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Diabetes Collaborative at Sea Mar Vancouver

Diabetes Collaborative at Sea Mar Vancouver. Tatiana Shelepova, MD & Jamie Zentner, MPH. Washington State Collaborative Learning Session 3 September 11-12, 2006. Sea Mar Community Health Centers. Vancouver, WA Pilot Population: 158 patients Ethnicity

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Diabetes Collaborative at Sea Mar Vancouver

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  1. Diabetes Collaborative at Sea Mar Vancouver Tatiana Shelepova, MD & Jamie Zentner, MPH Washington State Collaborative Learning Session 3 September 11-12, 2006

  2. Sea Mar Community Health Centers • Vancouver, WA • Pilot Population: 158 patients • Ethnicity • 43.2% Caucasian, 40.6% Russian, 16.1% Mix • Insurance • 57.4% DSHS, 18.1% None, 17.4% Medicare

  3. Aim Statement Sea Mar Community Health Centers Vancouver will redesign the provision of care to achieve the following goals:

  4. Measures

  5. Key Changes in Self Management Support and Delivery System Design Health System Community Organization of Health Care Resources and Policies Clinical Information Systems DecisionSupport Self-Management Support Delivery System Design • Clinic Manager • Clinic Champion, MD • Day to Day Leader • Medical Assistants • CSR • Medical Records • Front Desk • One-on-one counseling • DM classes

  6. Key Changes in Decision Support and Clinical Information Systems Health System Community Organization of Health Care Resources and Policies Self Management Support Delivery System Design Decision Support Clinical InformationSystems • Team attendance to wsc5 learning sessions • Participates in teleconferences • DM classes - benchmarks • CDEMS Registry • Interface CDEMS & Labcorp • Alert Notes in Mysis

  7. HbA1c: March 06’ vs. August 06’

  8. % of Patients with A1c < 7.0%

  9. PDSA Cycles: HbA1c • How was this accomplished? • More frequent follow-up visits • Physician spends more time discussing importance of management • Knowledgeable & motivated medical assistant • Next Steps: • Recruit patients with A1c > 7.0 to DM class

  10. LDL: March 06’ vs. August 06’

  11. % of Patients with LDL < 100

  12. Average LDL for Patients

  13. PDSA Cycles: Cholesterol • How was this accomplished? • More follow-up visits • More time spent discussing importance of management • More aggressive treatment with lipid agent • Next Steps: • Recruit patients with LDL > 100 to participate in class • More time spent discussing importance of management

  14. % Documented DM Education

  15. Barriers • Patients with few resources • Conflicting primary needs • No insurance • No show to appointments • Co-morbidities (mental health) • Creating opportunities in community for patients (healthy food & exercise)

  16. Keys to Success • Communication & Team Effort • Russian speaking staff • Personal contact & follow-up from MA • CDEMS & progress notes • Alert notes in Mysis • Russian diabetes education materials http://www.swmedicalcenter.com/body.cfm?id=1926

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