Southeast Health Disparities Collaborative

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Southeast Health Disparities Collaborative
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HealthPoint Family Care is a nonprofit health
care organization, offering primary medical and
dental care to children and adults at offices in
Covington, Bellevue and Bracken County,
Kentucky.The organization was founded in 1971
as a part-time volunteer project to provide
health care to the poor and uninsured.Now
HealthPoint (formerly Northern Kentucky Family
Health) has evolved into a network of medical
offices employing skilled physicians and nurse
practitioners. We are still a "safety net" for
patients who have no health insurance. But we
also accept major insurance plans, along with
Medicare and Medicaid.
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Mission/VisionOur mission is to be the area's
preferred primary health care partner, providing
outstanding, compassionate care to ALL.Our
vision is to be the leading provider of primary
care services in Northern Kentucky and the
surrounding Kentucky counties.
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The HealthPoint Family Care Values Patients We
exist to serve the needs of our patients. Our
work must be performed with a focus on the needs
of our patients and their families. People Our
people are our most important resource. Their
character determines our reputation and strength.
Teamwork We are a team. We must treat each
other with trust and respect and work together to
accomplish our vision and mission. Quality To
achieve customer satisfaction, the quality of our
services must be our Number 1 priority.
Continuous Improvement We must strive for
excellence in everything we do by continually
improving both our internal processes and our
patient services. Integrity We must always
conduct our business in a manner that is socially
responsible and commands respect from our
patients, competitors, regulators and the
communities we serve. Services Our services are
the end result of our efforts, and they should be
the best available to our patients. As our
services are viewed, so are we viewed. Financial
Strength Profits are required to survive and
grow. Our ultimate success depends on our ability
to maintain an efficient and profitable
operation.
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Diabetes Team Roster

• Senior Leader - Chris Goddard
• Medical Director Elmer Martin, MD
• Physician Leader Steven Neus, MD
• Team Leader Peggy Vazquez, RN
• Team Members
• Barbara Lippert
• Ruth Weissman
• Tammi Woods

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• HealthPoint Family Care will redesign its system
  to provide improved care for our patients with
  diabetes. We will accomplish this through
  implementation of the Care Model.

Networking
Community Resources
Patient Education
Self Management Tools
Commitment
CIS Registry
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Population of Focus HealthPoint Family Cares
population of focus will be all the diabetic
patients in Dr. Neus practice at the Bracken
County site. The initial size of our Population
of Focus will be approximately 115 patients and
new patients identified with diabetes will be
added as they come into the practice.
Dr. Neus and the Health Center staff are
committed to improving the quality of life for
the patients they serve. The Bracken County
Health Center was chosen to pilot the Care Model
because of this commitment and openness to
process improvement.
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Key Diabetes Measures

• Average HbA1c lt 7.0
• Two (or More) HbA1c in 12 months
• SM Goal Setting in Last 12 Months
• Patients gt30 Daily aspirin/anti-thrombotic use
• Patients with BPlt130/80
• Patients with LDLlt100
• Foot exam in last year
• Pneumoccal vaccine

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PECS Registry
The team has entered all 130 patients with
diabetes into the registry. We are looking
forward to learning more about the PECS system
and using all its capabilities to help manage our
patients with chronic diseases. This will be our
stepping stone to the implementation of our
future EMR.
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Present and Future
Partnerships
Health Foundation
DPCP of Kentucky
Community Pharmacy
Greater Cincinnati CHC's
HPFC Dental Podiatry Partners
Northern Kentucky Health Department