Transcript Share Our Selves Free Clinic A Unique Local Resource for

Diabetes
And
Community Medicine
Patrick Chen, M.D.
Share Our Selves
January 30, 2010
Objectives
1. Highlight services at a community clinic
2. Characterize a diabetic patient population
3. Describe a multi-disciplinary approach
Share Our Selves (SOS)
1550 Superior Avenue
Costa Mesa, CA 92627
(949) 650-0640
www.shareourselves.org
What is SOS?
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501(c)(3) non-profit organization
Health services for OC’s poor and uninsured
All services are free of charge
2009 operational budget $6.6 million
More than 100,000 patients/clients annually
45 employees
400 volunteers
Our Mission Statement
We are servants who
provide free care and assistance
to those in need and
act as advocates for systemic change
SOS – A Brief History
• Founded in 1970 to provide for OC’s poor
• Food
• Clothing
• Financial aid
• Evolution
• 1984 Medical Clinic
• 1987 Dental Clinic
• 2005 Comprehensive CARE Center
• 2009 SOS Family Center
5 Core Services
• Social Services
• Comprehensive CARE Center
• Family Center
• Dental Clinic
• Medical Clinic
Social Services
• Food
• Financial Aid
• Clothing
• Legal aid
• Education Classes
• Fundraising Drives
Comprehensive CARE Center
• Counseling - individual, group therapy
• Advocacy - case management
• Resources - linkage to benefits/programs
• Emergency Services - crisis intervention
Family Center
• Pregnant women,
families with kids 0-5 y.o.
• Education and
in-home support:
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Prenatal
Breastfeeding
Parenting
Diabetes prevention
Dental Clinic
• Hygiene, x-rays, extractions, restorations
• 2 dentists
• 8124 visits annually
Medical Clinic
• 15,000 visits annually
• Chronic program
– 2200 patients
• Walk-in clinic
– ER diversion rate: 29%
• Specialty clinics
SOS – Hoag Partnership
• Symbiotic collaboration between two
independent non-profit healthcare institutions
• Hoag provides $1.5 million in-kind support:
two physicians, meds, diagnostics, services
• SOS provides primary care, ER diversion, and
follow-up for discharged patients
Socioeconomic Profile
• Federal Poverty Level
– Single: $10,800
– Family of 4: $22,000
Socioeconomic Profile
• Medical Services
Initiative (MSI)
– OC’s safety net
program
– < 200% FPL
Employed Providers
• 1.5 FTE Internists
• Family Physician
• Physician Assistant
• Nurse Practitioner
• 1.5 FTE Pharmacists
Volunteer On-site Providers
• Internist
• Gynecologist
• Cardiologist
• Uro-Gynecologist
• Nephrologist
• Physician Assistant
• Optometrist
• Nurse Practitioner
• Diabetic Educator
• Physical Therapist
SOS Diabetes Program
• 393 patients
• 4.4 average visits/yr
• MSI and Uninsured
• Geographic focus
• Demand is increasing
SOS Diabetes Program
• Labs
• Education
• Specialty Care
• Mental Health
• Medications
• Case Management
A Multi-disciplinary Team
• Primary care
• Diabetes educators
• Specialty care
• LCSW/MFT
• Pharmacists
• Case Managers
ADA Guidelines
• Targets:
– Hb A1C
– BP
– HDL, LDL
• Medications:
– Statins
– Antiplatelet
– Immunizations
• Screening:
– Neuropathy
– Retinopathy
– Nephropathy
• Lifestyle Changes:
– Physical Activity
– Smoking Cessation
First Encounter
• How do patients get into the program?
– Walk-in patient
– Referral from a hospital
– Our patient develops diabetes
First Encounter
• Patient Contract
• Financial Screening
• Depression screening
• Medications
• Referral to a diabetes educator
Medications
1. SOS purchases
2. $4 Pharmacy programs
3. Patients Assistance Program (PAP)
4. Hoag Pharmacy
Medications
• Oral diabetic agents
• ACE Inhibitor / ARB
• Insulin
• BP therapy
• Statins
• Antidepressants
• Fibrates
• Vaccines
• Antiplatelets
• ED meds
Medications
Value Dispensed 2009
1. SOS - Metformin $167,984
2. PAP – Atorvastatin $372,740
3. Hoag – Insulin $74,852
Diabetic Education
1. Latino Health Access
2. SOS Medication Therapy Management
3. Hoag Diabetes Center
Diabetic Education
• Pathophysiology
• Exercise
• Glucometer Training
• Medications
• Nutrition
• Insulin Instruction
Integrative Behavioral Health
• Counselors are Providers
• Collaboration (“Our patient”)
• High-risk for depression
• Behavioral change is critical
Integrative Behavioral Health
• Depression Screening
– PHQ-9 each visit
• Depression Management
– Counseling
– Antidepressants
Integrative Behavioral Health
PHQ-2 Depression Screen
Over the past 2 weeks, how
often have you been bothered
by any of these problems?
Not at
all
Several
days
More
than half
the days
Nearly
Every
Day
Little interest or
pleasure in doing things
0
1
2
3
Feeling down,
depressed, or hopeless
0
1
2
3
•Score of 3: 83% Sensitivity, 90% specificity
- Administer PHQ-9
Integrative Behavioral Health
• Case Management
– Care coordination
– Special needs
• Family Conference
– Patient / Family members
– Provider
– LCSW / Case Manager
Family Center
• Target families of diabetic patients
• Diabetes Prevention Classes
• Exercise Classes
Specialty Care
• Nephrology
• Optometry
• Cardiology
Eye Care
• Bimonthly eye clinic
• Prescription lenses
• Retinopathy screening
• Referral to Ophthalmology
Foot Care
• “Feet and Finger sticks” each chronic visit
• Providers perform microfilament exam
• Referral to podiatry
• Hoag Wound Care Clinic
Nephropathy
• BUN/Cr, Ur. Microalbumin Qyr
• ACE Inhibitor / ARB
• Referral to Nephrology
Dental Care
• Referral to Cypress College Dental
Hygiene Program
• Referral to SOS Dental Clinic
Challenges to Care
• Patient resources
• Volunteer staff
• Transportation
• Access to specialists
• Clinical Space
• Increasing demand
The Future
• Electronic Health Records
• Standardized management algorithms
• Group Visits
• Self-analysis (targets, outcomes)
• Open another site