In the 1990s, the Health Resources and Services Administration's (HRSA's) Bureau of Primary Health Care (BPHC) created and began implementing the Health Disparities Collaborative (HDC). The HDC is an innovative, data-driven, public health partnership that has improved care for chronic diseases through improved health care delivery systems among the nation's network of providers that serve the uninsured and underinsured (3). The HDC was formed "to improve access to high quality, culturally and linguistically competent primary and preventive care for underserved, uninsured, and underinsured Americans" (4). The HDC pools health care resources and services at state, local, and community levels in order to deliver them with increased effectiveness and efficiency to FQHCs (3).

Federally Qualified Health Centers (FQHCs) traditionally are the point of contact with providers that deliver direct service to medically underserved and poor patient populations (5). To further maximize resources and services, the chronic care model (CCM) is used to systematically improve the care provided at FQHCs (6).

The CCM identifies essential elements of the health care system for providers to focus on and use to organize and encourage high-quality chronic disease care (7). According to the CCM, six components are required to produce interactions between an informed, activated patient and a prepared, proactive multidisciplinary team: 1) organizing patient health care; 2) forming community linkages; 3) encouraging self-management support; 4) maximizing delivery system designs for efficiency; 5) providing patient decision support; and 6) providing improved patient information-sharing systems (4). This model can be applied and implemented in clinical settings for various chronic illnesses and is credited with generating healthier patients, more satisfied providers, and cost savings (7).

With support from HRSA and the BPHC, the Institute for Healthcare Improvement has provided education and training to FQHCs for adoption and use of the CCM. The HDC uses the CCM to focus on several chronic diseases, including cardiovascular disease, depression, asthma, cancer, and diabetes. The HDC has also used the model to address combinations of chronic diseases simultaneously (8).

The diabetes section of the HDC focuses on improving diabetes and pre-diabetes performance measures through improved care delivery systems, increased access, and decreased health disparities among medically underserved populations (8). Of interest for this article is the HDC's use of the CCM as it relates to diabetes treatment and prevention of complications in patients with diabetes who use FQHCs.

The Division of Diabetes Translation at the Centers for Disease Control and Prevention (CDC) and HRSA share a common goal in treating and preventing diabetes. The agencies have been working as partners through the HDC since 1999. The Division of Diabetes Translation funds 59 Diabetes Prevention and Control Programs (DPCPs) in all 50 states, the District of Columbia, and U.S. territories. These programs are required through cooperative agreements with the Division of Diabetes Translation to address health disparities among people living with diabetes (9). HRSA funds direct services; CDC does not. CDC programs are designed to leverage resources to treat and prevent diabetes and its complications. Both HRSA and CDC share the goals of improving the quality of care and the quality of life of patients with diabetes. The DPCPs are encouraged to join the HDC Diabetes Collaborative (Collaborative) and to share resources with FQHCs to boost collective reach and goal attainment. A conceptual model of this relationship is shown in the Figure.

In 2005, the Diabetes Council of the Association of State and Territorial Chronic Disease Program Directors conducted an evaluation to help the organization understand DPCP perceptions about the nature and value of contributions made by the Diabetes Council to FQHCs. They also examined the impact that the Collaborative experience had on aspects of diabetes care as practiced by the FQHCs using the CCM.

The survey targeted all 59 DPCP coordinators and consisted of 36 items presented in five sections that queried DPCP coordinators about 1) their roles and experience as participants in the Collaborative; 2) the skills and expertise that were most useful in developing and maintaining an effective collaboration for improved diabetes health care; 3) which DPCP contributions they viewed as routine and which they viewed as essential; 4) the effect of DPCP contributions on components of the CCM used by FQHCs to make health systems improvements; and 5) which health systems improvements enhanced the principal CCM components.

The survey items varied in format (e.g., multiple-choice questions, rating scales with multiple selection matrices, open-ended text responses). Section one explained that participation was voluntary, that the survey would take less than 30 minutes, and that participation would be interpreted as consent to use the data provided in aggregate with other respondents. Respondents were assured of confidentiality, and individual identifiers were required to ensure adequate follow-up.

Section two asked about the respondents' roles with the Collaborative and their number of years of involvement. Sections three and four pertained to the resources, skills, and expertise needed to develop and maintain Collaborative partnerships between DPCPs and FQHCs. Section five dealt with an assessment of DPCP contributions and health systems improvements in relation to the CCM. There were measurements for the benefits and drawbacks of partnering and for indications of needed patient care improvement.

The survey was drafted and pilot-tested on six people who had previous experience with the Collaborative, were no longer actively involved, and would not participate in future data collection. Revisions were made based on feedback from the pilot test.

The revised survey was forwarded by e-mail to all DPCP coordinators. At each DPCP, the coordinator was instructed to ask the person on staff with the most involvement in the Collaborative to complete and return the survey. Respondents were given 21 days to complete the survey and were sent an e-mail reminder before the closing date. To improve the response rate, the due date was extended approximately 2 weeks.

Forty-eight (81%) of the 59 DPCP coordinators surveyed responded to the questionnaire. Eight of the respondents reported that they had not yet participated in the Collaborative and were not included in the analysis. Seventy-five percent of the remaining respondents had participated in the Collaborative for at least 3 years, and 19% had been involved for more than 5 years. When provided a list of options for reporting their primary roles and given the opportunity to "select all that apply," the most frequently selected choices were program liaison or DPCP coordinator (59%), diabetes educational support (54%), and technical assistant (52%). Less commonly identified were quality improvement support (36%) and health systems support (33%).

Respondents were asked to rank DPCP organizational skills (e.g., communication, leadership, conflict resolution, negotiation, meeting management) and technical expertise (e.g., the ability to access community resources and knowledge about quality-improvement methodology, diabetes patient education, data analysis, diabetes clinical care, information management) in terms of their importance for developing and maintaining partnerships with FQHCs. Many organizational skills were perceived as being important, but communications and leadership were ranked as being most useful in developing and maintaining a solid collaboration. The technical expertise area identified as most important to developing and maintaining the Collaborative was the ability to assess community resources. Organizational skills and technical expertise items were identified, and respondents were asked to indicate if a skill or expertise was needed to develop or to maintain Collaborative partnerships. No statistical differences (according to 95% confidence intervals) were shown to indicate different skills were needed to develop versus maintain partnerships (Table 1).

DPCP respondents were asked to rate the contributions they made to the Collaborative as being routine or essential. Linkages to community resources, educational materials, training, clinical staff exposure to other diabetes partners, technical assistance with clinical care, and technical assistance with patient education were most commonly identified as being essential contributions. These and other DPCP contributions are presented in Table 2.

Respondents were asked whether contributions affected each component of the CCM (e.g., self-management support, decision support, clinical information systems, delivery systems design, organization of health care, links to community resources). They were instructed to select all components affected by each contribution. DPCP coordinators reported self-management support as the CCM component most commonly affected by DPCP contributions.

As shown in Table 3, the greatest contributions to CCM components were in the areas of technical assistance with patient education, educational materials, financial resources, training, and linkages to community resources.

Respondents were also asked to indicate whether DPCP contributions affected the implementation of health systems improvements for each of the six CCM components. The health systems improvements that played a role in enhancing CCM components are presented in Table 4. Respondents indicated that use of clinical data to monitor indicators was the most common health systems improvement resulting from the DPCP partnership and that data sharing was another common improvement with more than 20% of respondents indicating that data sharing affected each of the six CCM components. Respondents were also asked to indicate which CCM components were supported by each health systems improvement. The CCM component most affected was patient self-management support; more than 15% of respondents checked this column (data not shown).