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Navigating the HbA1c Challenge: Multi-Factorial Approaches for Patient Engagement

This report from Thundermist Health Center explores the complexities of managing HbA1c levels in patients with diabetes. With a focus on engagement at three levels—staff, providers, and patients—the study reveals the multi-faceted issues affecting diabetes management. Key strategies include enhancing staff engagement through education and incentives, supporting providers with usable data, and facilitating patient engagement via group visits and walking sessions. These initiatives aim to improve outcomes and reduce the number of patients lost to follow-up, presenting a comprehensive approach to diabetes care in a resource-limited environment.

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Navigating the HbA1c Challenge: Multi-Factorial Approaches for Patient Engagement

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  1. The HbA1c Limbo: How low can you go? Experiments from the Learning Lab of Thundermist Health Center, Woonsocket Deb Chalko and Beni Seballos

  2. THE CHALLENGE: “IT’S MULTIFACTORIAL.” • STAFF ENGAGEMENT • Staffing • New staff members • Overload • Data • Tasks • PROVIDER ENGAGEMENT • Staffing • Understaffing • New providers • Overload • Data • Tasks • PATIENT ENGAGEMENT • Volume • 800 DM2 patients • New DM2 patients • Lost to follow-up • Psycho-social factors • Financial • Complex patients

  3. THE RESPONSE: “IT’S MULTIFACTORIAL.” PATIENT ENGAGEMENT Group visits Walking groups STAFF ENGAGEMENT Usable data Continuing education Incentives/rewards PROVIDER ENGAGEMENT Usable data Staff support Patient resources Continuing education

  4. PROVIDER ENGAGEMENT: USABLE DATAYou can lead a horse to water, but try not to drown it. • CDSS alerts and flow sheets • Provider Level Summary • Pro- Active Pre-visit Planning • Missed Opportunities Report • Monthly emails on PDSA standings • Quality Meetings PROVIDER ENGAGEMENT Usable data Staff support Patient resources Continuing education

  5. PROVIDER ENGAGEMENT: USABLE DATAYou can lead a horse to water, but try not to drown it. PROVIDER ENGAGEMENT Usable data Staff support Patient resources Continuing education

  6. PATIENT ENGAGEMENT: GROUP VISITSYou can lead a horse to water, but make sure it’s thirsty. PATIENT ENGAGEMENT Group visits Walking groups

  7. STAFF ENGAGEMENT: INCENTIVES/REWARDSYou can lead a horse to water, but offer bubbly. MISSION: CONTROL! STAFF ENGAGEMENT Usable data Continuing education Incentives/rewards

  8. THE RESPONSE: “IT’S MULTIFACTORIAL.” STAFF ENGAGEMENT Usable data Continuing education Incentives/rewards PROVIDER ENGAGEMENT Usable data Continuing education Patient resources Staff support PATIENT ENGAGEMENT Group visits Walking groups

  9. THE CHALLENGE: “IT’S MULTIFACTORIAL.” • PROVIDER ENGAGEMENT • Staffing • Understaffing • New providers • Overload • Data • Tasks • PATIENT ENGAGEMENT • Volume • 844 DM2 patients (11.5%) • New DM2 patients • Gain 50/quarter • 19 (38%) HbA1c < 8 • Contrast: Established patients 57% HbA1c < 8 • Lost to follow-up • 40-70 not seen in 12 mos • Psycho-social factors • Financial • 206 (24%) uninsured • Complex patients • 286 (34%) Medicaid • STAFF ENGAGEMENT • Staffing • New staff members • Overload • Data • Tasks

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