Learning Session

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Learning Session 2May 12-14, 2005Atlanta,
Georgia
Southeast Division Health Disparities
Collaborative
Family Health Centers of Southwest Florida
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DEMOGRAPHICS
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Dr. James Taylor, DO Vice President/Chief
Medical OfficerCarol Speelman, RN Clinical
Operations ManagerNerida Staeber, MSHA, RN
Bilingual Health Educator Ed Negron I.S.
Specialist
TEAM MEMBERS
Key Contact cspeelman_at_HCNetwork.org
[phone] Ext 5315
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A I M STATEMENT

• To redesign the health care system with the
  implementation of the Care Model in
• order to improve diabetic patient care.
• We will accomplish this by making changes in the
  following areas
• We will establish organizational protocols and
  patient education with an emphasis on
  self-management.
• We will enhance our bilingual educational
  process.
• We will monitor our patients treatment regimens.
• We will monitor our patients ongoing laboratory
  studies.
• Our Chief Medical Officer and team Clinician will
  regularly monitor the outcomes of our program.
• We will promote a team approach by incorporating
  other clinicians, case managers, outreach
  workers, and management personnel.

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POPULATION OF FOCUS

• Location
• DTFM Family Practice
• of Patients
• 200 to 300 patients
• (Currently have 330 patients registered in
  PECS)
• Selection Criteria
• Largest Number of Diabetics

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KEY DIABETES MEASURES
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OPTIONAL MEASURES
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Community

• Currently Testing
• Implemented into our Delivery System
• Partnered with Lee County Health Dept to provide
  biohazard waste containers free of charge to our
  diabetic patients.
• Partnered with Merck, Pfizer and Bayer to provide
  culturally appropriate health education
  materials.

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Decision Support

• Currently testing
• Standing orders for missing labs and referrals
  for use by support staff and Case Managers.
• Clinical Practice Protocols for Providers.
• Implemented into Delivery System

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Clinical Information System

• Currently Testing
• Integration of PECS into Practice Management
  system.
• Implemented into Delivery System

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Delivery System Design

• Currently Testing
• Screening tool for depression
• Implemented into Delivery System
• Annual evaluation of all clinical support staff
  for accuracy in taking vital signs.
• Quarterly educational session for all staff to
  ensure compliance with correct documentation of
  vitals.

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Senior LeadershipMaking the Case for Change

• On an ongoing monthly basis information regarding
  the progress of implementation and the results of
  the collaborative are shared with the CEO and
  Senior Executive Committee. This information is
  presented to the BOD on a quarterly basis.
• The entire provider staff at FHCSWF has been
  presented the concept and specific functions of
  the health disparity collaborative. The
  individual provider and corporate improvements
  noted are shared at this time in order to promote
  continued change.

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Communication Plan

• At the center level
• - Quarterly reports are given to all
  providers, showing
• compliance of their diabetic patients with
  HgbA1C.
• -Monthly reports to Senior Executive Team of the
  number
• of patients attending classes.
• -Presentations to the Medical Office Mangers
  informing
• them of the goals of the collaborative.
• At the Community level
• -Attended several migrant health fairs and
  offered diabetes screening and education.
• -Educated staff at Salvation Army on diabetes
  education and the collaborative.
• -Invited to speak at two local churches to speak
  about diabetes.

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

• Clinical decision making
• Staff assignments and responsibilities
• Education for staff

• Information systems
• Resources for time and equipment and staff.

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A story to share.the patient

• One of our most memorable patients was a 34 year
  old Hispanic male, father of three, with his wife
  expecting their 4thchild.
• His Hemoglobin A1c when he was first referred
  into our program was 12.7.
• Three months after he and his wife received
  Diabetes Education his Hemoglobin A1c was 5.5.
• This patient has continued to be compliant and is
  very grateful for his new lease on life.

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A story to share.our staff

• As a direct result of the problem we found with
  staff obtaining and documenting accurate vital
  signs, the Office Manager in the office of our
  POF talked with providers and staff about the
  importance of taking and documenting vital signs
  at her last staff meeting.
• She educated them on how to compare the last
  vital signs to the current visit in case they
  were questioning their findings.
• Review of 20 charts showed a marked improvement
  with only 1 chart missing 1 vital sign. Staff
  took the problem as a challenge and have worked
  as a team to better serve our patients.

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A story to share.the organization

• After the first Learning Session our Medical
  Director came back enthused with the information
  he had learned about aggressive treatment of
  Metabolic Syndrome.
• He developed practice guidelines which have been
  distributed to all providers in our organization.
  Those guidelines were very favorably received
  and we will be monitoring our entire diabetic
  population for overall compliance.