Jagruti Shukla, MD, MPH Medical Director September 9, 2008

1. Jagruti Shukla, MD, MPH Medical Director September 9, 2008

2. San Mateo Medical Center Main Campus Primary Care Clinic • 11 San Mateo County Clinics, FQHC • 9 Physicians = 6 FTE, Approx. 20,000 visits/year • Patient Population

3. Chronic Care Model – Past Experience • One Provider Team in SNI Collaborative in 2004 • Introduction of CDEMS Registry • Chronic Disease Management • Improvements in Clinical and Process Measures • Success working as a team

4. TOOLKIT INTERVENTION • Introduced by Administration • Random division of providers into Intervention and Control Groups • Formation of MD-MA-Clerk teams • Jointly set goals – 10 parameters total • Data transfer for all Diabetic patients into CDEMS

6. MAJOR ACCOMPLISHMENTS • Working together as teams • CDEMS data sheet used as the Progress Note • Chronic disease education at each visit • Monthly group visits for all providers • Some Population Management ( No labs 1 yr) • Improvements seen in both process & outcome measures

7. Reflections: What worked well • Experience of our pioneer team with CDM • Formal structure, timelines, reporting • Coaching Support • Weekly meetings - time allocation for brainstorming and reporting • Toolkit references • Targeted Interventions: Pneumovax

8. Reflections: Challenges • Time commitment for data input, reports, and meetings • Integration of CDM into usual workflow • Significant amount of front-end work prior to seeing benefits • Active communication with staff not involved • Sustaining and spreading successful ideas • Interpretation of the variation seen in the MD’s data reports

9. Next Steps • Establish patient care teams for all providers • Identify all clinic patients with DM and populate CDEMS Registry • Further develop role of MA, Clerk, and RN • Monthly group visits for all providers • Add Pharmacist and LSW into the clinic • Continue to monitor and discuss measures

10. San Mateo Medical Center Main Campus Primary Care Clinic Questions?