Population Health in Primary Care: Indiana Primary Care Learning Collaborative

BACKGROUND: In 2010, approximately 50% of Indiana adults reported having a history of heart disease, stroke, cancer, chronic lower respiratory disease, diabetes, or arthritis. As a consequence, population health and prevention of chronic disease and associated risk factors in the primary care setting became a priority for the Indiana State Department of Health (ISDH). The ISDH developed the Indiana Primary Care Learning Collaborative (INPCLC) with emphasis on state-funded federally-qualified health centers (FQHC), community health centers (CHC), and rural health clinics (RHC) (n=27).  The location of these clinics, both rural and urban, facilitated access to a wide-range of populations who were disproportionately affected by chronic disease, including African Americans, Hispanics, refugees, and individuals with low socioeconomic status.

METHODS: The INPCLC required participating facilities to track patients who smoked, were obese, had diabetes or hypertension, and who were due for primary preventive screenings, including breast, cervical and colorectal cancers.  The INPCLC also required pregnancy and health profiles be created for women aged 14-44.  Measures were developed and aligned with well known authorities (e.g. National Quality Forum) for standardized data collection. In order to improve outcomes, the INPCLC employed evidence-based guidelines, the Chronic Care Model, and the Associates in Process Improvement’s Model for Improvement. Facilities tracked clinical and process outcomes and reported aggregated data on a monthly basis for 12 months.

RESULTS: Over the course of the collaborative, improvements were recorded in all but one of the 21 measures. Clinics increased the mean percentages of tobacco users referred (+21.2%) and registered (+11.7%) to the Indiana Quitline. Clinics also increased the mean percent of adults (+16.0%) and children (+24.8) with a calculated BMI, and overweight adults (+22.1%) and children (+6.2%) with a shared care follow-up plan.  Among all improvements made in the diabetes and hypertension measure sets, the most notable was the decrease in the mean percent of diabetic patients with A1C>9% (-2.0%).

CONCLUSIONS: Clinics noted that participation in INPCLC has increased efficiency in provider-to-patient encounters, Meaningful Use reporting, and patient self-management.  Clinics also observed a reduction in patients missing appointments, improvement in managing patient populations, and indicated benefits from peer-to-peer learning. Clinics found process change techniques learned in the INPCLC not only improved patient outcomes, but often resulted in discovering charting and/or reporting errors, the correction of which improved patient service and clinic management.  Since data were aggregated and self-reported, all data collected in the INPCLC were used for quality improvement and not accountability.