Transcript No Slide Title

California Chronic Care Learning
Communities Initiative
Collaborative
Final Outcomes Congress
December 9, 2005
San Mateo Medical Center
• Location: Primary Care Clinic in the Main Campus of San
Mateo Medical Center
• Size: 122 Patients From Dr Rebecca Ashe’s panel
with diagnosis of Diabetes, Hypertension, and
Hyperlipidemia
• Population Served: All residents of San Mateo
County for health care needs with an emphasis on
education and prevention, without regard for
ability to pay.
ICIC Website: http://www.improvingchroniccare.org/
San Mateo Medical Center
Community
Resources and Policies
Self-Management
Support
• Patients are
encouraged to
attend self-help group
• Patients are
reminded to bring all
medications to each
visit
• Each patient is given
a Diabetes Care card
to track current labs
and meds
Health System
Organization of Health Care
Delivery
System
Design
• Group visits
with Dr Ashe’s
patients
• CDEMS for
better tracking
• Developed
Foot stamp
• Expanded role
for MA’s
(Foot exam prep
and Action Plans)
Decision
Support
• Diabetes Basic
classes
• Increased
communication
with clinics:
endocrinology
ophthalmology
and podiatry
Clinical
Information
Systems
• Use of
Diabetes
care flow
sheet
• Utilizing
CDEMS to
reach out to
patients with
poor control
San Mateo Medical Center
Community
Resources and Policies
Health System
Organization of Health Care
• Presentations to hospital committee’s for
spread of registry
•Collaboration with Kaiser on PHASE project
•Referrals to “Active for Life” Program
•Smoking cessation program
•Education Materials from California
Diabetes Society and
Nutrition Education classes sponsored by
American Diabetes Association
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
San Mateo Medical Center
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
•Improved patient tracking with use of CDEMS registry
•Planned Diabetes Group Visits
•Diabetes Basic Facts classes
•Improved teamwork of clinic staff and expanded roles for MA’s
•Establishment of Action Plans for better self-management
•Development of foot stamp and process for providers to perform
foot exams
Delivery System Design
• Team Roles & Tasks
– MA prepares patient for a foot exam
– MA initiates Action Plan with patient, MD and RN follow
up with them
• Planned Visits
– Group visits with Dr Ashe’s patients
• Continuity
– CDE, RN and MA conducting Diabetes Basic Facts
classes monthly in English and Spanish
- Increased communication with specialty clinics
• Follow-up
– CDEMS registry to track visits and labs
Functional and Clinical
Outcomes
Baseline
Dec 04
–
–
–
–
–
–
HbA1c < 7.0
Self mgt goals set
LDL < 100
Foot exam
BP < 130/80
On Ace/ARB
36.9%
32.3%
45.9%
28.5%
23.4%
76.6%
Actual
Oct 05
Target
44.6%
85.3%
59.8%
77.1%
35.0%
83.3%
60%
70%
70%
60%
40%
75%
Barriers
• Resistance to change – improving teamwork
by adjusting roles of clinic staff
• Labs not interfaced with CDEMS –
currently working with administration and
IT for solution
• Time – we continue to meet weekly as a
team at lunch and enter data manually
Keys to Sustaining and Spreading
Our Chronic Care Improvements
• Success achieved through continued support from
senior leadership
• To spread and sustain change we recently obtained
grant funds to interface labs with CDEMS and for
ongoing clinical data entry and IT support
Group Visit Session at
San Mateo Medical Center
“This visit was very helpful. I
have learned what to eat and
how to exercise.”
“I could start checking
my sugar at home.”
Patient’s Comments after a
Group Visit Session
“I have learned the
Basic Facts of
Diabetes and I will
exercise more and
have better eating
habits.”
“I know what happens
when you don’t take
your medicine. I will
follow all lessons
learned.”
THANK YOU