1. Benton Community Health Center January 2008 Benton Community Health Center  Total Number of Sites – 4  Initial Condition of Focus – Diabetes  Number of Sites Tracking Initial Conditions – 3  Current Registry Size for Initial Condition – 120 (approx.)  Additional Conditions – Vascular Disease  Number of Sites Tracking Additional Conditions – 1  Current Registry Sizes for Additional Conditions – None

2. Benton Community Health Center - Corvallis, Oregon January 2008 Benton Community Health Center Initial Condition Team Members: Bev Kirch, RN W. Scott Williams, MD Margie Pridgen, RMA Kathy Simonson, IT Additional Conditions Team Members: Stacy Ramirez, PharmD (Oregon State University College of Pharmacy) Benton County Public Health Key Leader Contact Information: Bev Kirch, RN (541) 766-6290 Bev.kirch@co.benton.or.us

3. Benton Community Health Center - Corvallis, Oregon January 2008 Benton Community Health Center Self-Management Plan: 6 month involvement with Oregon State University College of Pharmacy students Goal: All Community Health Center patients will have assessment Identify: All Community Health Center patients with A1C greater than 9. Refer to Living Well classes Improve Measure: In development stage. Waiting for results from one on one appointment with pharmacy students

4. Benton Community Health Center - Corvallis, Oregon January 2008 Benton Community Health Center Measure of your Choice Continue to track patients to reach goal of 7.0. Current average is 7.3 Offer planned laboratory visits to patients with no A1C in the last 6 months on a continual basis Continue to use PECs delivery system to see actual changes Implementation of electronic medical records to discontinue double entry

5. Benton Community Health Center - Corvallis, Oregon January 2008 Benton Community Health Center Plans for the Future  Continue with the care model  Continue care team approach  Identify resources to benefit Community Health Center patients  Use electronic medical records for reminder  Implement care model at other Community Health Center sites  Expand on teaching materials  Continue collaboration with OSU pharmacy student

6. Benton Community Health Center - Corvallis, Oregon January 2008 Benton Community Health Center Greater Learning Community Input Integration with Benton County Public Health for a focus on health promotions Identify patients that need help to work through the system. Guiding them to wellness classes such as:  Meals made easy  Exercise classes  Living well  Community resources

7. Benton Community Health Center - Corvallis, Oregon January 2008 Benton Community Health Center Success Story At the Benton Community Health Center we have increased our level of patient education, implemented the registry, provided training to all providers and support staff and we have a good standard of care. We are working in collaboration with Oregon State University College of Pharmacy student, Benton County Public Health and additional Community Health Center clinics. We are using the Chronic Care model as a vehicle for quality improvement.