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Community Linkages in Diabetes Care: It takes a village

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Director, Center for Community Health and Vitality. University of Chicago Medical Center ... Define roles and distribute tasks among team members ... – PowerPoint PPT presentation

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Title: Community Linkages in Diabetes Care: It takes a village


1
Community Linkages in Diabetes Care It takes a
village
  • Doriane C. Miller, MD
  • Director, Center for Community Health and
    Vitality
  • University of Chicago Medical Center
  • Merck Diabetes Collaborative Meeting
  • September 29, 2009

2
Overview
  • Tasks of self-management
  • Context Chronic Care Model
  • Promising Models
  • Take-home tips
  • Evidence-based Resources

3
Tasks of diabetes self-management
  • Taking medicine
  • Measuring blood sugar
  • Healthy diet
  • Physical activity
  • Managing stress and negative emotion
  • ENJOYING LIFE

4
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5
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6
Delivery System Design
  • Define roles and distribute tasks among team
    members
  • Use planned interactions to support
    evidence-based care
  • Provide clinical case management services for
    complex patients
  • Ensure regular follow-up by the care team
  • Give care that patients understand and that fits
    with their cultural background

7
Decision Support
  • Embed evidence-based guidelines into daily
    clinical practice
  • Share evidence-based guidelines and information
    with patients to encourage their participation
  • Use proven provider education methods
  • Integrate specialist expertise and primary care

8
Self-Management Support
  • Emphasize the patient's central role in managing
    their health
  • Use effective self-management support strategies
    that include assessment, goal-setting, action
    planning, problem-solving and follow-up
  • Organize internal and community resources to
    provide ongoing self-management support to
    patients

9
Clinical Information Systems
  • Provide timely reminders for providers and
    patients
  • Identify relevant subpopulations for proactive
    care
  • Facilitate individual patient care planning
  • Share information with patients and providers to
    coordinate care
  • Monitor performance of practice team and care
    system

10
Health Care Organization
  • Visibly support improvement at all levels of the
    organization, beginning with the senior leader
  • Promote effective improvement strategies aimed at
    comprehensive system change
  • Encourage open and systematic handling of errors
    and quality problems to improve care
  • Provide incentives based on quality of care
  • Develop agreements that facilitate care
    coordination within and across organizations

11
Community Resources
  • Encourage patients to participate in effective
    community programs
  • Form partnerships with community organizations to
    support and develop interventions that fill gaps
    in needed services
  • Advocate for policies to improve patient care

12
Evidence-based resources
  • www.diabetesinitiative.org
  • www.newhealthpartnerships.org
  • www.improvingchroniccare.org
  • AJPH Sept 2005 Racial and Ethnic Approaches to
    Community Health Detroit Partnership

13
Promising Models
  • Center for African American Health, Denver CO
    faith and health ministries collaboration with
    community health center
  • Open Door Health Center, Homestead FL community
    health outreach workers recruited from current
    patients
  • Humboldt-Del Norte IPA, Arcata CA volunteer
    peer support core, used existing breast cancer
    support network platform

14
Promising Models
  • Fargo Health Center, Fargo, ND web-based
    diabetes support group and blog, portal available
    to patients and providers
  • REACH Detroit Partnership trained Family Health
    Advocates deliver tested curriculum through group
    meetings

15
BUT HOW
16
Community Resources
  • Encourage patients to participate in effective
    community programs
  • Form partnerships with community organizations to
    support and develop interventions that fill gaps
    in needed services
  • Advocate for policies to improve patient care

17
Take Home Tips
  • Designated Driver
  • Designated Navigator
  • Infrastructure/System
  • Know your patient population
  • Know your internal/external community
  • Use volunteers
  • Be brave and creative

18
  • Doriane C. Miller, MDDirector, Center for
    Community Health and Vitality
  • University of Chicago Medical Center
  • 773-702-2739
  • doriane.miller_at_uchospitals.edu
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