Setting the Standard: Implementation of Chinatown Diabetes ACTION (Accelerating Collaboration to Improve Health Outcomes Now)

Objective: Charles B. Wang Community Health Center (CBWCHC) seeks to improve diabetes management for low-income and underserved diabetic Asian-Americans in New York City.  As part of Chinatown Diabetes ACTION, CBWCHC has implemented a comprehensive set of practices in diabetes management by incorporating the multidisciplinary approach of the Chronic Care Model (CCM).

Methods:

• Established a multidisciplinary Diabetes Collaborative Care Team to improve patient-provider encounters by focusing on the 6 elements of the CCM: clinical information systems, decision support, self-management support, delivery system design, the community and organizational leadership;
• Determined areas for improvement and conducted PDSA (Plan-Do-Study-Act) cycles to pilot workflow changes, Electronic Medical Record (EMR) enhancements and community outreach;
• Implemented system-wide practice and workflow changes in diabetes management;
• Continuous monitoring and evaluation of practice changes by collaborative team

Results:

• CBWCHC successfully created a Diabetes Registry and made numerous EMR enhancements to allow for tracking, care management, and care coordination of diabetics.
• CBWCHC pilot-tested bilingual diabetes management workshops and group visits using new interactive media tools that promote peer-to-peer interaction.

Conclusion:

• Data show the value and advantage of EMR integration into diabetes management for aggregate analyses, documentation of services and planning. 
• Improvements in knowledge, attitude and motivation for behavior changes in diet and physical activity can be seen from surveys and focus groups analyses.
• Best practices can be replicated in other community practice settings serving comparable populations with similar resources intact.  The implementation process has been documented with both successes and challenges encountered and can be readily disseminated.