quality improvement program 2009 annual report to pips report...copc primary care clinics last ......
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Quality Improvement Program 2009 Annual Report to PIPS
Lisa Johnson, M.D.Medical Director for Quality Improvement Programs Community Oriented Primary Care , SFDPH
COPC Primary Care Clinics
Last Revised: 04/14/2008
Castro Mission Health Center (CMHC)
Potrero Hill Health Center (PHHC)
Silver Avenue Family Health Center (SAFHC)
Southeast Health Center (SEHC)
Tom Waddell Health Center (TWHC)
Chinatown Public Health Center (CPHC)
Ocean Park Health Center (OPHC)
Maxine Hall Health Center (MHHC) Housing & Urban
Health Clinic HUH
Curry Senior Center
Community Oriented Primary Care Administration
CHPY Cole Street Clinic
CHPY Hip Hop to Health Clinic
CHPY Balboa Teen Health Center
CHPY Hawkins Clinic
CHPY Larkin Street Clinic
Medical Respite and Sobering Center (Fell St)
Special Programs for Youth (SPY)
Medical Respite and Sobering Center (Polk St)
Slide courtesy Alice Chen, MD
COPC Health Centers Primary Care clinics: serve general population
Castro Mission HC, Maxine Hall HC, Silver Avenue Family HC, Chinatown Public HC, Ocean Park HC, SouthEast HC, Potrero Hill HC
Special Population Health Centers: Geriatric Focus: Curry Senior Center (aka NMHC) Youth: CHPY (Cole, Larkin St, Hip Hop, Balboa) Forensic: SPY (Special Programs for Youth) at YGC Homeless or Marginally Housed, w/ high prevalence
psychosocial co-morbidities: Tom Waddell HC, Housing and Urban Health
COPC QI Program: 2008-09 Focus Areas
Efficiency / Capacity / Access (HSF demand) Clinical Quality - Develop and Support: Centralized Quality Data reporting Data Driven QI initiatives at Health Centers Innovative Programs
Population Management, Team Care (HCM) Behavioral Health / Primary Care Integration
(OPHC Depression screening Program, 3 sites integrating staff this y)
Chronic Disease Care PHASE, Chronic Pain Management
Collaborations: SF and Regional Safety Net
COPC – Utilization
Active Patient Panels of COPC PCCs =35,528 FY 08-09 Utilization (Visits and Undup Pts)
Total Visits 200,894, made by 40,873 undup pts Medical Visits 119,695, made by 34,402 undup pts:
9,386 (27%) were new to the PCC COPC Capitated patients: enrollment 9/09
HSF: 14,878 total – 28% Self-report NEW SFHP 11,181 total all lines of business Some are in “Shadow Panel” = enrolled but not yet
seen, thus not counted in the active patient panel
Efficiency/Productivity Improvement
Focus: increase Active Patient Panel at 8 COPC / HSF “medical homes” Minimum Panel size standards set: 1125 /1.0 fte
Tools for measuring and tracking capacity “shadow panel”, panel flux reports
Primary Care Redesign Project Demand moderation: return intervals, frequent flyers New Models of Care: telephone visits, group visits Team Care, health coach training, population
management
Active PCC Panel per Clinical FTE among COPC8 clinics
0200400600800
100012001400
Feb 08 Jun 08 Oct 08 Feb 09 Jun 09 Oct 09
COPC 8 PANEL SIZES (6/09): Active Patient Panel aggregate COPC 8 = 26,456Average panel size/fte for aggregate COPC 8 clinics rose from 1040 (2/08) to 1138 (6/09) Also growing: COPC 8 Shadow Panel = 8,923 enrollees
COPC Efficiency Measures Measure Frequency NotesPANELSActive panel size q 3 mo
Active panel size per clinical FTE q 3 mo Adjusted active panel size q 3 mo Adjusted active panel size per clinical FTE q 3 mo Avg medical visits to PCC per patient per year Yearly % of active PCC panel with PCP q 3 mo EFFICIENCY and ACCESSNo show rate q 3 mo Third next available appointment q 3 mo Requires manual sampling.Panel flux (attrition from patients leaving, new pts) q 3 mo MD visits per hour (productivity) q 3 mo NP visits per hour (productivity) q 3 mo Cycle time q 3 mo Requires manual sampling.
Clinical Quality: centralized reporting on measures for all COPC Active Pt Panels
Measure Frequency Notes
QUALITY
DM with HgA1c testing in past year q 6 mo NCQA/HEDIS
DM with most recent HgA1c <7, <8< , and > 9 in past year q 6 mo 2010 NCQA/HEDIS
DM with LDL testing in past year q 6 mo NCQA/HEDIS
DM with most recent LDL < 100 in past year q 6 mo NCQA/HEDIS
% of adults age 65 and over with pneumococcal vaccination ever q 6 mo USPSTF, ACIP
% of adults age 22 and over with tetanus vaccination in past 10 years
Q 6 mo ACIP
Lipid screening among men ≥ 40 yrs old and women ≥ 50 yrs old Q 12 mo USPSTF
Women age 42-51 with breast cancer screening in past 2 yearsWomen age 52-69 with breast cancer screening in past 2 years
q 3 mo USPSTF, NCQA/HEDIS
Women age 24-64 with cervical cancer screening in past 3 years q 3 mo USPSTF, NCQA/HEDIS
Adults age 51-75 with colorectal cancer screening q 3 mo USPSTF
Diabetes HgA1c & LDL Testing
Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 07/2009
Adult Immunizations in Primary Care
Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 05/2009
Pts age 22 and over with tetanus vax within 10 yrs
Pts ≥ 65 yrs old with pneumococcal vaccine
in lifetime
For Pneumovax: TWHC (50% to 73%), HUH (35% to 55%) had biggest gains.
Lipid screening among men ≥ 40 yrs old and women ≥ 50 yrs old (USPSTF A)(USPSTF Rec: screen q 5 yrs, starting at men age 35, women age 45)
Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 05/2009
Women’s Cancer Screening
Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 09/2009
September 2009 Eligible Women by Age Range
Age 24-64 Age 42-69 Age 52-69
COPC Subtotal 12,645 9,879 6,795
SFGH Subtotal 10,298 5,900 3,704
CHN TOTAL 22,943 15,779 10,499
COPC Allergy documentation in the LCR
Allergy Data for COPC Primary Care Clinics FY 08-09
75%62%
78% 77% 78%
30%
53%
43%31%28%
86% 79%93% 97%88%
0%20%40%60%80%
100%120%
July-08 October-08 January-09 April-09 July-09
COPC SPY OPHC
COPC Fiscal Year 08-09 External Audits
Auditing Agency Sites Visited Results
HIV Qual / CARE – June 2008
TWHC, CHPY Results Pending
Anthem Blue Cross-October 2008
TWHC PASS
Title X Family Planning – December 2008
CMHC, MHHC, SAFHC,CPHC, CHPY
Addressed all findings and recommendations.
Health Care for the Homeless- July 2009
CMHC, TWHC Results Pending – due in November
San Francisco Health Plan : FY 08-09
CHPY, CMHC, PHHC, MHHC,OPHC, CPHC, SEHC, TWHC
All facility Site Reviews were 96% plusAll Chart Reviews were 94% plus
UO Categories in COPC clinics COPC- UO's by type FY 08-09Top 5 categories (225 of 273)
35 3225
112
22 25
36
1621
05
10152025303540
Treatment-DiagnosisConsentIssues
Medication-Drugs
Safety/Security
Laboratory MedicalRecords
Q3-4_2008 Q1-2_2009
2009 Health Center Data Driven QI ProjectsAll Health Centers responsible for 2 Data Driven QI projects (2009 = YR 2)9 Health Centers participating in HSF Strength in Numbers PCC PERF MEASURE # 1 PERF MEASURE # 2 SIN project
CMHC Chronic Disease: DM Allergy documentation Chronic Pain Mgmt 02MHHC HCM: lipid screening HCM: adult IMZ Chronic Pain Mgmt 03SAFHC HCM: Ca screen (Pap) HCM: CRC screening HCM: CRC screening
04CPHC HCM: CRC screening Chronic Disease: DM Chronic Disease: Hep B 05OPHC Chronic Disease:
Depression HCM: adult IMZ Chronic Disease:
Depression
06PHHC HCM: CRC screening Chronic Disease: DM Chronic Pain Mgmt 07SEHC Chronic Pain Mgmt HCM: CRC screening HCM: CRC screening 08TWHC HCM: adult IMZ HCM: CRC screening Chronic Disease: HIV HUH Chronic Disease: DM Chronic Disease: CV N/A
CSS Chronic Disease: DM HCM: adult IMZ N/A
Primary Care: 2009 focus on improved prevention /screening measures As part of planning for HSF: PC QI worked with
PCRG and i2i workgroup to develop Population Management tools for HCM interventions Expanded centralized reports on Health Care
Maintenance measures Updated HCM field in LCR, built interface into i2i. Now can easily preview HCM prior to clinic visit,
generate outreach / reminder lists, do statistical reporting.
Demonstrated tools, supported pilot efforts, Result is increased focus on HCM at health centers
CPHC: Goal: 70% Td or Tdap Baseline: 56% (November 2008) QI strategies:
Train nursing staff to conduct pre-visit chart and LCR preview to identify patients due for Td / Tdap
Create standing orders to routinely administer vaccine
40%50%60%70%80%90%
100%
Nov-08 May-09 Jun-09 Jul-09 Aug-09 Sept-09
Tetanus: % of adults age 22 and over withdocumented vaccination in past 10 years
Why focus on preventive care? Significant disparities in receipt of preventive care
services among racial/ethnic groups and poor. Only 10% of female Medicare beneficiaries received all of 5
recommended preventive care measures (cervical, breast and colorectal cancer screening; pneumovax and influenza vaccines).
General Accounting Office congressional testimony on 3/23/02, available: www.gao.gov/cgi-bin/getrpt?GAO-02-777T.
Barriers to screening in Safety Net Patient Financial barriers, System resource constraints Literacy, language, and cultural barriers Conflicting guidelines for PCPs
7.4 hours/day to provide all USPSTF “A” and “B” services Yarnell KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care:is there enough time for prevention? American Journal of Public Health 2003; 635-641.
Slide courtesy of Alice Chen, M.D.
SFDPH Primary Care Approach Agreement on evidence-based guidelines, tailored
to our system’s resource constraints USPSTF guidelines - posted at Treatment Guidelines Clear referral guidelines for abnormal screening tests
Harness information technology EMR and Patient registry – LCR HCM, i2iTracks AHRQ electronic Preventive Services Selector
Systems interventions Standing orders Population Management (staff training MEAs, HW’s) Culturally and linguistically appropriate outreach
Slide adapted from Alice Chen, M.D.
Example: CRC Screening Improvement Clear evidence-based guidelines, agreed upon by
both GI and PC, compatible with DPH resources SF DPH recommends annual FOBT,for screening, with
diagnostic colonoscopy for abnormals (USPSTF)
Use of HCM field in LCR for data entry and reminders, i2iTracks for reporting and outreach
Systems interventions Population Management – staff training (MEA’s, HW’s) to
capture data (ouside colonoscopies) and encourage FOBT Standing orders to dispense FOBT cards if due Culturally / linguistically appropriate outreach
Slide adapted from Alice Chen, M.D.
CRC Screening in SFDPH Primary Care 38%
57%
28%
36%
67%
33%
47%
36%
13%
15%
46%
48%
43%
47%
41%
46%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Castro-Mission Health Center
Chinatown Public Health Center
Curry Senior Center
Maxine Hall Health Center
Ocean Park Health Center
Potrero Hill Health Center
Silver Avenue Family Health Center
Southeast Health Center
COPC8 Subtotal
Housing and Urban Health
Tom Waddell Health Center (PCP panel)
COPC Subtotal
Family Health Center
General Medicine Clinic Ward 1M
SFGH Subtotal
CHN TOTAL
% age 51-75 with colorectal cancer screening(Data capture for colonoscopies not complete at some PCCs)
How did CRC rates improve at 2 clinics? FLU-FOBT program at Chinatown PHC. Led by Mike
Potter, Albert Yu) with CDC funds 2008: results: Flu shot only: 52.9% 57.3% eligible completed FOBT Flu shot+ FOBT: (education and pre-paid mailer)
54.5% 84.3% eligible completed FOBT Difference of 25.4 points, p<0.001
Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh J. Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates. Annals of Family Medicine 2009; 7:17-23.
Overall CPHC rate Sept-09 = 57%7 COPC clinics to participate in similar program 2009 flu season
Ocean Park HC – gains all achieved with population management by MEAs and HWs – sustained effort over 18 months Baseline Jan-08 = 40%, Sept -09 = 67%
Slide courtesy of Albert Yu and Mike Potter
Depression Program at OPHCWhy? 5th OPHC dx, co-morbidity w/ chronic disease, need to
treat in Primary Care AIM: By July 2009, screen 80% of DM patients (PHQ tool) How? Adapt IMPACT Model: 4 elements Screen in Primary Care with PHQ-2/9 tool: 494 DM pts Develop New Role: Depression Care Manager
Internationally trained behavioral health workers working as a team with Social Worker
education, SMGs, monitors depression sx closely, f/u on meds, consults with providers, social worker/ psychiatrist
Psych back-up consultation q week - CBHS collaboration Tracking process and outcome measuresTo date at 5 mos: 80% of diabetics screened. Of those
screened, PHQ score for 25% = mild (9%) or moderate (16%) depression.
Slide courtesy of Lisa Golden, MD
PC Chronic Pain Management Initiative Feb 08: SFDPH-Wide Pain Taskforce Report– SFGH focus April 09: Primary Care Pain Workgroup (SFCCC, SFGH PC , COPC)
-- commitment to uniform minimum standard of care
August 09: COPC Chronic Pain Management Policy and Procedureapproved by PC QI – links to tools / templates • Informed Consent for Long-Term Controlled Substances Therapy for Chronic Pain • Patient-Provider Agreement for Long-Term Controlled Substances Therapy for
Chronic Pain • Chronic Pain Assessment and Treatment Plan Documentation Form
in draft: “Special Circumstances in Use of Controlled Substances in the Treatment of Chronic Pain: Inappropriate Use and Diversion".
Registry Use at 6 clinics (5 COPC and GMC): 1594 patients identified on chronic opiate pain management (7%
of the combined active pt panel of those 6 clinics) Measures selected (example: % with pain contract in chart)
Chronic Disease: PHASE Program Preventing Heart Attacks and Strokes Everyday
Kaiser funding to replicate in safety net settings
Goal: embed evidence-based CV risk reduction guidelines in day-to-day practice. Emphasis: med adherence (ASA, Statin, b-blocker, ACE-Inh) Lifestyle change: smoking cessation, diet, exercise
Implemented in 4 SFDPH clinics Jan 2008 - OPHC, CPHC, GMC, FHC - $400K over 2 years Funds used for staff training in TEAM CARE skills (panel
managers, health coaches, registry use) – partnered with Dr. Tom Bodenheimer and his training team
Applied for PHASE 2 (2010-1011) $300,000 over 2 yrs to expand program to total of 7 PHASE sites
SFDPH PHASE Results 9-09Percent of Total DM Patients with HbA1c < 7, <8
35 38 36 36 35 36 36 36 36
5761 60 61 60 62 62 63 64
343536 3535 35 35
555657 55 5656 56
0
10
20
30
40
50
60
70
80
90
100
7/1/
2008
8/1/
2008
9/1/
2008
10/1
/200
8
11/1
/200
812
/1/2
008
1/1/
2009
2/1/
2009
3/1/
2009
4/1/
2009
5/1/
2009
6/1/
2009
7/1/
2009
8/1/
2009
9/1/
2009
10/1
/200
911
/1/2
009
12/1
/200
9
1/1/
2010
% ofPatients with
HbA1c < 7
% ofPatients withHbA1c < 8
Goal for %of Patientswith HbA1c< 7
Goal for %of Patientswith HbA1c< 8
(N = 993)
Percent of Patients with LDL < 100
50 52 53 54 54 56 58 59 60 59
5249
48
48
47
47
0
10
20
30
40
5060
70
80
90
100
7/1/
2008
8/1/
2008
9/1/
2008
10/1
/200
8
11/1
/200
8
12/1
/200
8
1/1/
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2/1/
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3/1/
2009
4/1/
2009
5/1/
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6/1/
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9/1/
2009
10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
(N = 1122)Percent of Patients with BP< 130/80
38 38 38 37 37 37 38 39 41
38
38
36
36
33
32
30
0
1020
30
40
5060
70
8090
100
7/1/
2008
8/1/
2008
9/1/
2008
10/1
/200
8
11/1
/200
8
12/1
/200
8
1/1/
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2/1/
2009
3/1/
2009
4/1/
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5/1/
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6/1/
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7/1/
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8/1/
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9/1/
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10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
(N = 1122)
Population Size in Registry: All Patients at All Sites
500600700800900
100011001200130014001500160017001800190020002100220023002400
6/1/
2008
7/1/
2008
8/1/
2008
9/1/
2008
10/1
/200
811
/1/2
008
12/1
/200
81/
1/20
092/
1/20
093/
1/20
094/
1/20
095/
1/20
096/
1/20
097/
1/20
098/
1/20
099/
1/20
0910
/1/2
009
11/1
/200
912
/1/2
009
1/1/
2010
PopulationSize inRegistry
Subpopulation
N = 1193
DM patients (N = 1051)
SFDPH PHASE Results 9-09Percent of Patients on ASA
64 6671 72 73 74 75 77 77 79 79
68655546
44
20
30
40
50
60
70
80
90
100
7/1/
2008
8/1/
2008
9/1/
2008
10/1
/200
8
11/1
/200
8
12/1
/200
8
1/1/
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2/1/
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3/1/
2009
4/1/
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5/1/
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6/1/
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7/1/
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8/1/
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9/1/
2009
10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
(N = 1122)Percent of Patients on Statin
48
7175 76 76 77 79 80 82 83 84
737068
58
47
20
30
40
50
60
70
80
90
100
7/1/
2008
8/1/
2008
9/1/
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10/1
/200
8
11/1
/200
8
12/1
/200
8
1/1/
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2/1/
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3/1/
2009
4/1/
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5/1/
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6/1/
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7/1/
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8/1/
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9/1/
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10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
(N = 1122)
Percent of Patients on ACE/ARB
48
7075 75 76 78 80 81 82 83 84
7268
66
5647
20
30
40
50
60
70
80
90
100
7/1/
2008
8/1/
2008
9/1/
2008
10/1
/200
8
11/1
/200
8
12/1
/200
8
1/1/
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2/1/
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3/1/
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4/1/
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5/1/
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6/1/
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9/1/
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10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
(N = 1122)Percent of Patients on all 3 medications (Statin,
ASA, ACE/ARB) (N=1122)
30
4550 51 51 52 54 55 56 59 60
36
4345 47
2920
30
40
50
60
70
80
90
100
7/1/
2008
8/1/
2008
9/1/
2008
10/1
/200
8
11/1
/200
8
12/1
/200
8
1/1/
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2/1/
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3/1/
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4/1/
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5/1/
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6/1/
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7/1/
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8/1/
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9/1/
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10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
SFDPH PHASE Results 9-09Percent of Patients with Documented
Self-Management Goal EVER (N = 1122)
2934 37 41 43 44 45 47 48 50 51 52
28 31 3639
0
10
20
30
40
50
60
70
80
7/1/
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10/1
/200
8
11/1
/200
8
12/1
/200
8
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9/1/
2009
10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
Percent of Patients with Foot Exam
34 38 4047
51 53 54 55 57 59 59 58
4539
353220
30
40
50
60
70
80
90
100
7/1/
2008
8/1/
2008
9/1/
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10/1
/200
8
11/1
/200
8
12/1
/200
8
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10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
DM patients (N = 993)
Percent of Patients with Retinal Exam
32 32 30 3338 39 41 40 45 48 49 49
33313233
0
10
20
30
40
50
60
70
80
90
100
7/1/
2008
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10/1
/200
8
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/200
8
12/1
/200
8
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5/1/
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9/1/
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10/1
/200
9
11/1
/200
9
12/1
/200
9
1/1/
2010
DM patients (N = 993)Percent of Patients with Smoking Status
Documented (N = 1122)
62 66 67 68 71 7381 84 87 88
14
58
59
6065
140
10
20
30
40
50
60
70
80
90
100
7/1/
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10/1
/200
8
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/200
8
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8
1/1/
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9
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/200
9
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/200
9
1/1/
2010
Future directionsCollaborations to coordinate care in SF SF DPH Primary Care Clinics + SFCCC Clinics Primary Care (COPC) + Behavioral Health (CBHS) Integration Kaiser Specialty Care Initiative (Specialty + Primary Care Co-
Management of Chronic Conditions) SFHP / HSF QI Committees
Move to Standard Quality Measures in Safety Net Clinical Quality / Efficiency / Patient + Staff experience
Measures CPCA Standard Measures Group membership CAPH –Safety Net institute : Seamless Care Initiative (QI
Leaders Group membership)
SFDPH Primary Care Dashboard development