Medical sites at Howard, Wessington Springs, De Smet, Martin, Mission, Plankinton, Bryant, Lake Preston, Woonsocket, and White River, South Dakota. Dental sites at Howard, Martin and De Smet, South Dakota.

1
Medical sites at Howard Wessington Springs De
Smet Martin Mission Plankinton Bryant Lake
Preston Woonsocket and White River South
Dakota. Dental sites at Howard Martin and De
Smet South Dakota.
Horizon Health Care Inc.
2
Background Information
3
Team
4
Organization of Health Care

• Day-to-day leadership for continued clinical
  improvements Lance Lim MD Jim Cody NP/PA-C
• and Karen Bumann PA-C
• Collaborative activities are part of our
  Continuous Quality Improvement plan and Health
  Care Plan. Not included in the provider
  performance improvement or compensation plans.
• PECS registry is used.
• An Orientation Checklist was created for new
  Clinicians to obtain introduction to HDC and
  PECS.
• Spread activities continue with CVD/HTN and need
  to resume asthma activities.

5
Decision Support

• Priority consistent high-quality comprehensive
  care following ADA Clinical Practice
  Recommendations JNC principles on high blood
  pressure and NIH Guidelines for Diagnosis and
  Management of Asthma.
• Patients are educated on guidelines through
  individualized discussion diabetes newsletter
  diabetes self management goal setting education
  by Certified Diabetes Educator and RN Educator at
  some sites CVD/HTN self management goal setting
  asthma self management goal setting and asthma
  action plan.
• Periodic info to staff on any new recommendations
  for patient care review by staff of SMG setting
  sheets.

6
Delivery System Design

• PECS data entry staff responsible for preparing
  condition encounter note and having ready for
  next visit. Nurse or MA initiates use of
  encounter note (date V.S. meds lab report
  availability. Provider completes with final
  return to data entry.)
• Proactive vs. reactive staff focus at some sites
  limited to task/activity completion and
  numbers/reports. (Need focus on patient outcomes
  and prevention of disease complications).
• Follow-up visit reminders via previously existing
  computer recall system by transcriptionists/medica
  l records at most sites.
• Monthly provider and site comparison reports.
• Certified Diabetes Educator (CDE) and RN Educator
  available at seven of ten sites to assist with
  special needs.
• No group visits diabetes support group available
  in three communities.

7
Clinical Information System

• PECS 3.11 installed at all ten medical sites.
• Data is used for identifying areas needing work
  to improve patient outcomes status reports to
  clinicians and staff documenting outcomes for
  the Health Care Plan and quality improvement
  activities addressing HRSA performance review
  measures and required national reporting.
• Not fully utilize all the features of PECS such
  as for patient recalls but recognize need for
  staff training to use more features.
• At most sites one staff member at that site is
  responsible for data collection from the charts
  and PECS data entry throughout the month one
  medical assistant has joint responsibility for
  all data entry for the Lake Preston Bell Medical
  and Bryant sites doing the updating/data entry
  at least once per month.
• A RSR for each provider is generated monthly to
  show the status of their patient panel. PECS
  encounter note is used to prompt providers since
  abnormal or uncompleted items are in red.

8
Self-Management

• SMG setting is done by discussion one-to-one
  clinician with patient. Patient encouraged to set
  goal guidance by clinician.
• We use self-management goal setting sheets for
  diabetes and hypertension/CVD that have colored
  art with a brief goal statement and an
  accompanying sheet explaining the importance of
  each goal is available. A monthly diabetes
  newsletter was originally sent out to 30 POF
  registry patients now sent to a total of 48 from
  two sites with plan to expand mailing to all
  diabetes registry patients (approx. 275) by April
  2007.
• SMG setting status and outcome are discussed at
  each diabetes or HTN visit and a new goal set as
  necessary. Having a consistent method for
  follow-up and monitoring of goals was suggested
  at our HRSA Performance Review and a plan for
  this will be developed.
• We have found it is beneficial to KEEP IT SIMPLE
  --- helpful for the patient and the clinician!

9
Community

• Patient assistance programs are utilized as
  needed in addition to coverage by insurance
  Medicaid and Medicare Part D.
• Medication samples are received from
  pharmaceutical companies.
• Johnson Johnson provides free One Touch meters
  on a regular basis.
• Blood pressure cuffs are obtained from Pfizer for
  home BP monitoring.
• Educational materials/brochures about diabetes
  and hypertension are received free from the SD
  Department of Health. Pharmaceutical companies
  also provide educational materials on diabetes
  hypertension and asthma. No community partners
  donate money or medications. HHC has done
  diabetes awareness promotions during diabetes
  month.
• We have not recently been awarded any grants for
  necessary equipment costs or spread/expansion.

10
Diabetes Measures

• At six HHC sites
• 7.28 average A1c at POS sites 7.0 at POF. (By
  site 40 to 61 of our diabetes registry patients
  have an A1c lt 7 national average is 42.9).
• 90 with 2 A1cs in 12 months gt90 days apart.
• - 87 with documented self-management goals

• National Goals
• Average A1C 7.0
• At least 2 A1Cs in the last 12 months (gt90 days
  apart) 90
• Self-Management goal in last 12 mo. 70

11
Cardiovascular/HTN Measures

• National Goals At 2 HHC spread sites
• -50 of HTN pts. with
• BP lt140/90 - 24 of 38 pts. lt140/90
• -90 with 2 BPs recorded in
• past 12 months - 95 with 2 readings
• -70 of HTN pts. with SMG
• setting in past 12 months - 58 with SMG
  documented
• -60 of HTN pts with LDL lt100
• in past 12 months - 32 with LDL lt100

12
Most successful graph
13
Most challenging graph
14
Questions from the audience

• Thank you !