Results Across our Federally Qualified Health Centers

Cuyahoga County has three Federally Qualified Community Health Center organizations. Care Alliance, Neighborhood Family Practice and Northeast Ohio Neighborhood Health Services, Inc. (NEON) collectively provide services to thousands of low-income residents in Greater Cleveland. These health centers serve different neighborhoods and populations but have in common a commitment to providing quality care to Clevelanders who would otherwise lack access to primary care.

The three organizations have a long history of working together to improve diabetes care through the local Safety Net Clinicians’ Strategic Alliance and the national Health Disparities Collaborative. While these health centers struggle to find resources to serve their patients that typically are available larger hospital-affiliated and suburban practices, they share a passion for improving patient care and outcomes. Each has made a strong commitment to participating in the quality improvement efforts of the Better Health Greater Cleveland alliance.

Each health center has voluntarily participated in diabetes outcomes measurement through a Health Disparities Collaborative (HDC) for at least five years. The mission of the Collaborative is to improve documented care and health outcomes for underserved populations, transfer knowledge of best practices and develop infrastructure, expertise and leadership to drive improved outcomes. Nationally, the HDC has provided the support and information to help the Greater Cleveland health centers improve their care for patients with chronic disease. A Patient Electronic Chart System (PECS) was provided to FQHCs participating in the HDC to build registries of patients with chronic disease. Each of the three health centers has hundreds of patients with diabetes in their PECS registry. However, the data retrieved from PECS ultimately could not be used to fuel this report, owing to 1) differences in data collection methods across the three health centers; 2) inflexibility of the PECS system to create customized outcomes reports; and 3) our desire for comparability of results across the three organizations.

Instead, the three health centers worked with Better Health Greater Cleveland to collect data at each center from a random sample of 50 paper charts for qualifying diabetes patients. Charts were abstracted using a consistent format to collect the same measures used by the other participating practices. The health centers believe the sample data closely reflects the health care and outcomes present within our entire diabetic patient population.

Health centers face many challenges in improving their patients’ outcomes. Low-income and uninsured patients face difficulties in obtaining the basics that they need to manage their diabetes, including strips to test their blood sugar, medications and healthy food. Other challenges include their limited capability to track data on their patients’ care and outcomes without the benefit of electronic medical records. Despite these barriers, health centers have shown they can “do the impossible with nothing” and improve the care and outcomes for diabetes patients with minimal resources using other internal measurement and quality improvement strategies.

Outcome and Process Measures for the FQHCs: Five of the nine Better Health Greater Cleveland individual standards were readily available from medical charts for virtually all sampled patients. These included three outcome standards (Hemoglobin A1c < 8, Blood Pressure < 140/80, and LDL cholesterol < 100 or statin prescription) and two process standards (Hemoglobin A1c Done in 2007 and Microalbumin screened or ACE/ARB prescribed). The remaining two outcome standards (BMI < 30 and Not Smoking documented) and two process standards (Eye Examination documented and Pneumococcal vaccination) were not always available. We emphasize that the eye examination and pneumococcal vaccination rates are likely undercounts, as these are frequently obtained outside of the Health Center.

The data summarized earlier in Part Three of this checkup highlight some important distinctions of our health centers, which are characterized by their high proportions of uninsured and minority patients, including one whose diabetic population is half Hispanic. Those tables, as well as Tables 4a-b below, provide additional insight into the health centers and their unique characteristics and demonstrate how intense focus and case management for patients can yield higher-than-expected clinical results.

A few salient points include:

• The majority of Care Alliance’s diabetic patients are uninsured and 80% are homeless. Despite the significant struggles these patients face just to survive, they have some of the best clinical outcomes. Monthly support groups and case management have shown good results.
• Neighborhood Family Practice has a growing number of diabetics at its two sites. Almost half its patients in the 50-chart sample are Hispanic, an ethnic group that has a higher incidence nationally of diabetes. Bilingual group education in diabetes management has improved outcomes over time.
• NEON has a largely African-American population and has developed a number of innovative community outreach strategies to help their patients form natural support networks and improve their own health.
  The health centers are committed to working together to improve outcomes and share best practices to help address the unique challenges of safety-net urban practices. Better Health Greater Cleveland provides an excellent forum to develop effective community-wide improvement strategies.