Community Chronic Care Community Chronic Care NetworkNetwork

Wells Shoemaker MDWells Shoemaker MDMedical Director, PMGMedical Director, PMGPrincipal InvestigatorPrincipal Investigator

Federal Health ResearchFederal Health Research• NIH—What is True?NIH—What is True?• CDC—What is Happening?CDC—What is Happening?• AHRQ—What Works?AHRQ—What Works?

• Major emphasis upon technology Major emphasis upon technology tools to improve safety, consistency, tools to improve safety, consistency, affordability of care. affordability of care.

The ProjectThe Project• Expand a highly functional diabetes Expand a highly functional diabetes

registry to all patients, all providers, registry to all patients, all providers, all payors in Santa Cruz Countyall payors in Santa Cruz County

• Core: Decision support for providersCore: Decision support for providers• Connect people with careConnect people with care• Spread best practicesSpread best practices• Share with othersShare with others

Health DisparitiesHealth Disparities• Solution is NOT to put band-aid over Solution is NOT to put band-aid over

most disadvantaged, but rather:most disadvantaged, but rather:• Raise performance and consistency for Raise performance and consistency for

all community members with diabetesall community members with diabetes• ““Cultural challenge” for patients and Cultural challenge” for patients and

their families, but alsotheir families, but also• ““Cultural challenge” for professional Cultural challenge” for professional

change change

ChallengesChallenges• Create technical linkagesCreate technical linkages• Support trust and collaborationSupport trust and collaboration• Adoption of something new in Adoption of something new in

practicepractice• Scrupulously protect privacyScrupulously protect privacy• Embrace evolving electronic systemsEmbrace evolving electronic systems• Create a sustainable modelCreate a sustainable model

Partners in CCCNPartners in CCCN• PMG and SCMFPMG and SCMF• Safety Net CoalitionSafety Net Coalition• The AllianceThe Alliance• Public Health DepartmentPublic Health Department• Cabrillo CollegeCabrillo College• Pajaro Valley Community Health TrustPajaro Valley Community Health Trust• RDCRDC• HIP-CHIP-C