Transcript Bronx Diabeaters Montefiore Medical Group 2
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 hundreds of health centers from all over the country
Northeast Cluster
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.
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6.
What were goals in first year for MMG HDC?
Identify successes of FHC.
Spread to CHCC, CFCC and WB in Diabetes Establish working teams.
Determine key measures for all sites.
Establish uniform/compatible data collection system for registry.
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
FHC (DM) CHCC (DM)
WB (non 330) DM
CFCC (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.
Noel Brown, M.D.
Joanne Dempster, M.D.
Blanche Doati Victoria Gorski, M.D.
Danette Ortiz Staff Nurse Medical Director Team Leader Associate Director Academic Leader 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 Physician Champion
Marta Rico, MD Chris Meserve, MD
Team Leader Team Members
Carol Lau, FNP, Associate Director 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
<8% 70% 70% 90% 90% (90% 90% 70%
Shared Core Measures
Average HgbA1c % of patients with BP< or = 130/80 % of patients with an LDL <100 % of patients who have had pneumococcal vaccine % of patients with documented LEAP foot exam in the past 12 months % of patients receiving annual flu shots) % patients on aspirin (or other anti-coagulant) 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.
2.
3.
4.
5.
From registry get print out of all charts without pneumovax.
Pull charts and have provider review (some charts didn’t have it recorded but had pneumovax given).
Put yellow stickies in charts without pneumovax.
Combine fluvax and pneumovax forms.
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 Clinic FHC CFCC CHCC WB
Number of Patients with 1+ visits
ACTIVE PT.
760 191 273 606 % Patients with HbA1c < 8.0
Average HbA1c for DM Patients % Patients % Patients with BP <= 130/80 with LDL<100 % Patients on Aspirin with LEAP exam (12 % Patients % Patients with Pneumoccoc al vaccine months) (ever)* % Patients with Flu Vaccine (12 months) % Patients with Retinal Exam (12 months)
ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.
60% 64% 64% 61% 7.9
7.8
7.7
8.0
56% 47% 65% 46% 54% 66% 57% 50% 53% 59% 59% 38%
ACTIVE PT.
60% 35% 38% 32%
ACTIVE PT.
78% 54% 54% 69%
ACTIVE PT. ACTIVE PT. ACTIVE PT.
40% 18% 35% 19% 28% 31% 22% 22% % DM Patients with SM Goal (12 months) 33% 47% 15% 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
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: 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
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 FHC Montefiore Medical Group Health Disparities Collaborative 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.
Charts pulled and data entered from the CVDEMS
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.
CVDEMS Data Capturing Contd.
Bi-weekly automatic lab data 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
Clinic FHC CFCC CHCC WB
Number of Patients with 1+ visits
ACTIVE PT.
760 191 273 606 % Patients with HbA1c < 8.0
Average HbA1c for DM Patients % Patients % Patients with BP <= 130/80 with LDL<100 % Patients on Aspirin % Patients with LEAP exam (12 months) % Patients with Pneumoccoc al vaccine (ever)* % Patients with Flu Vaccine (12 months) % Patients with Retinal Exam (12 months)
ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.
60% 64% 64% 61% 7.9
7.8
7.7
8.0
56% 47% 65% 46% 54% 66% 57% 50% 53% 59% 59% 38%
ACTIVE PT.
60% 35% 38% 32%
ACTIVE PT.
78% 54% 54% 69%
ACTIVE PT. ACTIVE PT.
40% 18% 35% 19% 28% 31% 22% 22% % DM Patients with SM Goal (12 months)
ACTIVE PT.
33% 47% 15% 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 Provider is principle caregiver and problem solver Shared expertise Shared responsibility Provider gives instructions to be complied with Behavior is externally motivated Provider identifies problem Provider solves problems Patient sets goals Internal Motivation Patient identifies the problem Patient is taught 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 Medications Physical Activity Coping You choos e 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 Group Medical visits Support groups Walking club Individual Sessions Cooking Classes Waiting Room Talks Phone Contacts Salsa Classes Peers Support Community 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 102 (48 IM, 31 Peds, 28 ObG)Residents Nurse practitioners, midwives Numerous other providers Total users 2004 – 18,682 Of those 1042 (5.6%) are patients w/Diabetes mellitus
Demographics
Black/African-American 30% Hispanic/Latino 46% White (not H/L) 12% Unknown/unreported 11% Asian/Pacific Islander 1% Native Am/Alaskan Native .02%
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 193
rd
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
45,000 visits / year Family Medicine Residency Program 18 Providers 16 Residents # Diabetic patients: 755
Primary Insurance
Medicaid Self Pay 39% 29% Medicare BC/BS Empire 13% Bronx Health Plan GHI
Demographics
Black/African-American 30% Hispanic/Latino 41% White (not H/L) 13% Unknown/unreported 8% Asian/Pacific Islander 7% Native Am/Alaskan Native .02%
Languages
English Spanish Cambodian Vietnamese Other 56.70% 36.20% 5.30% 1.30% 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 2 nd and 3 rd 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.