To promote development of one standard of care throughout the system, that is both evidence based and cost effective. DESCRIPTION OF PROGRAM/INTERVENTION: Description: An initial curriculum was developed based upon a survey of provider's interests and system needs identified by the quality management department. Prior to meetings planning committee reviews or creates disease specific standard indicators for appropriate measurement of guideline implementation. Monthly meetings consist of a lecture given by a recognized expert and a discussion of the perceived barriers to achieving that care in our institution. The indicators are then presented followed by a review of charts of identified patients with the discussed medical illness. Results of previous peer reviews are presented with a discussion of what could be done to improve them. Individualized provider specific feedback is distributed confidentially. FINDINGS TO DATE: Results: Re-measurement of disease specific indicators have shown significant increase in provider compliance with established standards of care: a 24% increase in the use of ACE-Inhibitors in CHF, a 45% of increase in screening for microalbuminuria in diabetics. Yet, some of the newer disease management knowledge, such as use of beta-blocker in patients with CHF showed no significant change. KEY LESSONS LEARNED: Key Lessons: A program that combines disease management and a continuing medical education involving self-evaluation through peer-reviews more effective to disseminate and implement system based clinical practice guidelines, also improves providers communication and involvement in those initiatives. identified and a multi-disciplinary team consisting of a hospital pharmacist, dietician and discharge planner visit and educate the patient and family. Standardized education materials are provided. The GHC home-visiting nurse service, called Family Health Workers(FHW) also visits the CHF Project patient while in hospital. At discharge, the hospital pharmacy provides an updated medication list to the patient, the FHW, the patient's pharmacy and the GHC electronic medical record. The same FHW visits the patient within 48 hours of discharge, and arranges for further follow-up as needed. FINDINGS TO DATE: [1] Over the first six months, the CHF Project has been well received by all. A crucial and well-appreciated role of the FHW is to sort out discharge medications at the initial home visit. [2] There have been a total of 174 CHF patient admissions, of which 57 belong to the GHC and were exposed to the intervention. [3] There has been a 68%, [95% confidence interval (CI) 9% ± 96%] decrease in readmission rates compared to historical controls and a non-significant 57% [95%CI -5 to 89%] decrease compared to concurrent non-GHC controls. [4] There has also been a non-significant trend towards decreased mortality. KEY LESSONS LEARNED: A community-based collaborative to help CHF patients in the crucial discharge transition period can be effective in a non-tertiary care setting. Further efforts are needed to expand access to the program for all patients, to study and improve upon separate components of the program and to sustain the improvements already achieved. (range 23 ± 87); 69% of patients were African American; 60% were Female; 58% had less than a high school education; over 50% relied on Medicaid or pharmacy assistance for medications. Average duration of disease was 10.4 years (range 0 ± 42). Although 81% of patient had hypercholesterolemia and 88% had hypertension, only 30% were on a lipid lowering agent and only 60% were on or had ever taken an ACE-inhibitor. Baseline HgbA1c at enrollment was 10.8% and did not differ significantly from values obtained 6-12 months prior to enrollment (mean 10.2%). At three to four months follow-up, the mean reduction in HgbA1c was 1.7% points (p < .0001).Baseline diabetes knowledge score on our 11 question diabetes knowledge test (DKT) averaged 36%. Of 69 patients who have retaken the DKT, there was a 23% point improvement from baseline to follow-up (p < .0001). Blood pressure and total cholesterol did not change importantly from baseline to follow-up. Multiple regression analysis shows that higher educational status, when adjusted for baseline HgbA1c, is associated with a significant improvement in HgbA1c. Other socioeconomic factors, such as race and gender were not significant predictors. KEY LESSONS LEARNED: A pharmacist-assisted care program can improve patient's knowledge of diabetes and significantly reduce HgbA1c. We did not see improvement in blood pressure or lipid control -two areas that we did not specifically intervene upon. To further improve care and reduce the risk of macrovascular complications, we plan to test pharmacistassisted, algorithm-based, hypertension and cholesterol management in a randomized controlled trial. STATEMENT OF PROBLEM OR QUESTION: Nursing staff in VA primary care clinics are required to document numerous patient education and screening activities, and they are using progressively more advanced software in the electronic patient record to accomplish this documentation. However, time limitations make it difficult to accomplish all these educational and screening mandates while the patient is in clinic, and staff may miss documenting activities which were previous accomplished but not quickly found in the record. OBJECTIVES OF PROGRAM/INTERVENTION: We experimented with the process by which nurses documented that patients were taught the proper use of metered dose inhalers (MDIs). We chose to update our electronic documentation of this activity (1) at a time other than the patient visit and (2) by using a population based approach. DESCRIPTION OF PROGRAM/INTERVENTION: At our facility, two teams of similar provider and support staff composition provide primary care in non-teaching clinics. Of the 6129 patients in group practice A, 640 use MDIs, and 572 of 5596 group practice B patients use MDIs. Information about this population of MDIs users was compiled, and their names and telephone numbers were listed in the chronological order of their next appointment. Starting in May 2000, clerks began calling each patient as their next appointment approached, in order to remind patients to obtain MDI instruction when they attended clinic. In group practice B, nurses also used the list during lulls in routine clinic screening activities to contact patients, ask them about prior MDI education, and then update the electronic record accordingly. Five months later, electronic documentation of MDI patient education was extracted from the computer patient database. Documentation data was also obtained about one education/ screening activity not targeted in this study (depression screening) because this activity applies to all group practice patients and are electronically documented in the same manner as MDI teaching. FINDINGS TO DATE: In group practice B, MDI inhaler education and depression screening were documented on 84% and 60% of the 572 MDI patients. In group practice A, the same percentages were 52% and 65% of their 640 MDI patients. Chi square comparisons were made of patients receiving only MDI instruction or MDI teaching and depression screening. In each comparison, group practice B performance was significantly (p < .05) higher. Logistic regression also showed that group practice B was associated with a higher likelihood of MDI teaching documentation (odds ratio 3.54, p < .001). KEY LESSONS LEARNED: As the number of routine patient education guidelines expands, there is not sufficient time during each clinic visit to complete and document them all.