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									Cluster: WCC

      Glacier Community
      Health Center, Inc.

          Learning Session #2
           May 12-14, 2005
           Atlanta, Georgia
Glacier Community Health Center, Inc.
• Cut Bank, Montana
• Three providers, total of 12 staff members
• Opened February 23, 2004
• Population Served
  –85 Patients Diagnosed with diabetes
  –82% White (of which 4% are Hutterite)
  –16% Native American
  – 2% Other
                        Team Members
Name                     Title                      Role on Team
John J. Maher            Executive Director         Senior Leader
Peter D. Barran, MD      Medical Director           Physician Champion
Linda Hanson, PA-C       Physician Assistant        Clinical Expert
Denise Greenwood         Registered Nurse           Clinical/Tech Expert
Phyllis Harne            Licenced Practical Nurse   Clinical/Tech Expert
Betsy Seglem             Special Projects Coord.    Day-to-Day Leader

  Team Leader Contact    Email: bseglem@theglobal.net
                         Telephone: 406-873-5670
          AIM Statement

Glacier CHC will create a model of
 patient care, using the chronic care
 models as identified by evidence-based
 medicine to improve treatment to our
 patients with diabetes and associated
                       Selected Measures
National Key Measure                                                Goal
1. Average HbA1c                                                    < 7.0

2. Patients with 2 HbA1c’s in last year (at least 3 months apart)   > 90%

3. Documentation of self-management goal setting                    >70%

4. Cardiac Risk Reduction:
       ACE inhibitors or ARB medication                             >75%

5. Patients with BP <130/80                                         >40%

6. Patients with LDL<100                                            >70%

7. Patients with dilated eye exam in last 12 months.                >70%
Currently Testing:
• Patients’ knowledge of their diabetic diet and daily self-
  management assessments.

Implemented into our Delivery System:
• Flash cards of diabetic meal plans
• Diabetic self-management booklet
• Reinforcement of daily foot exam
Currently Testing:
• The effectiveness of our marketing efforts, depending on the
  outcome of our high risk screening clinic.

Implemented into our Delivery System
• Built relationship with Pharmacy Program at the University of
  Montana who provide components of our high risk screening
• Partners with local pharmacist.
• Partners with registered dietician at the local medical facility.
          Healthcare Organization
Currently Testing:
• Training program for all employees on the collaborative model
• Amount of Collaborative information required by Board of

Implemented into our Delivery System:
• Care Model and Model for Improvement part of our quality
  improvement program
• Collaborative report submitted to Board of Directors on
  quarterly basis.
                  Decision Support
Currently testing:
• Standing orders for labs and referrals are used by nursing staff
  according to the guidelines of evidence-based medicine.

Implemented into Delivery System:
• Routinely provide interactive education programs for all staff
  including case studies
• Use evidence-based medicine guides to embed guidelines for
  medication and treatment into daily practice
• Established criteria for referral of patients to specialists and
  assure that providers have access to expert support from
  specialists for consultation
        Clinical Information System
Currently Testing:
• Easy access for providers to obtain clinical information from the
  registry. Computers with access to network placed in provider
  work stations.
Implemented into Delivery System:
• Sticker on the chart flags patients in our registry.
• Front office staff creates appropriate encounter form and places
  on chart with large green clip.
• Nursing staff notes current patient information on form. Then
  provider updates objective findings of patient.
• This information is then entered into the PECS system which is
  used to track, report and communicate results and outcomes of
  care effectiveness over time and across providers and
           Delivery System Design
Currently Testing:
• Assure that appointment systems support the needs of our
  patients including: initial screening activities and referral to
  outside providers.

Implemented into Delivery System:
• Primary Care Patient Care Teams made up of provider, nurse
  and medical assistant. Using team huddle prior to start of
  session for planned patient interventions.
          Functional and Clinical Outcomes

Measures                             Goal   as of 4/15/2005
• 2 HbA1cs in last yr                >90%          0%
• 1 HbA1c in last yr                               58%
• Average HbA1c                      <7.0          7.9
• Documented self                    >70%          ----
      management goal setting
• BP < 130/80                        >70%        19%
• ACE inhibitor for pt over age 55   >75%        55%
• Dental exam in past year           >70%        ----
• REGISTRY SIZE                      110         85
National Key Measures
National Key Measures
Additional Key Measures
Additional Key Measures
Additional Key Measures
Additional Key Measures
                  Senior Leadership
                   Making the Case for Change

• What information did you share with your ED/CEO and/or
  Board of Directors to encourage them to make
  improvements in the management of Diabetes?
   – The Senior Leader has talked to the Board of Directors about the
     Program, providing optimal care and evidence-based medicine to
     our diabetic care.
   – The Board of Directors has agreed to support the Collaborative in
     every way possible.
• How did you promote the work?
   – Talked with community members and Board members, describing
     our statistics and identifying the patients in our clinic who are at
     risk due to their chronic illness of diabetes.
         Communication Plan
• At the Center level:
   – Encounter forms provide communication between
     patients, front desk staff and providers.
   – Monthly reports to staff indicate progress.
   – Quarterly reports to Board of Directors demonstrate
     competency and the quality of our program.
At the Community level:
   – Newspaper article about the diabetes program
   – Invitation to registered diabetic patients to participate in
     the first organized testing session for individual risk
         Anticipating Barriers and Issues
  Those that the team             Those that leadership
     can resolve:                   needs to address:
• Determine appropriate staff   • Communication
  responsibilities              • Community resources and
• Additional education for        partnerships
  new staff                     • Coordination of outside
• Patients unable to afford       resources to provide low cost
  necessary equipment/            screening for CHC diabetic
  medications to achieve          patients.
  optimal diabetic control.     • Acquisition of screening
                                  equipment and professional
     A story to share….the patient

       “I have diabetes and I’m on pump therapy.
The staff is able to help me handle my diabetes questions,
 problems, and keeps track of possible complications. If
      they don’t know the answers to my questions
 right away, they have resources available to them that
                      will help in my care.”

                                             Kathy Carpenter
                                              GCHC Patient
        A story to share….our staff
“Linda Hanson PA-C went over a written „Foot Exam for Diabetic
Patients‟ document with our clinic‟s nursing staff. Soon after, we
had a very nice older diabetic gentleman patient who agreed to let
Phyllis Harne LPN, Denise Greenwood RN, and me sit in on a foot
screening. Linda encouraged us to do them on all our diabetic
patients. Since they usually sit in one of the chairs, as opposed to
the exam table, after I get done taking their vitals I have them take
off their shoes and socks. I then ask them all the necessary
questions and record all their answers and findings on the
screening sheet. I think that the benefit of our doing this exam
periodically is the patients will be more aware of the importance of
checking their feet and will know that we are truly interested in
their diabetic care.”
                                              Karen Schwartz, CNA
A story to share….the organization

 A recent local newspaper article gave our
 clinic top billing as a comprehensive class
           act for diabetic patients.
As a result, our established diabetic patients
have been excited about the screening tools
that are now implemented into their routine
                  care visits.

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