St' JamesSantee Family Health Center, Inc'

1
St. James-Santee Family Health Center, Inc.

• Diabetes Collaborative

2
St. James-Santee Family Health Center, Inc.

• Three Clinical Sites Located in Charleston, and
  Georgetown Counties, SC
• 3 Providers, 1 Mid-Level Practitioner
• Adult/Pediatric Medical Care, Transportation
• Predominately Indigent, underserved, rural
  residents
• 3,200 patients annually
• Approximately 600 Diabetic Patients
• Diverse population with predominately African
  American patients with an increasing amount of
  the Hispanic Population

3
Team Members

• CEO/ED Ms. Roberta Pinckney, ED
• Physician Champion Kenneth Jones,MD, Medical
  Director
• Day-to-Day Leader Ms. Michelle Sears, BSN, RN,
  DON, DOQ
• Clinical/Technical Expertise Ms. Linda Lynah,
  DOO
• MIS Contact Ms. Sandra Gilliard, CFO

4
Aim

• St. James-Santee will redesign its current
  patient care delivery system to improve outcomes
  pertaining specifically to our diabetic patients.
  We will accomplish this through the
  implementation of the Care Models six change
  concept components. This will be evidenced by
  the following
• At least 80 of our patients will receive at
  least 2 HgbA1cs 3 months apart within 12 months.
• At least 70 of our patients 55 years and older
  will have current prescriptions of ACE Inhibitors
  or ARB medication.
• At least 80 of our patients will have a blood
  pressure of lt136/84 or will have a documented
  medication evaluation with possible medication
  change or possible dosage increase.
• At least 80 of our patients will have a
  fasting LDLlt120.
• At least 90 of our patients will have a
  documented comprehensive foot exam annually.
• At least 80 of our patients will have
  documented self management goals annually.
• At least 80 of our patients will have an
  average HBAIclt8.0.
• At least 80 of our patients will be
  administered the influenza vaccination annually.

5
Population of Focus

• Main Site-Approximately 200 Existing Diabetic
  Patients and new patients identified with
  diabetes will be added as they come into the
  practice and/or initially diagnosed.
• Our Main Site was selected so that the care
  delivery system change and performance
  improvement goals could be closely monitored.
  All providers at the main site will be included
  in the collaborative. This will allow for a
  smoother transition as the improvements are
  initiated system wide.

6
Choose one of the following two slides (and
delete the other one), appropriate to the topic
area that you are addressing
7
Key Diabetes Measures
8
Key Depression Measures
CSD Clinically Significant Depression
9
Optional Measuresif applicable
10
Registry

• Our team populated the registry with export data
  from an existing Cardiovascular Collaborative
  Database. Manual data entry was also utilized.
• Demographical Data is presently entered into the
  system by a data entry personnel. Implementation
  of a PECS export option from our existing data
  base is being investigated.
• Thirty-one patients currently in our data base.

11
Key Partnerships

• National Direct Diabetic Supply Home Pharmacy
• Diabetic Coalition
• MUSC Masters in Health Administration Educational
  Intern Program
• MUSC Reach 2010 Community Outreach