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Community Connections for Chronic Disease
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Community Connections for Chronic Disease Project was developed in response to a growing concern regarding not only an increase in the national and local prevalence of diabetes, but also the disproportionate burden of the disease that some minority populations and low-income families bear. The project was designed by a Health Action Plan workgroup comprised of experts in the field of diabetes and representatives from managed care plans and Public Health. This collaboration resulted in the development of an innovative project that integrates Public Health's expertise in working in communities with managed care plans' health care delivery system in an effort to model a new approach in the management of patients with diabetes.
The project builds upon a larger effort in the area of diabetes that is being carried out by the Washington State Department of Health employing the Robert Wood Johnson-adopted Chronic Care Model that was developed locally by the Group Health Cooperative of Puget Sound and the Sandy McColl Institute for Healthcare Innovation. The Chronic Care Model is an organizational approach to caring for people with chronic disease in a primary care setting. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared proactive practice team.
The Community Connections Project links with safety net providers that have participated in the aforementioned diabetes collaborative and bring to the partnership a preparedness that includes a diabetes database registry and a new provider orientation in the care of diabetes that follows the Chronic Care Model. However, despite best intentions, providers, particularly those that serve uninsured and underinsured populations, face a great challenge to adequately manage their chronically ill patients. Rushed practitioners, lack of care coordination, patients inadequately educated and supported to manage their diabetes, and lack of staff to provide active follow-up all combine to present significant challenges in assisting patients to manage their chronic conditions and improve health outcomes.
In August 2000, the Community Connections Project partnered with Community Health Centers of King County to implement the Community Connections Project at their Auburn primary care clinic. In October 2001, Community Connections expanded to a second site at the Federal Way Community Health Center. In 2002, the Community Connections project was "brought home" to Public Health when it was implemented at North Public Health Center. The strategic collaboration with community health clinics allows the project to focus on a racially and ethnically diverse patient population as well as underinsured and uninsured individuals and families.
In an effort to effect improved patient outcomes, the Community Connections Project adds the resource of a trained Project Nurse to assist in case managing clients living with diabetes at partnering provider sites. The role of the Project Nurse is multi-faceted. Some of the key project activities performed by the Project Nurse are to:
- Provide one-to-one diabetes education to clients
- Assist clients to establish self-management goals and provide support to achieve them
- Establish and facilitate ongoing 6-week diabetes support groups
- Education of all nurse staff in core areas of diabetes education as outlined by the American Association of Diabetes Educators
- Case management of identified high-risk clients and working to connect them to health services
- Establish and facilitate a diabetes team for direction of clinic activities in diabetes care
If you would like more information about the Community Connections Project contact:
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