West Central Cluster Summit

1. West Central Cluster Summit “Moving Ahead With Spread” November 8-10, 2004 Dallas, TX

2. Colorado Coalition for the Homeless • Stout Street Clinic • Denver, CO • Sites include main clinic and outreach to local shelters via mobile medical van • Serves homeless clients only

3. AIM and Key Measures AIM: Redesign the clinic delivery system to improve care to clients with diabetes. We will accomplish this by using the CCM, with changes in the following areas: • Key Measures: • Registry size • Blood Pressure below 130/80 • Increase Cigarette Cessation Counseling and Decrease # of clients • who smoke • % of clients with Self-Management Goal • Average HbA1c • % of clients offered pneumococcal vaccine

4. Team Members • Tania Engle • Ed Farrell • Lucy Llamas • Danielle Maze

5. How it all Started…. Diabetes collaborative started in 2000 Population of Focus – • all clients with diabetes • approximately 220 clients in registry initially • Team committed to improvements in care • Seamless entry, Eye Clinic focus, and diabetes care kits were most important areas for improvement

6. Spread • The Health Outreach Program visits several area shelters and motels and refers diabetic patients to the clinic. • This has increased the number of homeless diabetics receiving care.

7. Community Linkages Eye Clinic • Sustain current system of care, which includes 28 volunteer staff and delivers free ophthalmology and optometry services. Dental Services • Dental Services to be offered by Colorado Coalition for the Homeless in December 2004!! The site is across the street from the clinic • Outside referral system established for $20/visit Foot Care • Medicaid/care clients receive custom orthotics from the “foot guy.” • Exploring the possibility of on site podiatrist.

8. Sustaining Activities • Orientation for new staff includes collaborative. • Group visits in espanol and English continue • Chronic illness goals are a part of the health care and strategic plans • Chronic care model supported by Board of Directors

9. Measures Graphs

10. Measures Graphs

11. Measures Graphs

12. Best Practices • All staff updated in LEAP foot exams once a year • Eye clinic volunteers have prioritized visits for diabetic patients • Monthly group visits occur on 2nd Tuesday every month. • Real-time, seamless data entry occurs in exam room. Or at least we’re working on it.

13. Lessons Learned • Focus on one or two goals • Keep goals simple and achievable • Encouragement needed for data entry to occur regularly

14. Overcoming the biggest Challenges/Barriers • Data entry- Make a “CVDEMS (or PECS) To Do” pile so that all entries can be done at one time • Seamless entry – will be purchasing computers for all exam rooms. • MA staff turnover - current staff has stabilized, need to improve orientation process

15. Next Steps • Make the dental program a success • Continue goals in smoking cessation and blood pressure control • Sustain current gains.

16. Sustaining Activities All-volunteer Eye Clinic is very successful: • Twice weekly ophthalmologist dilated exams. • Complete optician services are available, including lenses, frames, and eyeglass repair. Group Visits are also a success: • Continue diabetic group visits in English and Spanish.

17. Two Success Stories to share…. Ms. TS, a 41 YOF with DM I, retinopathy and nephropathy. Her Hemoglobin AIC is now 5.8. This is a huge improvement from her AIC of 16.0 in 2001 when she started care at Stout Street Clinic. Mr. AF, a 56 YOM with DM 2, severe mental illness, and HTN. His worsening diabetes control improved after his severe periodontal disease and dental abscesses were treated. This kept him from requiring nursing home transfer, as his DM is now controlled without insulin.