UCOD

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U-COD

• Unalaska Collaborative on Diabetes

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Iliuliuk Family and Health Services, Inc.

• Unalaska, Alaska

• Three Full-Time Medical Providers
• Two Full-Time Behavioral Health Counselors
• One Full-Time Dentist
• Eleven Clinical Support Staff

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Iliuliuk Family and Health Services, Inc.

• Population Served Approximately 15,000
• Residents of Unalaska (4,400)
• Transient workers at Shore-based Seafood
  Processors (3,000)
• Crew members of Fishing Fleet (8,000)
• Multi-ethnic Caucasian a Minority
• 94 Patients currently diagnosed with diabetes
  entered in registry

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U-COD Team Members

• Jeanne Kemp, RN Team Leader
• Sonia Handforth-Kome Senior Leader
• George Khoury, MD Physician Champion
• Charlotte Nery Administrative Expert
• Maria Kueber, MA/EMTIII Clinical Expert
• Chris Bobbitt, MCSE IT Specialist
• Craig Booth, DDS Dentist
• Elaine Fahrenkamp, PhD - Counselor

Team Leader Key Contact Info 907-581-1202
jkemp_at_ifhs.org
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Aim

• Our health center will develop a chronic care
  model with initial emphasis on diabetes. We will
  redesign our system of care using the care model
  and our progress will be measured using the key
  measures listed below
• Within 9 months 50 of our designated population
  will have an Hgb A1C equal to or less than 7.0.
  
• We will utilize self-management education, which
  will include instruction in the use of blood
  glucose monitors for each client.
• We will also partner with local community
  organizations as possible to assist our clinic in
  reaching our goal.

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Key Diabetes Measures
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Self-management

• Currently Testing
• The spread of the self-management tool as clients
  come in for scheduled visits
• Implemented into our Delivery System
• SM tool now in each exam room (English/ Spanish)
• SM goals reviewed with patient at every scheduled
  visit with any provider.

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Community

• Currently Testing
• Developing voucher/pay system for Lions Club to
  pay for optometrist visits
• Implemented into our Delivery System
• Monthly diabetes support/education group
• RN hired to provide diabetes education

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Healthcare Organization

• Currently Testing
• Optimizing CPT Coding for diabetes education
  visit by NP who is also CDE
• Orientation package for all employees on the
  collaborative models
• Implemented into our Delivery System
• Care Model and Model for Improvement part of our
  quality improvement program and incorporated in
  strategic plan
• Practitioner contracts have been modified to
  require full participation in Collaborative
  efforts
• Collaborative report submitted to Board Of
  Directors on monthly basis and ED presents
  quarterly to the board

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Decision Support

• Currently testing
• Use of encounter note to trigger clinical
  decision making.
• Standing orders for missing labs and referrals
  for use by nursing staff
• Implemented into Delivery System
• Routinely provide interactive education programs
  for all staff
• Establish criteria for referral of patients to
  specialists and assure that PCPs have access to
  expert support from specialists for consultation

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Clinical Information System

• Currently Testing
• Easy access for providers and nursing staff to
  clinical information from the registry. Computer
  with access to network placed in provider/nursing
  work station
• Implemented into Delivery System
• Designated personnel for tasks and registry
  maintenance
• Using the registry to track, report and
  communicate results and outcomes of care
  effectiveness over time and across providers
• 3 nurses are currently trained and entering PECS
  data on a regular basis

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Delivery System Design

• Currently Testing
• Appointment and recall systems that support the
  needs of our patients for follow-up activities
• Implemented into Delivery System
• Use designated caseworker to connect with
  patients via phone calls, support group and
  informal patient outreach
• Designated health educator and patient advocate
  to work on goals of collaborative

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Functional and Clinical Outcomes

• Measures Goal as of 05/2005
• 2 HbA1cs in last yr gt90 38.7
• Average HbA1c lt7.0 7.6
• Documented self gt70 26.9
• management goal setting
• BP lt 130/80 gt40 29.3
• ACE inhibitor for pt over age 55 gt75 75.8
• Dental exam in past year gt70 8.6
• REGISTRY SIZE 94

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National Key Measures
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Senior LeadershipMaking the Case for Change

• Executive Director involved from outset of
  collaborative. Part of weekly team meetings
  involved in data extraction, helped to build data
  base in PECS.
• Shares monthly reports with board of directors.
• ED is a member of Lions Club, working with them
  to develop assistance for clients to obtain eye
  exams at reduced cost.
• ED also included meeting collaborative goals as 1
  of 4 major goals in strategic plan

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Communication Plan

• At the center level
• Share monthly reports with all staff
• Daily interaction among practitioner and medical
  staff regarding collaborative
• Held 2 training sessions for all nursing and
  practitioner staff during 1st action period.
• At the Community level
• Monthly diabetes support/education meetings
• Working with Lions Club on assisting clients to
  obtain eye exams at reduced or no cost.

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Anticipating Barriers and Issues
Those that the team can resolve
Those that leadership needs to address

• Teaching space and time
• Staff responsibilities
• regarding education of clients who does
  what?
• Education for additional staff

• Information systems EMR

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A story to share.the patient

• Client with diabetes since 2/04 along with
  multiple other health problems.
• As a result of collaborative, group educational
  meetings, and overall increased motivation of
  client, he began to take control of his health,
  began exercising on a regular basis, and
  diligently working on his food choices.
• Labs demonstrate a great change
• 9/04 Hgb A1C 9.8 Wt gt 450 lbs. BP 130/100
• 3/05 Hgb A1C 6.6 Wt. 400 lbs. BP 110/80
• Initially resistant to any education re health
  issues, he recently came to clinic asking, When
  is the next diabetes group meeting? I was out of
  town for the last one.

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A story to share.our staff

• Becky, LVN and Maria, MA were asked to
  participate in a career day at the local jr./high
  school.
• They decided it would be fun to offer blood
  glucose testing at the career fair. They got in
  touch with the school, and received great support
  from the principal and superintendent. The
  school nurse, designed a consent form which the
  school nurse distributed to all students in those
  grade levels. On career fair day, they had a
  great time, not only sharing about nursing as a
  career, but also giving solid personal health
  information to the students. The school nurse is
  following up on any elevated levels.

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A story to share.the organization

• At a recent potluck, Jessica, one of our PAs
  suggested we all test our blood sugars after
  eating Becky, LPN got out the glucometer, and
  within a few minutes all of the staff had checked
  their blood sugars!
• Heres our results
• Were having fun while incorporating the
  collaborative into our professional and personal
  lives.
• Turns out that Jessica had the highest blood
  sugar
• (see photo)