Location: San Angelo, Texas

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Esperanza Health Center

• Location San Angelo, Texas
• Size 5 full-time,5 part time providers
• Programs offered at center
• Case Management
• Community Educator
• Social Service Coordinator

• Population Served
• Number of Patients Diagnosed with Diabetes 1048
• Ethnic mix
• 5 African American
• 62 Hispanic
• 33 White

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Team Members

• Name Title Role on Team
• LUIS RODRIGUEZ MEDICAL DIRECTOR
  CHAMPION LEADER
• MIKE CAMPBELL C.E.O
  EXECUTIVE DIRECTOR
• BECKY REYES DON
  DAY-TO-DAY
  LEADER/CONTACT
• MARICELA ALMAZAN LAB SERVICES COORD.
  PECS DATA ENTRY
• LONNIE FRAZIER CASEMANAGER
  CLINICAL/TECH. EXPERTISE
• HORTENCIA JACOBO EDUCATOR
  CLINICAL/TECH. EXPERTISE
  

Team Leader Contact Email BeckyReyes_at_esperanzahe
alth.org Telephone[phone]
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Aim

• ESPERANZA HEALTH AND DENTAL CENTERS WILL REDESIGN
  ITS SYSTEM TO PROVIDE IMPROVED CARE FOR OUR
  PATIENTS. WE WILL ACCOMPLISH THIS THROUGH
  IMPLEMENTATION OF THE CARE MODEL. THIS WILL BE
  EVIDENCED BY
• -AT LEAST 90 OF OUR PTS. RECEIVING AT LEAST 2
  HBAICS 3 MONTHS APART WITHIN ONE YEAR.
• -AT LEAST 70 OF OUR PTS. WILL HAVE DOCUMENTED
  SELF-MANAGEMENT GOALS.
• -AN AVERAGE HBA1C LESS THAN 7.0.
• -AT LEAST 60 OF OUR PTS. WILL HAVE CURRENT RXS
  FOR STATINS.
• -AT LEAST 40 OF OUR PTS. WILL HAVE BPlt130/80.
• -AT LEAST 70 OF OUR PTS. WILL HAVE LDLlt100.
• ESPERANZA HEALTH AND DENTAL CENTERS WILL DEVELOP
  AND MAINTAIN A REGISTRY OF ALL OUR PTS. WITH
  DIABETES. WE WILL FOCUS ON ALL OF THE COMPONENTES
  OF THE CARE MODEL SYSTEM. TRAINING OF MEMBERS
  AND HIRING OF AN EDUCATOR WILL GUIDE THIS CENTER
  TOWARDS THE COLLABORATIVE GOALS. ONCE, THE CARE
  MODEL AND CHANGES HAVE BEEN IMPLEMENTED, THE
  OTHER PROVIDERS AND THEIR PANELS WILL BE
  INCLUDED.

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Population of Focus

• La Esperanza Health and Dental Centers population
  of focus will be all of the patients under Dr.
  Rodriguez care at the Chadbourne location that
  are active and have been diagnosed with diabetes.
  We curently have 521 patients. New patients
  identified with diabetes will be added as they
  establish care with Dr. Rodriguez and/or are
  initially diagnosed.

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Key Diabetes Measures
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Senior Leadership Support

• How has leadership supported the team?ATTENDING
  CALL CONFERNCES, ATTENDING MEETINGS. C.E.O AND
  BOARD MEMBERS AGREED THAT ANY RESOURCES NEEDED
  WOULD BE AVAILABLE UPON REQUEST.
• How has middle management been engaged to support
  the team? BECKY REYES, D.O.N HAS BEEN IN ALL
  CALL CONFERENCES AND KEEPING TEAM MEMBERS
  INFORMED OF COLLABORATIVE.

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Registry

• Registry used at our Health Center will be PECS
• How we populated/entered patient data into
  registry by Feb 2005
• We identified patients by running queries in our
  practice management system / billing system.
• Chart Abstraction process was completed by
  medical records personnel pulling charts from
  medical records. List of DM patients was provided
  to medical records.
• Maricela Almazan is entering patient data into
  the PECS registry.
• Maricela Almazan is the primary staff member
  responsible for maintaining the PECS data entry.
  Manuel Del Real will provide back up support for
  data entry.

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PDSA Cycles completed during Prework

• List the PDSA cycles you completed
• NONE
• Are you sure about this. Did you identify
  patients by flagging the medical records with
  stickers or in the practice management system.
  What about how you came up with the process of
  abstracting information for the records and
  entering the data into PECS.

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Communication

• Our board of directors were informed of the
  collaborative by our CEO and our medical
  director. The clinical staff and providers gained
  knowledge of the collaborative through various
  staff meetings. Information about the
  collaborative was published in our clinics
  newsletter, The Hope Scope, to inform other staff
  members interested in the project.

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Key Partnerships that will help our work in
Health Disparities

• LIONS CLUB
• P.A.P _at_SHANNON, CITY SOCIAL SERVICES
• 55 PLUS-COMMUNITY
• HHA
• REFILL SYSTEM (340BETTER)
• PROSPECTIVE-DM ASSOCIATION (LOCAL)