NORTHLAND COMMUNITY HEALTH CENTER

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NORTHLAND COMMUNITYHEALTH CENTER
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Background Information
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TEAM
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TEAM MEETINGS

• Prior to our change in administration, we were
  holding weekly senior team meetings at which we
  discussed HDC project work, work-flow issues,
  needed changes, and the implementation of change.
  The senior team would then bring the
  ideas/recommendations to the local team for
  discussion and implementation.
• Currently we are bringing our HDC issues and
  discussions to our Medical Staff and QA meetings
  where we discuss them in relation to our Health
  Care Plan, work on measures and goals, assign
  projects as needed, and make decisions in
  conjunction with administration. At this time our
  Medical Staff meets monthly and QA Committee
  meets quarterly.
• Senior Team members meet individually as needed
  to answer questions and concerns on a
  daily/weekly basis.

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Organization of Health Care

• Since our change in leadership occurred, our
  interim CEO has been actively involved not only
  with the day-to-day activities in our
  organization but also in our HDC activities,
  providing ideas and suggestions where indicated.
• She along with our day-to-day leader identify
  needed changes and improvements and bring them
  back to the staff for discussion and
  implementation.
• Clinical improvement is emphasized throughout the
  organization, and we are coordinating our HDC
  activities with our Quality Improvement Program
  and Health Care Plan.

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Decision Support

• Our providers practice utilizing evidence-based
  guidelines. Currently we have diagnosis-based
  written clinical protocols by which they function
  and which are available for staff review. We have
  not yet initiated evidence-based standing orders
  but are in the process of discussing them for
  possible implementation.
• Providers educate the staff on evidence-based
  guidelines through their clinical work and will
  bring this information as necessary to the staff
  at scheduled clinic meetings.
• Patients are educated on the guidelines not only
  through patient education handouts and
  consultants handouts, but also through verbal
  reinforcement during patient visits and phone
  call follow-ups.

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Delivery System Design

• Northland Community Health Center staff
  currently function under some written protocols
  as well as some less formal protocols. We
  recognize the need to establish/revise both
  organizational policies and procedures as well as
  staff protocols to help clarify roles and
  expectations.
• Reception and nursing staff are generally
  familiar with their roles/duties during the
  patient visit, and are currently working toward
  more proactive responses to changes in work flow.
  Despite a history of reactive responses, they now
  begin to see the need to work ahead rather than
  behind and the need to help facilitate the flow
  of work not only for themselves but also for
  coworkers and providers. The HDC team is trying
  to help foster an atmosphere of mutual
  cooperation for the betterment of the healthcare
  team.
• Patient follow-up is most often done by the
  providers, but may be assigned to nursing staff
  as providers deem appropriate. As we do not
  currently function with multiple disciplines
  within our organization, case management is
  handled by the providers and nurses with referral
  to outside resources as necessary.

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Delivery System Design cont.

• In order to meet our patients special needs, our
  providers visit with them to identify what those
  needs are, explore their options, and then make
  referrals and orders as needed for such things as
  Home Health, special devices, lift chairs, home
  oxygen, etc. It is usually handled through their
  visit with their provider with action and
  followup either by the provider or the nurses.
• We currently do not do group visits but are
  exploring the options utilizing our resources
  such as other community health centers,
  pharmaceutical reps handling diabetic
  medications, and Diabetes Centers
  representatives.
• We are still looking at and studying our lab
  reports flow as this has been an ongoing issue.
  We have changed our method of logging lab results
  which has freed up our LPNs time considerably
  making her more available for patient care.

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Clinical Information System

• Our Outreach Coordinator is our data entry person
  for PECS. After the information is entered, we
  are then able to generate our Diabetes Reports
  for our individual providers as well as a report
  for our whole POF. We review the results and look
  at which measures need improvement. Discussion is
  then held at Medical Staff Meeting to determine
  what actions are needed to make the improvements.
  
• We will be entering the Cardiovascular
  collaborative next and currently those patients
  are being entered into our system. The providers
  have been asked to help select pertinent optional
  measures for this collaborative to add to the
  required measures.
• We are utilizing the PECS Encounter Note for
  provider prompts regarding patient needs.
• More review and study is needed in regards to our
  non-appt. Supply and Demand which we are
  currently working on. Our plan is for more
  detailed monitoring to determine areas of needed
  improvement.

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Self-Management

• Our providers currently discuss/develop
  self-management goals with their Diabetic
  patients and document them in their dictation.
• Several different tools are available for review
  and use, but no specific tool has been
  implemented at this time.
• Our providers follow-up and monitor patient
  progress on their goals at their clinic visits.
• Consideration is being given to involve other
  staff members in the work of self-management
  goals. Available community resources are
  considered on a case by case basis.

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Community

• Our local pharmacy administers the 340B Drug
  program for our sliding fee scale patients which
  allows them to receive their medications at a
  discount. We also have a limited number of
  patients on the Prescription Assistance Program
  which is managed by our Outreach Coordinator.
  When they qualify for this program, they get
  their prescriptions free.
• Our local hospital provides the space and
  telemedicine equipment which allows our Diabetic
  patients to receive their initial education
  locally which is then reimbursed by Northland
  following any insurance coverage.

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Diabetes Measures

• National Goal
• Average HbA1C 7.0
• At least 2 HbA1C in the last 12 months (gt90 days
  apart) 90
• Self-Management goal in last 12 mo. 70

• Your Clinic MAR. GOAL - 67.5
• lt7 gt75
• GOAL - gt90 56.3
• GOAL - gt70 2.1

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Showcase your most successful graph from the
measures graph template data report
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Showcase your most challenging graph from the
measures graph template data report
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Questions from the audience?