Improving Health Outcomes by Linking the Clinic to the Community
Thomas Sequist, MD MPH
What you have heard about US health care
Improving Chronic Care Outcomes
Atrius Health 

Harvard Vanguard Medical Associates
•	Multi-specialty group practice

•	17 ambulatory health centers

•	400,000 adult patients

•	175 primary care physicians

HVMA Diabetes Care Model
Baseline Racial Disparities
Panel Diversity and Disparities in LDL Control
The “Not Me” Phenomenon
Intervention Components
•	Cultural competency training
▫	1 to 2 day course (89% team attendance)
▫	Monthly educational materials

•	Clinical performance feedback
▫	Monthly distribution
▫	Race-stratified (HbA1c<7%, LDL < 100, BP < 130/80)
▫	Provider level (benchmarked to practice)

Patient Survey Feedback
Impact on Clinician Awareness
Clinician Support for Intervention
Clinician Views on Disparities
“Even though their diabetes might be under horrendous control, it wasn’t the top thing on life’s list.  You know they might have a kid in jail, or they might have been in the midst of an eviction proceeding or others are at risk of losing their jobs.  There were a lot of other topics that were higher on their list than their HbA1c of 13”

I think that I feel very overwhelmed by this whole kind of concept because in many respects I think that a lot of this is very, very difficult to change because of what happens outside of these four walls.
Clinician Views on Reports
Well it was an initial kind of negative feeling, you know, like I’m failing in these particular situations. But then there was a feeling of, well these are the things that we’ve really got to focus on so we’re just going to have to pull this apart and try and focus on these things.

It’s just not useful information.  I see very little that I have accessible at my disposal to make any impact on it, and telling me that it's there, it changes or doesn't change, seems to be random and have absolutely nothing to do with what I personally do or can do.
Views on Cultural Competency Training
•	Feeling that training educated on history of racism, trust, and bias

•	Helped them to explore these concepts in clinical setting

“You know I never knew there wasn’t a grocery store [there], I felt so stupid, but now I understand…”
Where Does this Leave Us?
•	Address social determinants

•	Address built environment

•	Systematic approach?

Different Viewpoints
Our Roadmap
•	Change measurement paradigm
▫	Allow clinicians to view communities

•	Target communities for action
▫	High disease prevalence
▫	Poor quality
▫	High penetration

•	Identify successful strategies
▫	Positive outliers and trajectories
▫	Resource catalogue

•	Clinical integration
▫	Clinician liaison
▫	EHR tools
Our Barriers
•	Traditional performance focus on clinicians

•	Clinician sphere of responsibility

•	Systematic approach to community partnership

•	Health center resources
Community Base Performance Measurement