Increasing Enrollment into Chronic Disease Self-Management Programs

This initiative was chosen because of the low enrollment numbers for the Nebraska Living Well Program. When starting the initiative, the QI facilitator and QI coordinator wanted to ensure that the right people were included on the QI team. Two counties in Nebraska (Buffalo and Lancaster) were part of the QI team. Building relationships and trust was a focal point in team development. Once the team was established and committed to the project, the Plan phase of the Plan, Do, Study, Act (PDSA) cycle began. During the Plan phase, information was collected to document the current process. Baseline data were organized to help frame the issue and to help the team develop an initial aim statement. Once these initial steps of the planning phase were complete, the QI facilitator and QI coordinator met to draft team QI documents (team charter, fishbone diagram, logic model, and process map). The QI team reviewed and added to these documents. This approach helped to build trust and support for the QI initiative. The team charter document allowed all team members to understand their roles and responsibilities during the planning and implementation of the project. This document identified the aim statement and provided a clear understanding of what the team wanted to accomplish. The fishbone diagram helped the QI team identify the root causes of the issue. By using this type of document, the team identified common themes that were potentially contributing to the problem. The process map allowed the team to visualize and articulate the current process and to identify where in the process the problems were occurring. The logic model is a multi-use communication tool that allowed the team to describe the program. It also served as a high-level depiction of the flow of materials and processes that led to the team's desired outcome. During the Do phase of the PDSA cycle, the QI team implemented strategies that focused on increasing enrollment in the Living Well Program. The first strategy involved improving awareness of the program among the general public and health care providers. The team dedicated time to meeting with health care providers and created media pieces and promotional materials for the general public. In Buffalo County, the team worked with Sentinel Health Care for the QI initiative. Sentinel Health Care is a nonprofit hospital organization—a collaboration of Good Samaritan Hospital and the physicians in Buffalo County. The team spoke to the office managers at the clinics in the area and gave them an overview of the Lunch & Look sessions that were being planned. These sessions were intended to bring health care providers together to learn more about the Living Well Program with the intention that their patients would be referred into the program. The office managers agreed to the plan and would accommodate the team on a mutually agreeable date. A four-panel display board was developed to showcase the Living Well Program. In addition, prescription pads were designed and printed. These pads were provided to primary care and specialist physicians and advanced practice registered nurses after they attended the Lunch & Look sessions, where they received additional print information to refer patients to the program. In the future, pads will be provided to ancillary health care providers. Another strategy involved e-mailing a promotional poster to recruit participants for the summer class, using an existing human services e-mail list. Additional promotional information and registration options were created. These materials included postcards that listed the spring, summer, and fall session schedules and included a place where personal contact information can be completed. The poster and postcards can be replicated, and information can be updated for future community awareness promotions. In Lancaster County, a presentation and promotional handouts were provided to 25 office managers by Lancaster County Medical Society (LCMS) to share information about upcoming workshops and contact information for referring patients. In addition, promotional materials were provided to more than 150 health care provider offices through LCMS member organizations. These materials included upcoming workshops and contact information. A promotional flyer was also included in the LCMS spring newsletter and was mailed to more than 100 mid-level health care providers and all internal medicine, family practice, and other specialist offices in Lancaster County. An ad was then created to include in the LCMS Health & Medical Journal, and an insert was placed in the local newspaper for physicians, which reaches 92,000 households. Finally, a television show segment about living well began airing on a local cable channel. The show included interviews with Living Well Program leaders, workshop participants, local physicians, and video clips of a workshop. During the Study phase of the PDSA cycle, the team reviewed the findings from the improvement theory. They determined that the improvement theory led to an increase in program enrollment in the two counties studied. In addition, Buffalo County, which is testing a referral process through Sentinel Health Care, was found to have a higher participant completion percentage than Lancaster County, which emphasized a media campaign to increase enrollment. Based on the findings, the team concluded that a combination of a media campaign and a referral system would lead to an increase in program enrollment. However, the team believes that a referral system is the most effective way to increase the number of individuals who successfully complete the program. The team plans on testing this theory further. During the Act phase of the PDSA cycle, the team plans to continue the process to determine the long-term effectiveness of the intervention. Lancaster County has recruited four health organizations that have agreed to participate in a referral system. Both counties would like to continue to monitor the number of individuals who successfully complete the programs and determine whether their participation was the result of a referral.

The team used various measures to evaluate the effectiveness of the QI initiative. The team used a pre-test/post-test evaluation design. The following measures were monitored during the QI initiative: • number of individuals who enroll in the program, • number of providers who are aware or who are made aware of the program in the future, • number of providers who participate in a referral system in the future (exactly who? how do they find out? estimate of people reached?), • number of referrals, and • number of individuals who successfully complete the program.