The Diabetes Improvement Project of the Consortium of Safety Net Providers of Middle Tennessee has been running since 2010. Members of the Consortium are Matthew Walker Community Health System, United Neighborhood CHS, University CHS, Faith Family Health Clinic, Siloam Health Center, St. Thomas Health System, and Nashville General Hospital/Meharry Clinics. These seven systems serve over 106,000 uninsured or poorly insured people.
The diabetes project traces on a monthly basis over 7000 patients with Diabetes. We track on each visit BMI,HgA1c levels, BP, and LDL Cholesterol. We also track retinal photographs, renal function, and neuro/foot checks. Ninety two percent of all diabetics in these clinics have high BP or high cholesterol. Only 8 percent have all risk values normal (HgA1c, LDL, and BP). Our focus in on those patients with all the 20% with all 3 values abnormal. Each month, all the clinic directors meet and review data from the previous month and share successes and failures. We use the Statistical Process Control (SPC) methods of Deminig. We can determine success or failure of interventions within a few months by this method.
We also will be tracking ER use and Hospital admissions. Currently there are around 7500 ER visits of uninsured or poorly insured Davison County resident diabetics to the Davidson County Hospitals. These visits are generating around $65 million in charges for all of the hospitals.