The Chronic Disease Management Department has continued to grow since its inception in the summer of 1998. This department has spearheaded many initiatives: Breast and Cervical Cancer; Diabetes; Cardiovascular Disease; Smoking Cessation; ADHD; Asthma and Lead Poisoning.

The Chronic Disease Management Department provides in-home coaching and support to clients who suffer from chronic diseases, and educates clients on the importance of ownership of their medical care management. Also, in conjunction with the clients’ physicians, the coaches provide clients with self-management options to improve their quality of life. In 2001, the C.I.R.C.L.E. of Care coaches had 536 encounters.  This was an 88-encounter increase from last year.

Grace Hill utilizes patient registries for specialty populations to provide better care, through extensive tracking and follow-up.

This tracking system also helps link neighborhood workers, or coaches, in the field with the clinic team. The coaches have been cross-trained to provide more comprehensive care to clients with multiple diagnoses. This process has helped increase their knowledge base and makes them a vital part of the care team.

As the chronic disease team takes on new initiatives, new synergies are created. These synergies help to constantly drive the teams to providing better client care. 

Diabetes initiative

Grace Hill was chosen as the lead center for the Midwest Cluster to participate in the Institute of Healthcare Improvement breakthrough series on caring for clients with chronic conditions. The Diabetes Collaborative was started in September 1998. During the course of the 13-month collaborative, Grace Hill started with a population of focus of 103 clients. Since that time, the registry has grown to include over 500 patients with a diagnosis of diabetes. We have instituted cluster clinics at five of our six sites, which provide one stop shopping for our clients, to reduce multiple visits. There are also self-management classes that help clients identify goals to improve their health. Health coaches continue to follow up on late HBS/C reports by contacting clients and making follow-up appointments.

Asthma initiative

Asthma was Grace Hill’s second national collaborative with the Institute of Health Care Improvement. The approach used for this collaborative was different due to the fact that both adult and pediatric clients were included. Over 150 adults and 800 pediatric asthma cases were identified. To help the clinicians concentrate on the epidemic of asthma, again using the chronic care model to change current practices to meet the needs of clients, Grace Hill embarked on another 13 month collaborative to change the way clinicians care for their asthma clients. Grace Hill started asthma classes for both parents and children. The Neighborhood Asthma Coordinator position was re-developed to help connect children in the clinic to the schools and to act as a liaison between the clinic and the school nurse. The Neighborhood Asthma Coordinator, along with the Americorp member assigned to work with her, conducted 8 Open Airways classes in the neighborhood public schools. These classes helped school age children learn to live with asthma and learn to control their disease rather than having the disease control them.

 Cardiovascular disease

The cardiovascular collaborative was initiated in January 2000. The purpose of this collaborative was to focus on clients with moderate hypertension. Through collaborative, education and self-management practices are taught, much like the diabetes collaborative, and clients are helped to manage their disease outside the clinic setting. Clients with moderate hypertension were chosen for interventions because Grace Hill cares for over 1,500 clients with high blood pressure. Clinicians focus on helping clients meet their “target blood” pressure.

Lead poisoning initiative

The lead poisoning initiative was started in January 2001, with a half-day kick-off meeting with the Saint Louis University School of Public Health presenting on the devastation of lead poisoning if left untreated. This imitative team is unique in that it includes community stakeholders. The Washington University School of Law and Saint Louis University participate in the bi-monthly team meetings. The two stakeholders intervene in the community to help provide quality housing for Grace Hill clients. The programs also utilizes the AmeriCorp HealthCorp Members for home cleaning demonstrations. They teach the parents of children with lead poisoning and at risk parents how to clean their homes to prevent their child’s lead levels from going higher. The collaborative also has two registries, one for case managements and one for “at risk” clients.

Attention deficit hyperactivity disorder (ADHD) collaborative

The Attention Deficit Hyperactivity Disorder (ADHD) Team was formed in September 2001 to address the continuity of care for these clients and their families. Grace Hill participated in the National Initiative for Children’s Healthcare Quality (NICHQ) Collaborative. The team is focused on improving the accuracy or diagnosis of clients with ADHD assessments (when concerns have been identified by the parents or school), increasing the number of clients with care plans addressing ADHD in their medical records, using the clinical registry to track progress, increasing involvement of community health nurses to follow clients through home visits, and improving the client’s targeted functional behaviors. 

If you would like additional information about the Chronic Disease Management Department at Grace Hill, please call (314) 539-9638.