Martha Carter, R.N., C.N.M., M.B.A., an alumnus of the Executive Nurse Fellows program at the Robert Wood Johnson Foundation (RWJF), is on to something.
As director of FamilyCare HealthCenter, a Federally Qualified Health Center in West Virginia that serves low-income and other underserved populations, she has seen significant improvements in her patients’ health in recent years. Diabetic patients have lower blood-sugar levels, patients with hypertension have lower blood pressure, and fewer children with asthma have had to make trips to the emergency room.
In short, her patients are happier and healthier, and overall costs to the health care system are down.
How does she account for this turnaround? A program she implemented in 2003 that helps patients and providers better manage chronic diseases.
Key components of the program—called the Chronic Disease Management Program—include tracking patient care in an electronic database; teaching patients how to care for themselves and supporting their efforts; sending reminders to patients and staff about upcoming care; helping patients afford needed medications; and giving regular performance reports to the center’s staff and board.
“We’re making improvements, sustaining them over time, and we can prove it with documentation,” says Carter, who completed the three-year Executive Nurse Fellows Program in 2008 and was a 1999 recipient of the Robert Wood Johnson Community Health Leadership Award, which honors outstanding individuals who tackle challenging health and health care problems in their communities.
Carter’s Performance Draws National Attention
FamilyCare HealthCenter’s impressive results have caught the eye of national health experts at the Center for Quality at the Health Resources and Services Administration, a division of the U.S. Department of Health and Human Services, and the National Center for Minority Health and Health Disparities at the National Institutes of Health.
Organization officials asked Carter to share the highlights of her program at a two-day “best practices” summit in Bethesda, Md., on June 10 and 11. During the “Harvest of Driver Insights” conference, Carter and representatives from 24 other high-performing health care centers around the country presented their findings and shared lessons that can be adopted by health care centers nationwide.
“Our work has implications for health system change across the country,” says Carter. “Really, it’s an affirmation that health care centers are transforming care.”
The new system at FamilyCare HealthCenter is modeled after the “Chronic Care Model,” which helps providers take a proactive rather than reactive approach to patients with chronic conditions. Created with support from the Foundation, chronic care guidelines can be found here.
Nearly half of all Americans live with a chronic condition, and that number is projected to climb in the coming decades as the population ages, according to Improving Chronic Illness Care, a national program funded by RWJF.
Yet patients with chronic diseases—such as diabetes, heart disease, asthma, depression and others—suffer from glitches in the health care system, according to Improving Chronic Illness Care. Practitioners often fail to follow established practice guidelines, do not coordinate care with other providers, do not follow up with their patients, and do not give patients adequate training to manage their illnesses.
Carter has eliminated many of these deficiencies at her organization, and hopes these lessons can help inform the ongoing debate over health care reform. “Community Health Centers are poised to play key roles in health reform,” she says. “We need to show what we’re doing and show how it can save human and financial cost.”
Click here to learn more about the Foundation’s Executive Nurse Fellow program. Click here to learn about the Foundation’s Community Health Leaders program.