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					      Making the Montefiore Medical Group
      Health Disparities Collaborative Work
          at Montefiore Medical Center

                           The MMG HDC Team

                                 Bronx CREED
                               September 30, 2005


In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
    This is NOT ―Zach‘s Diabetes Thing‖
   Coordinated effort on the part of a lot of folks.
   This afternoon:
    •    Eleanor Larrier Introduction
    •    Me Introduction
    •    Nandini Deb: Clinical Information Systems
    •    Jennifer Klein: Diabetes Education
    •    CFCC: Judy Leuchter, Peer Educators
    •    FHC: April Evangelista, Health Ed PDSA
    •    WB:      Sean Misciagna, M.D., FM Resident
    •    Nutrition: Helen Persovsky


     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
―We don‘t just talk about reducing health
             disparities . .

                               we reduce ‗em!‖




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
             So . . .
how do we reduce health disparities?


      ‗THE COLLABORATIVE MODEL‖


            What‘s so great about that model?



In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
               OLD QI METHODOLOGY

   ―Swoop and Poop‖



 Do everything to everyone all at once.
 Punish whoever doesn‘t have good scores.
 Create simplistic and token responses to
  real problems.


    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                  REAL PROBLEM

   Health care worker lack of comprehensive
    understanding of the dimensions of pain,
    pain control, addiction, emotional response
    to pain and end of life issues, etc.

   Patients feel too much pain in the hospital,
    report being ignored, addicts turned away
    from pain treatments, etc.


     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
   THE ―SOLUTION‖ TO THESE COMPLEX
     AND MULTIDIMENSIONAL, REAL
              PROBLEMS:




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
    Collaborative Philosophy and Method
 Fix what is wrong, help clean the mess
  yourself.
 Tests of change on small populations, then
  ―SPREAD‖ to everyone - GRADUALLY
 Realize that making mistakes is part of the
  process. Without mistakes no one learns.
 Share senselessly, steal shamelessly




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                               Chronic Care Model

   Can be applied to all chronic conditions:
    •    Asthma
    •    Depression
    •    Hypertension
    •    Coronary Artery Disease
    •    HIV
    •    Diabetes
    •    Domestic Violence
    •    Emergency Preparedness

     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Six Elements of the Chronic Care Model
   Medical Information Systems
    • the registry
    • populated progress note
   Self-Management (e.g., classes, health educators)
   Community (e.g., salsa classes)
   Delivery Systems Design (e.g., planned visit)
   Decision support (listserv guidelines)
   Organization of Health Care (spread to MMC)



    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                                  PDSA
 Plan, Do, Study, Act
 Disciplined, results oriented method of
  group discussion.
 Topic tracking and adherence.
 Track progress.
 Learn from failures.
 Over and over and over and over again.



In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
            Collaborative Sponsorships
           of Montefiore Medical Group
    • Bureau of Primary Healthcare/National
      Collaborative
    • New York City Department of Health:
      Spread Collaborative
    • Academic Chronic Care Collaborative
      (ACCC by American Association of
      Medical Colleges)



In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                            What is the National
                           Diabetes Collaborative?



   Made up of                                                                                                              Northeast
                                                                                                                            Cluster
hundreds of health
 centers from all
 over the country




   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
That‘s all very special, so tell me, how
 do you get collaborative stuff going?
   Get blessed.
      • Great leaders, great support, wonderful energy, motivated people.
      • Where do they come from?
      • We pick them out.

   Do something good with no money. Then write about it
    and present it to everyone every chance you have.
   Get money. ―Salvador Dali: With Gold You Get Gold.‖
   Get going. Getting going is easy, thinking about getting
    going is hard.
   Keep going (THE VERY HARDEST PART!)

    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
               What were goals in first year
                    for MMG HDC?
1.       Identify successes of FHC.
2.       Spread to CHCC, CFCC and WB in
         Diabetes
3.       Establish working teams.
4.       Determine key measures for all sites.
5.       Establish uniform/compatible data
         collection system for registry.
6.       Identify key measures needing
         improvement and begin interventions.

     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                Goal #1
Spread to CHCC, CFCC and WB in Diabetes




 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                 Public Health Law.
Montefiore Medical Group Health
Disparities Collaborative



                                       Montefiore Medical Group
                                      Health Disparities Collaborative




                                                                                                                  WB
                                                                                                               (non 330)
                                                                                                                  DM
         FHC                                                CHCC                                               CFCC
         (DM)                                               (DM)                                                (DM)




                 Bronx Community Health Network Sites
    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                                    Goal 2.0

   Create centralized working group/leadership
    team:
    •    Facilitate, supervise, train, develop the sites.
    •    Coordinate allocation of resources.
    •    Plan for future
    •    Communicate with larger Collaborative
         organizations.




     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
              Montefiore Medical Group:
             Health Disparities Collaborative
                    Senior Leadership
   Jon Swartz, M.D., Senior Leader
   Arnel Tirado, Senior Leader
   Victoria Gorski, Senior (Academic Leader)
   Jennifer Klein, Director, Health Education
   Nandini Deb, Information Specialist
   Arthur Blank, PhD
   Eleanor Larrier and Celia Alfalla, M.D., Bronx
    Community Health Network
   Rita Louard, M.D., Joel Zonszein, M.D., Endocrine
   Clyde Schecter, M.D., Research
   Helen Persovsky, Nutritionist
   Zach Rosen, M.D., Project Director

    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
              Bronx Defeat Diabetes Project
                       (BDDP)

   Bronx Community Health Network
    (Eleanor Larrier and Celia Alfalla)
    • Obtained $3 M grant/3 years for community
      based initiatives – Diabetes Educators, Peer
      Educators, Diabetes Training, Specialty Care,
      etc.




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                             Goal #2.1
                     Establish working teams.




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
                                 MMG HDC
                                Multidisciplinary
                                 Work Teams
               •Administrative Director
               •Medical Director
               •Physician Champion
               •Nurse or Nurse Manager
               •Diabetes Educator
               •Peer Educator



In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
        Montefiore Family Health Center
            The Bronx Diabeaters:

                                 Ibis Castro, Health
                                  Educator, MFHC
                                 Jose Delgado, Associate
                                  Director, MFHC
                                 Wayne Joseph, MD,
                                  Attending, MFHC
                                 Zach Rosen, MD, Medical
                                  Director, MFHC
                                 April Evangelista,
                                  Diabetes Educator


In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
      Williamsbridge Family Health Center
              ―The Sugarbusters‖
  •    Sandra Barnaby, R.N.                                                     Staff Nurse
  •    Noel Brown, M.D.                                                         Medical Director
  •    Joanne Dempster, M.D.                                                    Team Leader
  •    Blanche Doati                                                            Associate Director
  •    Victoria Gorski, M.D.                                                    Academic Leader
  •    Danette Ortiz                                                            Front desk supervisor
                                                                                (day-to-day leader)


In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
           Comprehensive Family Care Center
                      (CFCC)

   Medical Director                                         Marta Rico, MD
   Physician Champion                                       Chris Meserve, MD
   Team Leader                                              Carol Lau, FNP, Associate                                  Director
   Team Members                                       Carmen CintronLopez, Assistant Administrator
                                                       Joanna White, Administrative Nurse Manager
                                                       Judy Leuchter, Health Education Manager
                                                       Bobbie Jamison, Health Educator
                                                       Jennifer Sanchez, PECS data entry
                                                       Estelle Vargas, LCSW




      In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                           CHCC Team


 Joe Deluca, M.D., Team Leader and
  Physician Champion
 Jennifer Santiago-Rivera Health Educator
 Donna Wade, Nurse Manager
 Erwin Duran, Data Entry
 Carmen Guerra , Nurse




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                         Goal #3:
              Determine key measures for all sites.




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
Goal                                         Shared Core Measures
<8%              Average HgbA1c
70%              % of patients with BP< or = 130/80
70%              % of patients with an LDL <100
90%              % of patients who have had pneumococcal vaccine
90%              % of patients with documented LEAP foot exam in
                 the past 12 months
(90%             % of patients receiving annual flu shots)
90%              % patients on aspirin (or other anti-coagulant)
70%              Signed self management contract in chart


In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                       Other measures

 Smoking
 Passive smoking (asthmatics)
 Nutrition
 Exercise
...




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                         Goal #4
              Establish uniform/compatible
            data collection system - Registry




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
                                  Goal #5
                           Identify key measures
                           needing improvement
                             and begin PDSA‘s




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
FHC: Percent of DM Patients with Pneumococcal Vaccine
                     (10 years)
 PDSA




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                        FOOT EXAM PDSA (s)
1.    From registry get print out of all charts
      without pneumovax.
2.    Pull charts and have provider review
      (some charts didn‘t have it recorded but
      had pneumovax given).
3.    Put yellow stickies in charts without
      pneumovax.
4.    Combine fluvax and pneumovax forms.
5.    Etc. etc. etc.

     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
So where’s the data?


In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                     DM Collaborative: Key Measures By Site
                             May 2004 – May 2005


          Number                                                                      % Patients                                            % DM
                                                                          % Patients             % Patients % Patients
             of      % Patients  Average % Patients % Patients                            with                                             Patients
                                                               % Patients with LEAP                with Flu  with Retinal
          Patients   with HbA1c HbA1c for with BP <=   with                          Pneumoccoc                                            with SM
                                                               on Aspirin exam (12               Vaccine (12 Exam (12
          with 1+        < 8.0  DM Patients 130/80   LDL<100                          al vaccine                                           Goal (12
                                                                           months)                months)     months)
 Clinic    visits                                                                       (ever)*                                            months)
          ACTIVE                                                                      ACTIVE
                      ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.                     ACTIVE PT.    ACTIVE PT. ACTIVE PT. ACTIVE PT.
            PT.                                                                         PT.
FHC        760           60%          7.9         56%         54%          53%         60%          78%           40%          28%           33%
CFCC       191           64%          7.8         47%         66%          59%         35%          54%           18%          31%           47%
CHCC       273           64%          7.7         65%         57%          59%         38%          54%           35%          22%           15%
WB         606           61%          8.0         46%         50%          38%         32%          69%           19%          22%           8%

TOTAL 1830              61%           7.9         53%         54%         50%         45%          69%           30%          25%           23%

       Goal             70%           6.5         70%         70%         70%         90%          90%           70%          70%           70%



  Note: Data from FHC and WB are for patients with Pneumococcal
  Vaccine in the past 10 years
           In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
            FHC: Number of Patients in Registry




                     as of Quality Council, this 1, 2005
Latest Data Montefiore September information is provided under Section 2805-m of the New York
  In response to the
                                         Public Health Law.
                FHC: Average HbA1c for DM Patients




Latest Data as of September 1, 2005

  In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
  FHC: Percent of DM Patients with One HbA1c (12
                    months)




Latest Data as of September 1, 2005

  In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
 FHC: Percent of DM Patients with Last HbA1c >=9.5




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
     FHC: Percent of DM Patients with BP <=130/80




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
 FHC: Percent of DM Patients with LDL <100 (of DM
            patients with Lipid Screen)




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM patients with SM Goal (12 months)




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
  FHC: Percent of DM Patients with Daily Aspirin Use




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
   FHC: Percent of DM Patients with Foot Exam (12
                     months)




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
  FHC: Percent of DM Patients with Retinal Exam (12
                     months)




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Microalbumin Screen
                    (12 months)




Latest Data as of September 1, 2005

   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                  Moving Forward:
           Goals for MMG HDC Diabetes
      ABC‘s improvement.
      Selected Targeted Population Parameters
       for MMG HDC (e.g. self-management
       scores)
      Selected Targeted Population Parameters
       by site (e.g. LEAP at FHC)
      Incorporation of MIS into MMC CIS
      Monte Home Care Collaboration
      Build on Peer and Health Educator gains.

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                Clinical Information Systems




                                                            DM Collaborative Core Team:
                                                                 Dr. Jon Swartz, Dr. Zach Rosen,
                                                                 Arthur Blank, Jennifer Klein
                                                                 and Nandini Deb
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                            Public Health Law.
                                CIS currently used:
   CVDEMS
     - Cardiovascular and Diabetic Electronic
     Management System
     - Microsoft Access Based Program

   PECS
      - Patient Electronic Care System
      - Microsoft Access Based Program



    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
 Montefiore Medical Group
 Health Disparities Collaborative


                                Montefiore Medical Group
                              Health Disparities Collaborative



          FHC                          CHCC                           CFCC                            WB




    CVDEMS
                                       PECS
                                                                      PECS
                                                                                                  CVDEMS
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
               CVDEMS Data Capturing
               Process: FHC AS MODEL



Data Collection:
   At each visit, Nurses print out CVDEMS form with last
    encounter data and demographic information of the
    patient

   Providers update form at current visit—CVDEMS
    form gets into chart

   EHIT generates weekly encounter list at FHC
    (~100/week)
    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                 CVDEMS Form




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
        CVDEMS Data Capturing Contd.
Data Monitoring
   Semi-annual generation of list of all patients with no visits
    in the last 6 months, given to Health Educators for
    outreach

   Annual pruning of patients with no visits in the past year
    (after outreach attempted)

   Bi-yearly reassignment of Providers/matching Providers
    with patients

   Data quality checks—random sample of 5% charts
    reviewed to assess validity, reliability and completeness of
    data

     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
          automatic lab Data Capturing Contd.
Bi-weekly CVDEMSdata transfer to CVDEMS and
   PECS for FHC, WB, CFCC and CHCC:


   Tuesday: Program identifies all patients who had labs
    done in the last two weeks


   Wednesday: Program dumps all labs for the identified
    patients


   Wednesday: Lab results are sent back to the sites



     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                    Monthly Reports


   Monthly report generation:


           - Registry Summary Report


           - Provider Report



    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                Registry Summary Report




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                  Provider Report




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                 Key Measures by Site



            Number                                                                           % Patients                                          % DM
                                                                                 % Patients             % Patients % Patients
               of        % Patients  Average    % Patients % Patients                            with                                           Patients
                                                                      % Patients with LEAP                with Flu  with Retinal
            Patients     with HbA1c HbA1c for with BP <=      with                          Pneumoccoc                                          with SM
                                                                      on Aspirin exam (12               Vaccine (12 Exam (12
            with 1+          < 8.0  DM Patients  130/80    LDL<100                           al vaccine                                         Goal (12
                                                                                  months)                months)     months)
 Clinic      visits                                                                            (ever)*                                          months)
             ACTIVE                                                                       ACTIVE
                         ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.                      ACTIVE PT.    ACTIVE PT. ACTIVE PT. ACTIVE PT.
               PT.                                                                          PT.
FHC           760           60%           7.9         56%         54%         53%          60%          78%          40%           28%           33%
CFCC          191           64%           7.8         47%         66%         59%          35%          54%          18%           31%           47%
CHCC          273           64%           7.7         65%         57%         59%          38%          54%          35%           22%           15%
WB            606           61%           8.0         46%         50%         38%          32%          69%          19%           22%           8%

TOTAL 1830                  61%           7.9        53%          54%         50%         45%          69%           30%          25%           23%

       Goal                 70%           6.5        70%         70%          70%         90%          90%           70%          70%           70%



 Reporting Period: May 2004-May 2005
          In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                      Our Persistent Challenges
   CVDEMS and PECS rigidities

   CVDEMS forms not completely filled out

   Problems due to manual data entry

   Resource constraints at the sites

   System crashes—very painful!




     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                          Our Successes


   Structured monitoring of data

   Automatic lab data transfer for all the
    sites

   Monthly Reports for FHC, WB, CFCC
    and CHCC


     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                         Our Plans for the Future
   Montefiore CIS system with Provider entry of
    data

   Chronic Disease Management Screen—with
    capabilities to present the entire history of the
    patient.

   How to use this data repository to ask research
    questions?


     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                Acknowledgements

   Each and everybody who has worked and currently
    working with the DM Collaborative

   Special thanks to Jasmine Smith, Erwin Duran and
    Jennifer Sanchez — our data support personnel

   Nadav Tanners (Having fun at Yale!)

   Yan Chai — DFSM Data Manager



     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                 SELF-MANAGEMENT




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                      Patient Self-Management

   Patients already self manage
    • All patients make decisions and engage in
      behaviors that affect their health.
    • They are in control.
    • They decide on what health behaviors they will
      or will not engage in.




     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
        Traditional vs Collaborative Care

   Provider as expert                                                     Shared expertise
   Provider is principle                                                  Shared responsibility
    caregiver and problem solver
   Provider gives instructions to
                                    Patient sets goals
    be complied with
   Behavior is externally                                                 Internal Motivation
    motivated
   Provider identifies                                                    Patient identifies the
    problem                                                                 problem
   Provider solves                                                        Patient is taught
    problems                                                                problem solving skills

     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                 Self-Management Education

 Based on Self Efficacy Theory (Self
  Confidence)
 Emphasizes
    • Problem Solving
    • Decision making
    • Confidence building
   Goal Setting



     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
  What would you like to do to improve
             your health?

Monitoring                                    Physical Activity

                                                                                                                   You
                                                                                                                  choos
                                                                                                                    e
 Medications
                                                    Coping                                 Unhealthy Behaviors




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
             Self-Management Goal Setting
   My Action Plan
    •    What
    •    Where
    •    When
    •    How often
   Barriers
   Problem Solving to overcome barriers
   Support needed to reach goal
   Confidence level



     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                     Self-Management Goals

Teaching Techniques
 Facilitative
 Participatory
 Collaborative
  • Use of Motivational Interviewing techniques to
    elicit Self- Management Goals




  In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
     Self-Management Support at MMG
   Educational Classes                                                    Waiting Room Talks
   Group Medical visits                                                   Phone Contacts
   Support groups                                                         Salsa Classes
   Walking club                                                           Peers Support
   Individual Sessions                                                    Community
   Cooking Classes                                                         involvement




     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
 Montefiore Comprehensive Family Care
Center – Bronx Community Health Network
          (MMG-CFCC/ BCHN)

               1621 Eastchester Road
              Bronx, New York 10461




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
       Montefiore Medical Group
    Comprehensive Family Care Center
About Us
   75,000 visits / year
   Internal Medicine, Pediatrics, &
    ObGyn Residency Programs
    60 atttending MDs                                                     Demographics
   102 (48 IM, 31 Peds, 28                                                     Black/African-American 30%
    ObG)Residents                                                               Hispanic/Latino 46%
   Nurse practitioners, midwives                                               White (not H/L) 12%
   Numerous other providers                                                    Unknown/unreported 11%
   Total users 2004 – 18,682                                                   Asian/Pacific Islander 1%
   Of those 1042 (5.6%) are patients                                           Native Am/Alaskan Native .02%
    w/Diabetes mellitus

                                                                           Languages
                                                                            English
                                                                            Spanish




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                                           AIM

AIM:
 Montefiore Medical Group – CFCC will
 redesign our care delivery system to maximize
 the health and quality of life for our patients
 with Diabetes mellitus, by assuring that they
 receive effective, evidence-based services, using
 a coordinated care plan.
We will achieve this by implementing a
 comprehensive approach, using the
 components of the Chronic Care Model



   In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                               Self Management, highlights
GROUP LEARNING
   Group Educational Series: English and Spanish
   Team presentation of learning sessions (Health Educator, Residents,
    Physician, Social worker and Nutritionist).
   Collaborative, interactive format
   Alumni lunches held once a month to re-visit self-management , education
    and problem solving issues

GROUP ACTIVITES
   Walking club twice a week, open to all CFCC patients
   Birthday Lunch
   Breakfast Club: pilot




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                            Self Management, cont.

INDIVIDUALIZED GOALS
   Individualized sessions at the end group to define self-management goals.
   Individual mini-sessions prior to provider visits consisting of diabetes
    education, nutritional counseling, and self-management goal setting.
   Individualized sessions with nutritionist.

PEER SUPPORT
   CFCC patients with diabetes trained as Peer Educators for Bronx Defeat
    Diabetes Project. We have 4 peer educators.
   Participation in all group activities.
   Waiting room contacts with ADA risk assessments completed.
   Development of peer patient panels to encourage compliance and supply
    support. Ongoing training in 1-1 diabetes management education.
   Outreach activities within the health center and into the community.


    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
            Montefiore Family Health Center


               360 East 193rd Street
              Bronx, New York 10458




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
                                                Public Health Law.
     Montefiore Medical Group Family
              Health Center
About Us                                                                 Demographics
   45,000 visits / year                                                      Black/African-American 30%
   Family Medicine Residency                                                 Hispanic/Latino 41%
    Program                                                                   White (not H/L) 13%
   18 Providers                                                              Unknown/unreported 8%
   16 Residents                                                              Asian/Pacific Islander 7%
   # Diabetic patients: 755                                                  Native Am/Alaskan Native .02%

Primary Insurance                                                        Languages
 Medicaid       39%                                                      English                         56.70%
 Self Pay       29%                                                      Spanish                         36.20%
 Medicare BC/BS Empire 13%
                                                                          Cambodian                       5.30%
 Bronx Health Plan
                                                                          Vietnamese                      1.30%
 GHI
                                                                          Other                           0.40%


    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
        Self Management Highlight
     Diabetic referrals via Walkie Talkie
   GOAL: Coordinate efforts with 2nd and 3rd floor
    PCTs, Health Educators and Nutritionist to increase
    percentage of self-management goals set at FHC.
   ACTION: Individual health educator or nutritionist
    counseling sessions with diabetic patients pre/post
    provider visit.
   PROCEDURE: Use walkie-talkie between central
    locations: PCTs call health educator or nutritionist
    through walkie talkie once a diabetic is prepped.
    While waiting for the provider patient is then seen by
    the health educator or nutritionist in the exam room.
   RESULT: SUCCESS 8% increase in the percentage
    of self-management goals set from July until August
    at FHC.
     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
           Resident Collaborative Involvement

 Thinking outside the box to improve
  community oriented primary care of chronic
  disease
 Identifying community resources
    • Care doesn‘t just happen inside the clinic
    • Better understanding of pt‘s social context
    • Contributing to the community and the bouquet
      of services that already exist
   Looking to the future


     In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                           Nutrition




In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
          Ways I Work With Patients

 One to One sessions
 Group sessions
 Setting self-management goals
 Community Outreach




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                          Teaching Methods

 Food models
 Visuals
 Power points
 Food demonstrations




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                              Challenges

 Scheduling follow-ups
 Show up rates
 Reminder calls
 Follow up on self-management goals




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
                                                Successes

 Cooking classes
 Changes on patients HgA1C
 Outreach lectures




    In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

				
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