discharges a patient and also when a PCP sends a patient to the ER.
Higher Learning Opportunity for PCMH Practices! CCGC hosted a second Shared Learning Collaborative for PCMH & IPIP Practices on January 22 & 23. This was an opportunity for the practices to share best practices and help each other work through challenges in their practices. Topics included: Patient Experience, Practice Leadership, Data, Planned Care Model Overview, Advanced Access, Job Function Round Tables, Motivational Interviewing, Practice Viability, Making Time for Improvement, Utilizing Community Resources, Registry, Self-Management, Patient Engagement, Clinical Protocols, Medical Neighborhood, Model for Improvement, Behavioral Health Integration and Resistance to Change. Coach’s Note: This month I would like to highlight Provident Adult and Senior Health a Level III Medical Home located in the Denver Metro Area. Provident is unique in that they are the only pilot practice that follows their patients from the clinic through the hospital, skilled nursing, rehab, and any other care settings. Bill Nooning (CEO) and Kevin Svoboda (COO) founded Provident with the idea of creating a healthcare delivery system that you would want your mother to experience. In the last couple of months, they have been busy implementing the following systems:
Their measures for Diabetes and Heart/Stoke are as follows:
Colorado Family Medicine Residency PCMH Project
Enter The University of Colorado Family Medicine Residency Program. The UH residency program includes two education training tracks; the UH track is located at the AF Williams Clinic in Stapleton and the Denver Health (DH) track is located at the Lowry Clinic. Through the leadership of Frank deGruy, Department of Family Medicine Chair, Dan Burke, UH Residency Director, and an energetic and creative faculty and staff, The UH Residency Program has transformed itself into a program that emphasizes the PCMH through all aspects of its curriculum. The emphasis on the PCMH began in 2007 when the UH Residency Program joined a group of 14 other Family Medicine Programs that were chosen to be part of the P4 Program (Preparing the Personal Physician for Practice). Also known as P to the fourth power, P4 is a six-year project to inspire and examine substantial innovation focused on changing the way family physicians are trained to practice medicine. In addition, the UH residency programs became part of the Colorado Family Medicine Residency Patient Centered Medical Home Project in January 2009 and are receiving quality improvement coaching and curriculum redesign support from the project team. The goal for both the P4 initiative and the Colorado Family Medicine Residency Patient Centered Medical Home Project is to train future physicians to practice as a PCMH. For its P4 initiative, the University program chose to implement a new PCMH-curriculum focusing on chronic disease management, cutting edge information systems, health behavior change, community integration, and leadership in the specialty of family medicine. Curricular changes include instituting family medicine intensive teaching blocks preceding first year hospital rotations, establishing a Medical Home Curriculum, and reorganizing the residency curriculum so that residents have an experience focused on caring for their own panel of patients during the second half of residency. The UH program is continuing to build on this foundation through the Colorado Family Medicine Residency Patient Centered Medical Home Project by integrating practice and quality improvement into the residency curriculum. Residents are actively involved on the quality improvement (QI) teams within the UH clinics. The residents are involved in the Plan Do Study Act (PDSA) cycles currently underway on the QI teams. As the UH programs work toward NCQA-PCMH certification, the residents will be involved in development of registry measurements and population management for their panel of patients. A UH 3rd resident recently said,” Participation on the QI teams has led to several ‘ah ha’ moments since it has given me insight into what it actually takes to work together as a team.” |
NCQA News Update! We are pleased to announce that another practice moved from Level II to Level III PPC-PCMH NCQA Recognition! That brings us to 14 practices that have been recognized at Level III and 2 practices recognized as Level II. 
P4P Program Is Here! Through the collaboration of the health plans, members of the physician advisory committee and Kavita Nair from the University of Colorado Denver, School of Pharmacy, we are happy to announce that the P4P program parameters have been established. The health plans will be working on updating their contracts and determining the bonus structure.
Are you a Card Carrying PCMH Patient? The hospital sub-group has determined the need to identify PCMH patients when they are admitted to the ER and/or hospital, this will also help identify the PCP for the hospital to help ensure that timely communication occurs. The group decided to meet this need by creating a business card that can be customized with practice specific information. CCGC will provide the first printing for each practice. 
Read All About It! The patient advisory committee in conjunction with the physician advisory committee created a poster to further educate and engage patients on the Patient-Centered Medical Home model of care. This poster along with the brochure and handout are available to for purchase. Please contact 
