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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: firstname.lastname@example.org 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 co-morbidities. 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% Self-management 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 Community 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 program. • 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 Directors 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 populations. 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 factors. 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 development. 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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