Transcript smg-pgip-presentation-v2-12-2013

Managing Diabetic Patients
Presented by Elizabeth Eaton,
RN, MPH, Care Facilitator
Sparrow Medical Group North
PGIP Quarterly Meeting
December 6, 2013
Disclosure
• I have no conflict of interest to
declare
• I do not have any relevant financial
relationships with any commercial
interests
Sparrow Medical Group has been
committed to improvement of
Diabetes for the past 6+ years
 Manual Registries- started July
2008
 Diabetic Lean Process in two of
our Family Practice offices
initiated May 2010
 Rolled out to remaining
Beginning of Process
 Hired a RN, Care Facilitator- (Me) to
work in the 8 family practice offices
 focus was to start with diabetes and
diabetic patients.
 Used the registries to identify
patients at highest risk
 EMR phase-in began August 2010
Identification of Diabetic patients to
work with Care Facilitators (hybrid
care managers)
• Provider referral
 RN Care Manager may meet with
patient same day as PCP visit
 PCP may ask patient to schedule
an appointment to meet with RN
Care Manager within the next
month (appt made at check out)
Patient Identification con’t.
 Support staff referrals
 MA’s consult with the RN Care Manager
with suggestions for patient’s in need or
they may suggest directly to the patient
that they should make an appointment
with RN Care Manager
 Front office staff schedule
appointments for patients with the
Care Manager
 Care Managers have a separate unique
schedule
Patient identification cont.
• MiPCT lists
• Patient Self Referral
 posters in exam rooms
 take home flyers at checkout
• Epic (EMR) DM registry
 Identify those with elevated
A1C’s
 Identify co-morbidities and/or
recent hospitalizations
Medical Assistant Role
 MA assigned to work the registries runs a DM
report at least every 3 months
 Reviews for missing quality measures
 Ensures lab orders are in Epic
 Notes on schedule if labs are needed
 Front staff reminds pt to get lab work done
before appt.
MA notes in care coordination section of
patient record if patient needs: foot exam,
eye exam, mammogram, etc.
Notes on schedule if labs are
needed, our front staff reminds pt
to get lab work done before appt.
Physicians
 Refer to RN Care Facilitator/Care Manager
• MiPCT is on the problem list
• medication assessment and reconciliation,
disease education, home safety,
nutritional counseling, weight reduction,
injection teaching, etc.
• verbally to RN Care Manager
• noted in PCP visit note & chart cc’d to RN
Care Manager
• written in checkout instructions for patient
to make appointment with Care Facilitator
Coordinating Care
 RN Care Manager and PCP have
frequent care coordination meetings
• during breaks
• between patients
• end of day
• messaging in EMR
 RN electronically copies PCP on all
pertinent patient interactions
RN Care Facilitator
 Uses MiPCT list to determine eligible patients
and notifies staff/physicians through EMR and
highlighted paper schedules
 Provides care management services
• to include patient education
• Patient goals
• Referrals to community agencies
• Patient ongoing support with phone visits,
office visits, MySparrow email visits
Care Management Services
1. Patient Education
Patient Education Plan and Teaching Record
Accompanied by: {Accompanied By:20518}
Patient's Readiness for Education: Is it appropriate to provide education to this patient
at this time?{yes no:315493::"Yes"}
Topic
Group
Date:
1:1
Date
Objective
Complete
Comments
Healthy Eating
Being
Active/Exercise
Monitoring
Medication
Management
Problem Solving
Reducing Risks
Healthy Coping
Progress Notes: ***
Plan:
{diabetes recommend:315299}
Patient has been given material for ongoing education: books, websites , support
group, and exercise opportunities: {yes no:315493::"Yes"}
2. Patient Goal setting
3. Provide and plan for ongoing support
*RN Care Manager sets up follow up with
patient at the end of visit ( both timeframe
and how):
*return visit
*telephone call
*via MySparrow/email
Additional Care Management
 Provides staff education on chronic
diseases, self management,
medications, PCMH, etc.
 Collaborates with physician regularly to
review medical plans
 Offers group visits to DM patients
 Remains updated on community
resources
QUESTIONS?