UMHS Dominos Family Medicine

1. UMHS Dominos Family Medicine Pam Szymanski, RN, Complex Care Nurse Navigator

2. Patient with Diabetes: New Diagnosis • Patient identification • PCP referral to Moderate Care Manager or Complex Care Manager • Complex Care Manager continues to follow if patient is in caseload has DM diagnosis • Moderate care nurses may work with the patient for diabetes education • CCM will refer patient to MCM • CCM will schedule patient to see the MCM • For patients who were admitted to hospital due to diabetes: CCM conferences with PCP to determine if patient benefits from Endocrine Specialist. May also see the PCP

3. Patient with Diabetes Diagnosis • Panel Manager • Medical Assistant with responsibility for working with the electronic registry to identify gapsin care • Pilot at Dominos Family Medicine: • Panel Manager pulls a gap report on patients that have Diabetes with an A1c 7.0 or greater this is then given to the physician • Physician identifies which patients would benefit from Diabetic education and send this information back to the panel manager

4. Patient with Diabetes Diagnosis (continued) • Panel Manager schedules the patient with the Moderate care nurse for Diabetic education on a day the patient is seeing the physician • If unable to reach the patient or no physician appointment is scheduled an encounter is sent to the moderate care nurse to follow up • Moderate care nurse also identify patients with elevated A1c of 7.0 or greater when triaging and follow up with the physician if diabetic education is warranted

5. System Level • EPIC EMR has alerts for urine micro albumin and foot exam • Registry List – Moderate care nurse receives a list of patients with a A1C > 7 identified as appropriate for diabetes education by the physician • Outreach - Birthday letter • Panel manager pulls gap report from EMR on Best Practice alerts (BPA) and if annual testing has not been done calls the patient and schedules an appointment or submits a lab requisition dependent on what BPA has not been completed annually

6. Practice Level Staff Resources • Dietician • referrals placed by Moderate care nurse, CCM (according to physician/practice established standing orders) • Pharm D • Moderate care nurse, PCP, CCM refers patient to Pharm D for medication barriers: ex compliance, side effects, financial barriers(according to physician/practice established standing orders) • Panel Manager • described above