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California Chronic Care Learning Communities Initiative Collaborative

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Final Outcomes Congress December 9, 2005 San Mateo Medical Center Location: Primary Care Clinic in the Main Campus of San Mateo Medical Center Size: 122 Patients From ... – PowerPoint PPT presentation

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Title: California Chronic Care Learning Communities Initiative Collaborative


1

California Chronic Care Learning Communities
Initiative Collaborative Final Outcomes
CongressDecember 9, 2005

2
San Mateo Medical Center
  • Location Primary Care Clinic in the Main Campus
    of San Mateo Medical Center
  • Size 122 Patients From Dr Rebecca Ashes panel
  • with diagnosis of Diabetes, Hypertension,
    and
  • Hyperlipidemia
  • Population Served All residents of San Mateo
  • County for health care needs with an
    emphasis on
  • education and prevention, without regard for
  • ability to pay.

ICIC Website http//www.improvingchroniccare.org/

3
San Mateo Medical Center
Health System
Community
Resources and Policies
Organization of Health Care
DeliverySystem Design
Decision Support
ClinicalInformationSystems
Self-Management Support
  • Use of Diabetes
  • care flow sheet
  • Utilizing CDEMS to reach out to patients with
    poor control
  • Group visits
  • with Dr Ashes
  • patients
  • CDEMS for
  • better tracking
  • Developed
  • Foot stamp
  • Expanded role
  • for MAs
  • (Foot exam prep
  • and Action Plans)
  • Diabetes Basic
  • classes
  • Increased
  • communication
  • with clinics
  • endocrinology
  • ophthalmology
  • and podiatry
  • Patients are
  • encouraged to
  • attend self-help group
  • Patients are reminded to bring all
  • medications to each visit
  • Each patient is given
  • a Diabetes Care card
  • to track current labs
  • and meds

4
San Mateo Medical Center
Health System
Community
  • Presentations to hospital committees for
  • spread of registry
  • Collaboration with Kaiser on PHASE project

Organization of Health Care
Resources and Policies
  • Referrals to Active for Life Program
  • Smoking cessation program
  • Education Materials from California
  • Diabetes Society and
  • Nutrition Education classes
    sponsored by
  • American
    Diabetes Association


Informed, Activated Patient
Prepared, Proactive Practice Team
Productive Interactions
Functional and Clinical Outcomes
5
San Mateo Medical Center
Informed, Activated Patient
Prepared Practice Team
Productive Interactions
  • Improved patient tracking with use of CDEMS
    registry
  • Planned Diabetes Group Visits
  • Diabetes Basic Facts classes
  • Improved teamwork of clinic staff and expanded
    roles for MAs
  • Establishment of Action Plans for better
    self-management
  • Development of foot stamp and process for
    providers to perform
  • foot exams

6
Delivery System Design
  • Team Roles Tasks
  • MA prepares patient for a foot exam
  • MA initiates Action Plan with patient, MD and RN
    follow up with them
  • Planned Visits
  • Group visits with Dr Ashes patients
  • Continuity
  • CDE, RN and MA conducting Diabetes Basic Facts
    classes monthly in English and Spanish
  • - Increased communication with specialty
    clinics
  • Follow-up
  • CDEMS registry to track visits and labs

7
Functional and Clinical Outcomes
  • Baseline Actual Target
  • Dec 04 Oct 05
  • HbA1c lt 7.0 36.9 44.6 60
  • Self mgt goals set 32.3 85.3 70
  • LDL lt 100 45.9 59.8 70
  • Foot exam 28.5 77.1 60
  • BP lt 130/80 23.4 35.0 40
  • On Ace/ARB 76.6 83.3 75

8
Barriers
  • Resistance to change improving teamwork by
    adjusting roles of clinic staff
  • Labs not interfaced with CDEMS currently
    working with administration and IT for solution
  • Time we continue to meet weekly as a team at
    lunch and enter data manually

9
Keys to Sustaining and Spreading Our Chronic Care
Improvements
  • Success achieved through continued support from
    senior leadership
  • To spread and sustain change we recently obtained
    grant funds to interface labs with CDEMS and for
    ongoing clinical data entry and IT support

10
Group Visit Session at San Mateo Medical Center
This visit was very helpful. I have learned
what to eat and how to exercise.
I could start checking my sugar at home.
11
Patients Comments after a Group Visit Session
  • I have learned the Basic Facts of Diabetes
    and I will exercise more and have better eating
    habits.
  • I know what happens when you dont take your
    medicine. I will follow all lessons learned.

12
THANK YOU
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