Project on Chippewa Reservation Leads to Better Health Outcomes
From 2001 to 2004, staff from the Peter Christiansen Health Center of the Lac du Flambeau Band of the Lake Superior Chippewa piloted an evidence-based medicine/continuous quality improvement model of care for diabetes, asthma and heart disease.
Staff from the University of Wisconsin Medical School assessed the project's progress toward objectives, challenges, impact and lessons learned.
Key Results and Findings
- Developed and implemented a structure and process for continuous quality improvement.
- Reviewed and adopted new clinical care protocols for three selected conditions: asthma, diabetes and cardiovascular disease.
- Provided training and technical assistance to tribal clinicians and staff persons.
- Based on the Wisconsin Medical School assessment, project staff reported that patient outcomes improved from fiscal year 2001 to fiscal year 2002, at least in part due to changes in clinical practice.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $382,719.
In recent years, two approaches to the delivery of health care evidence-based medicine and continuous quality improvement have become the hallmarks of effective clinical practice.
Evidence-based medicine entails an approach to practicing medicine in which the clinician is aware of the evidence in support of clinical practice as well as the strength of that evidence. The approach guides treatment procedures through the application of best practices, established protocols and clinical pathways (i.e., plans for the best clinical practice for specified groups of patients with a particular diagnosis that aid the coordination and delivery of high-quality care).
Continuous quality improvement is a method of improving patient outcomes that is proactive, self-evaluating and focused on optimal care. However, while the use of these approaches has been tested extensively within the mainstream health care industry, certain delivery systems, including safety-net and Indian tribal clinics, have not benefited from the diffusion of these processes.
Tribal clinics face additional obstacles in providing care to their patients: their funding is more limited; connections with integrated health care systems are weak; their patients have high rates of serious chronic conditions, including diabetes and substance abuse; and their isolation from mainstream medicine often leaves tribal clinic staff in need of training to integrate evidence-based medicine and best practices.
At the time this grant was approved, a primary goal of RWJF's Clinical Care Management Team was quality improvement in chronic care. The team was also interested in trying to understand how to improve quality of care in populations that have less access to health care and greater health disparities. This project provided an opportunity to focus on both goals.
The Clinical Care Management Team has since become the Quality Team. One ongoing program managed by the team is Improving Chronic Illness Care, a national research, demonstration and dissemination program to help organized health systems improve their care of the chronically ill; more information is available online.
The Evidence-Based Clinical Management of Patients with Chronic Conditions Project was a partnership between the Peter Christiansen Health Center of the Lac du Flambeau Band of the Lake Superior Chippewa and the University of Wisconsin Medical School, which contributed to the project on a contractual basis with the center. The health center, which serves 5,500 Native American patients through its clinic, is located in northern Wisconsin on the Lac du Flambeau Reservation.
The project sought to demonstrate that improvements in systems of care can achieve these objectives:
- Improve patient care and outcomes, including higher functional status, and reduce morbidity and mortality associated with asthma, diabetes and cardiovascular disease.
- Reduce the overall disease burden and costs of specialty, hospital and emergency-room care associated with these conditions.
- Promote structural changes that lead to improved continuity of care among primary, specialty and tertiary providers.
In April 2002, project staff hired a continuous quality improvement coordinator to oversee the project. The following month, the coordinator introduced and outlined the project at an on-site conference for the entire clinical staff. Drawing upon up-to-date information on evidence-based medicine, practice guidelines and clinical pathways from a number of sources (including materials available online from sites such as the National Guideline Clearinghouse a public resource sponsored by the federal Agency for Healthcare Research and Quality and through the Improving Chronic Illness Care program), the coordinator and other clinical staff members developed a Continuous Quality Improvement Plan in August 2002.
With input from an interdisciplinary Quality Improvement Committee (composed of clinic staff and representatives from community health services, contract health services and the tribal council), project staff focused on strengthening clinical systems for patient tracking and follow-up, completing documentation and data entry and connecting clinical data to the day-to-day patient care procedures. To ensure the adoption of health care protocols and clinical pathways, staff furnished training opportunities to providers and clinic staff. They also facilitated effective self-management of chronic disease through patient education.
A process evaluation by staff from the University of Wisconsin Medical School assessed the project's progress toward objectives, challenges, impact and lessons learned. Project staff used the evaluation which was based on site visit interviews with clinicians, clinic staff and consultants to inform the final report to RWJF.
Project staff achieved results in the following areas:
- Developed and implemented a structure and process for continuous quality improvement. The Quality Improvement Committee served as the primary change agent. Meeting monthly by themselves and then, eventually, with the entire clinic staff, the committee provided the input necessary to implement the restructuring of clinical procedures.
- Reviewed and adopted new clinical care protocols for three selected conditions:
- Asthma: Using information from the National Asthma Education and Prevention Program Expert Panel Report Guidelines, along with input from a University of Wisconsin Medical School allergist consultant, project staff established a protocol and set of documentation tools for patient care. To capture asthma-related patient data and provide appropriate health care reminders to providers, project staff created an asthma registry. The registry collects data on care and outcomes of care, as specified by guidelines. Clinic staff can use the system to prepare patient management summaries before each clinic visit and to update the record after the visits. The summaries also permit assessment as to whether care conforms with the guidelines. Project staff participated as one of 10 sites in a project of the Indian Health Service to test asthma registries (the RPMS [Resource and Patient Management System] Beta Test Site Project). To oversee the effort, the continuous quality improvement coordinator convened a monthly Asthma Advisory Committee comprised of clinic staff, the tribal school nurse and ad hoc members from the respiratory therapy and emergency departments of the off-reservation medical center. The committee assisted in developing an Asthma Plan for the clinic, which laid out goals, objectives, action steps, required resources, performance measures and persons responsible.
- Diabetes: Project staff implemented a Staged Diabetes Management Project. Using a database approach for decision-making, Staged Diabetes Management is designed to provide clinicians with evidence-based medicine guidelines, facilitate patient empowerment and improve the detection of diabetes in the community. The clinic also hired a new dietician, as well as a new diabetes nurse educator to conduct home visits for teaching self-management skills to patients. In addition, clinic staff collaborated with the Great Lakes Inter-Tribal Council Epidemiology Center to conduct the third annual diabetes program audit in March 2003. The audit revealed shortcomings in the documentation of patient data, which project staff addressed through further training.
- Cardiovascular disease: Project staff developed and implemented a model patient registry for management of patients with cardiovascular disease. Residing in a clinical database, the registry can generate a medication list and track treatment outcomes, follow-up visits and outside referrals. Benefits of the registry include up-to-date clinical summaries for each visit, less "chart-searching" by providers, automated follow-up visit scheduling, evaluation of clinic treatment patterns and outcomes and potential cost savings by reducing recurrent cardiovascular events.
- Provided training and technical assistance to tribal clinicians and staff persons. These included all-day on-site conferences; presentations at staff meetings, dinners and luncheons; off-site conference attendance; demonstrations; consultations with providers by the continuous quality improvement coordinator; and hands-on work with providers by consultants in the University of Wisconsin Medical School.
- Developed and implemented procedures to educate and support patients in managing their illnesses. The procedures include patient consultations with project staff (a nurse educator, dietician, the continuous quality improvement coordinator and/or pharmacists). Patient education materials include videotapes in the clinic waiting room, self-assessments, worksheets and handouts. For diabetic patients, nurses and dietitians sometimes make home visits or provide transportation for patients.
- Developed a Pain Management Pilot Program in response to a need to intervene with drug-seeking patients. Using American Academy of Pain Medicine guidelines, the clinic's Pain Management Team (comprised of clinic staff, medical center staff and tribal agency representatives) designed a pain management protocol and patient contract. Since the program began in May 2003, more than 25 patients have signed contracts, which stipulate drug evaluations at set intervals, spell out the consequences of breaking the contract (which include alternative therapies and random drug tests) and give permission for the clinic to share information with other providers.
- Planned, organized and implemented community health promotion activities. These included the Lac du Flambeau Chapter of the Relay for Life, which raised $27,153 in 2003, and an Employee Wellness Program that provides health education materials, pedometers and body mass index/blood pressure monitoring for over 30 members.
Project staff reported that patient outcomes improved from fiscal year 2001 to fiscal year 2002, at least in part due to changes in clinical practice.
- The percentage of diabetic patients with better blood sugar control (HbA1C values less than 7.0) increased from 28 percent to 41 percent.
- The percentage of diabetes patients participating in the Staged Diabetes Management Project increased from 29 to 81 percent.
- 76 percent of patients with both cardiovascular disease and diabetes had blood sugar levels below 7 percent and 67 percent had LDL cholesterol below 100 outcomes better than the national average for the general population.
- Staff reported improved compliance among asthma patients as a result of on-site pulmonary function testing, better medication compliance and fewer emergency room visits.
Project staff published four health information articles in the monthly tribal newspaper, Lac du Flambeau News, and one in the quarterly newsletter of the Great Lakes Indian Fish and Wildlife Commission. See the Bibliography for details. Staff also made six presentations for professional groups, including one at the Annual CDC Diabetes Conference.
- Tribal clinical settings require special considerations. Staff should not expect to transplant mainstream health care practices directly into tribal clinics. Strategic planning, mission statements, and long- and short-term goals are not common in tribal clinics. In addition, targeted conditions are more prevalent in the American Indian population, but community awareness of health issues is low. Cultural competence is imperative. (Project Director)
- Project staff need to confront the challenges of the rural settings of most Native American clinics. In this case, staff helped prevent isolation and assure consistent information by involving consultants and providing opportunities for clinicians to attend conferences. (Project Director)
- For projects conducted in tribal clinics, it is important to include the tribal council in the decision-making process. Clinics on reservations are run by tribal councils. Gaining tribal council support was imperative for the shift from "business as usual" at the clinic to the adoption of evidence-based medicine protocols. Staff for this project involved the tribal council in the grant proposal process, and also let council members review the primary paper written on the project (unpublished at this writing), to make sure the council was in agreement with the changes that the project brought to the clinic. (Project Director)
AFTER THE GRANT
Project staff has integrated the registry-based patient tracking procedures developed during the project into standard clinic operations. Project staff will also consult with three tribes in Minnesota (Fond du Lac, Mille Lac and Red Lake) on replicating the cardiovascular registry. In addition, staff from the University of Wisconsin Medical School will promote the project within the school as an effective partnership model that can be replicated with other tribal or rural clinics.
GRANT DETAILS & CONTACT INFORMATION
Developing an Evidence-Based Model of Clinical Management of Patients with Chronic Conditions
Lac du Flambeau Band of Lake Superior Chippewa Indians of the Lac du Flambeau Reservation of Wisconsin (Lac du Flambeau, WI)
Dates: October 2001 to March 2004
Adrienne Laverdure, M.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Hanson P. "The traditional diet and American Indian health." Mazina'igan, newsletter of the Great Lakes Indian Fish and Wildlife Commission, Summer 2003.
Hanson P. "Exercise and Diabetes." Lac du Flambeau News, March 2003.
Hanson P. "Ganawedan Gid'Onzaam-Ishipi-Miskwiiwin (Take care of your high blood pressure)." Lac du Flambeau News, July 2003.
Hanson P. "Gi daa bimose nawaj dash ginwenzh mino bimaadizayan (You should walk more thus you will live longer and better)." Lac du Flambeau News, September 2003.
Hanson P. "Aaniish Ezhi-Maamaajide'ishkaa Zaagaswewin? (Why Does Smoking Cause Heart Attack?). Lac du Flambeau News, November 2003.
Report prepared by: Robert Crum
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Doriane Miller
Program Officer: Terry L. Bazzarre