Initiative Overview

Santa Cruz – Community Chronic Care Network

Stage 4

Project Summary and Objectives: The Santa Cruz County Diabetes Mellitus Registry Project, now called the Community Chronic Care Network (CCCN), builds on a history of productive collaboration among the County’s public, private, and not-for-profit health sectors. The objective of the three-year (10/04 to 9/07) AHRQ-funded project is to adapt an internet-based diabetes registry developed and used by a local IPA for community-wide use.

Current Status: As the first step in community-wide implementation, a Pilot Project is currently underway to add MediCal managed care patients to the existing registry database. The Pilot Project includes adding new data elements and revised decision support logic developed by the CCCN Clinical and IT Committees. Expansion of the registry to County and other Safety Net Clinics is scheduled for Fall, 2005.

Geographic Coverage: Santa Cruz County Setting: Outpatient settings including private, public and safety net clinics.

Key Business Issues Addressing:• Community Collaboration• Provider Adoption• Decrease Clinical Complications• Equitability of Chronic Care Management• Sustainability of Community Registry & Data

Exchange

Contact:Eleanor Littmaneleanor.littman@chroniccarenetwork.org831-465-7871

Initiative Organization

Santa Cruz – Community Chronic Care Network

Stage 4

Entity: Community Chronic Care Network – community collaborativeLegal entity - Health Improvement Partnership Council Inc. (501(c)(3))Fiscal agent – Pajaro Valley Community Health Trust (conversion trust; 501(c)(3))

Initial Funding:Agency for Healthcare Research and Quality

Continued Funding Model:• Grant applications •Partner support•Reimbursement for chronic care management services

Governance: Steering Committee of executive leaders from each partner organization.

Advisors:AHRQ funded National Resource Center

Partners:Regional Diabetes Collaborative Health Improvement Partnership of Santa Cruz

CountySafety Net Clinic Coalition of Santa Cruz County Cabrillo CollegeCentral Coast Alliance for Health County of Santa Cruz Health Services Agency Pajaro Valley Community Health Trust Physicians Medical Group of Santa Cruz (IPA)Sutter/Santa Cruz Medical Foundation

Workgroup:Clinical Committee – selected physicians, nurses and dietitians from partner organizations and diabetes self management education programs.IT Committee – IT leaders from partner organizations plus HIM Directors from local hospitals.User and focus groups (planned) to support training and implementation activities.

Initiative Approach

Santa Cruz – Community Chronic Care Network

Stage 4

Project Approach: Adapt an internet-based diabetes registry developed and used by a local IPA for community-wide use

CalRHIO Project Components:

ED Linkage: No

Med Management:

No

Data Planned for Sharing:• POC (e.g. bp, referrals, patient goals)• Lab (e.g. HbgA1c, Lipid Profile)• Pharmacy (hypoglycemic plus CAD

meds)• Claims/encounter (identify patients,

referral visits e.g. retinal exams)

Administrative Efficiency:

No

Personal Health Record:

Potential, applying for grant for patient portal to diabetes registry

Architecture: Yes

Sharing Approach:• Create patient master index• Import registry data from claims, lab, pharmacy and point of care for patients in master index• Central data repository for point of care access

Security Approach: Users authenticate using strong passwords over 128 bit SSL browser based connection. No data is left on local machines. Application times out automatically. Participating clinics/offices responsible for site security.

Next Steps:• Roll-out registry in Safety Net Clinics (Fall/Winter 2005)• Expand claims data to include Medicare & PPO’s (Winter/Spring, 2006)•Coordinate withSanta Cruz Medical Foundation post-Epic implementation (Summer, 2006)

Applications: Browser-based diabetes registry running in a SQL Server dot net environment.

Critical Success Factors:• Complete community registry• Provider adoption• Demonstration of clinical outcomes