The San Francisco Department of Public Health’s Community Oriented Primary Care (COPC) network of 12 community based clinics serve a multicultural low income population, providing primary care services, social work support, health education and nutrition counseling to adults and children who are low-income and either uninsured or on public insurance such as Medi-Cal.  The patient population is multicultural and includes recent immigrants from Central and South America, Asia, and the former Soviet Union.  Many patients are monolingual in, Cantonese, Mandarin, Spanish, or Russian.   

The Division of Community Oriented Primary Care (COPC) has undertaken a project to develop and implement tools to track the quality of chronic disease care for the active patient panels of each of our Health Centers.  Examples of these chronic conditions are diabetes, asthma, cardiovascular disease, Hepatitis B and C, etc.  

After determining baseline performance with quality data reports, the COPC management and QI teams at each health center will lead efforts to improve care of these chronic conditions using innovative ideas from the IHI, HRSA’s Chronic Disease Collaboratives and other sources (examples: the chronic care model, the change model and clinic flow redesign).  Quality indicators will be measured and tracked over time using a recently chronic disease registry (i2iTracks Disease Registry).   

Four community-based clinics within COPC have already undertaken redesign of the delivery system for chronic conditions through participation in diabetes collaboratives that are based on the Chronic Care Model.  These clinics are developing new methods of patient self-management support and are implementing a disease registry in order to improve care. 

COPC is offering an AmeriCorps Educational Stipend Position, for a total of 450 hours of work between January 2008 through end of August 2008 (approximately 15 hrs /week). 

Responsibilities will be:

1. Working with Lisa Johnson, M.D. (Medical Director for Quality Improvement Projects, Community Primary Care, SFDPH) and Winnie Tse (Primary Care Data Analyst) on data collection and entry, and data reporting out of the i2iTracks Disease Registry.  Knowledge of Microsoft Word and Excel required.  Training in i2iTracks Registry use will occur on the job. 

2. Working with the Diabetes Care Improvement Teams at 2 clinics, under the supervision of the Medical Director of the Health Center, on chronic care quality improvement projects.  Duties may include:

·         Working with patients to provide health education / self-management support

·         Working with the diabetes registry to do population based outreach and interventions with diabetic patients

·         Become a member of the Health Center Diabetes Improvement Team including attendance at team meetings and participation in design and implementation of improvement activities.   

The placement site would be influenced by any language skills - Spanish, Cantonese, Mandarin or Russian would all be especially desirable although not required.