hdcls storyboard FHC of Boo

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					  Family Health
Family Health Center
Center of Boone
   Boone County
 Learning Session #2
  May 12-14, 2005
    Midwest Cluster
  Atlanta, Georgia
               Family Health Center of
                   Boone County
             “Health is 7 or Less”
• Located in Columbia, Missouri
• 3.9 MDs, 4.6 NPs + 11 Residents (FP & Med/Peds)
• Primary Care, Dental, & Behavioral Health Services
• Population Served (calendar year 2004)
  –6229 patients
  –519 patients diagnosed with diabetes
  –17 homeless patients
  55.6%   White                        1.2% Asian
  31.1%   Black                        0.3% American Indian/Alaskan Native
  7.1%    Unreported/Refused to Report 0.1% Other Pacific Islander
  4.5 %   Hispanic
             Health is 7 or Less
              Team Members
• Kathy Davenport – Team Leader
       573-886-6717       (kdavenport@fhcmo.org)
• Gloria Crull – CEO
• Kay Strom – COO
• Darren Stice – CFO/IT
• Sharon Carmignani – Medical Director
• Kerry Lewis – LPN
• Beth Geden – Provider Champion
• Craig Walden – LPN
• Cynthia Woodcock – Provider Champion
• Sophia Allen – LPN
• Brian Fischer – Dentist
Family Health Center will redesign its
 system to provide improved care for our
 patients with diabetes. We will
 accomplish this through implementation
 of the Care Model, with special
 emphasis on the collaborative
 development of a self management
 system with our patients. Improved care
 will be evidenced by the key measures.
                 Key Diabetes Measures
                     Measure                       Goal

Average HbA1c                                      < 7.0
Patients with 2 HbA1c’s in last year (at least 3   >90%
months apart)
Documentation of self-management goal setting      >70%

Cardiac Risk Reduction:
ACE inhibitors or ARB medication                   >75%
Patients with BP <130/80                           >40%
Patients with LDL<100                              >70%
If have integrated dental clinic:                  >70%
Dental exam in past year

Currently Testing:
• Nutritional Education Material for readability and patient
• Tracking Number of DNKA’S (did not keep appointments) by
  patients, sending dnka letter,and tracking patient response.
Implemented into our Delivery System:
• To decrease DNKA (Did not keep appointments) rates by
  implementing DNKA policy and DNKA letter.

Currently Testing:
• Opportunities with additional insurance companies to
  see their patients.

Implemented into our Delivery System
• Discussions with Mercy Health Plan and Health Link
  insurance companies.
• Contracts with Blue Cross /Blue Shield and United
  Health Care.
         Healthcare Organization

Currently Testing:
• Using University of Missouri Student volunteers to
  assist with testing Nutritional Educational materials
  for readability and patient interpretation.
Implemented into our Delivery System:
• UMC Student here every Thursday from 10 a.m. to 3
                Decision Support

Currently testing:

Implemented into Delivery System:
      Clinical Information System

Currently Testing:

Implemented into Delivery System:
         Delivery System Design

Currently Testing:
• Revisions of forms

Implemented into Delivery System:
• Implemented new patient-friendly medication sheet
  throughout entire population of focus.
          Functional and Clinical Outcomes

Measures                             Goal   as of 03/27/05
• 2 HbA1cs in last yr                >90%          37.2%
• Average HbA1c                      <7.0          8.2
• Documented self                    >70%          16.0%
      management goal setting
• BP < 135/85                        >70%         43.4%
• ACE inhibitor for pt over age 55   >75%         70.6%
• Dental exam in past year           >70%         25%
• REGISTRY SIZE                      >104         94
                Senior Leadership
                 Making the Case for Change

• Diabetes Registry Summary Report was shared with the
  Quality Improvement Committee of the Board of
  Directors, Administrative Staff, Provider Staff and Nursing
• Health Disparities Collaborative Chronic Care Model has
  been made an agenda item for every scheduled meeting
  throughout the entire organization.
• Storyboard has been posted in the employee breakroom
  and patient waiting area.
          Communication Plan

• At the center level: Health Disparities Collaborative
  Chronic Care Model has been made an agenda item for
  every scheduled meeting throughout the entire
         Anticipating Barriers and Issues

  Those that the team               Those that leadership
     can resolve:                     needs to address:
• Obtaining the patient’s buy-   • Adequate time allocation for
  in to set self-management        participating staff.
  goals                          • Resources for Diabetic
• Distribution of team             Education (CDE & Materials)
  responsibilities.              • Setting the stage for clinic
• Additional education for         wide adoption.
    A story to share….the patient

A patient of one of our Provider Champions became ill
and had to go to the hospital Emergency Room. She took
with her the patient-friendly medication record that had
been completed and explained during her clinic visit.
She reported that the Emergency Room staff was able to
treat her appropriately and more quickly because of
having this record.
      A story to share….our staff

Team members, Sophia Allen and Craig Walden, have
developed their role as care partners and have become
more proactive in getting patients to return to the clinic
for scheduled clinic visits. They have used the telephone
and mailed the patients letters.
 A story to share….the organization

Placing the storyboard in the employee breakroom
created opportunities for non-participating staff to learn
about the Health Disparities activities. Increased pride
in our organization for being involved in national quality
improvement efforts.

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