Family HealthLa Clnica

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Family Health/La Clínica

• Midwest Cluster

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Family Health/La ClínicaPECS team

• 400 S. Townline Rd. Wautoma Wisconsin
• Size 2 M.D., 1 P A-C, 1RN, 1 HE
• Programs Medical, Dental, WIC, Domestic
  Violence Prevention, Outreach, Health
  Education
• Population Served
• 4,895,Total number of patients served
• 103 patients diagnosed with diabetes
• 785 migrant patients
• Patient Ethnicity
• 50 White, 50 Hispanic/Latino

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Team Members

• Ted Kay CEO,Senior Leader
• Dr. Fred Groos, Senior Leader
• Laurie Van Grinsvan, Physician Champion
• Zella Van Natta HE, Clinical Support
• Denise Rigden, RN Team Leader
• Nancy Pulver, Business Office Manager, Technical
  Support
• Maria Loera, Medical Assistant, Clinical Support
• Esperanza De Hoyos, Health Information
  Specialist, Clinical Support

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Aim

• Using the Care Models six components, Family
  Health/La Clínica will redesign the clinical
  practice to provide improved care to our patients
  with Diabetes and Depression. We will accomplish
  this by making changes in multiple areas. We
  will decrease complications associated with
  diabetes and improve patient self management
  methods. We will increase the recognition rate of
  depression and integrate an active follow-up into
  our primary care processes. We will accomplish
  this by implementing several measures.

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Population of Focus

• 103 diabetic patients
• 32 new patients spread to Depression
• All diabetic patients, and one providers patients
  diagnosed with Depression
• Transition from DEMS to PECS

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Key Diabetes Measures
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Key Depression Measures
CSD Clinically Significant Depression
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Registry

• We joined the MPCA server which is hosting PECS
• The registry was populated with 103 Diabetic
  patients originally in DEMS, we are in the
  process of adding Laurie Van Grinsvens patients
  that currently have a diagnosis of Depression (32
  total).

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Key Partnerships

• Wisconsin Primary Health Care Association-
  Technical Support
• Abbott Labs- Free Glucometers for Diabetic
  Outreach patients
• Sisters of The Sorrowful Mother- Funding for the
  Outreach Program, including Medications and
  Diabetic testing supplies
• Bousch Eye Center S.C.- Dr. Bousch will see our
  diabetic patients for a yearly dilated eye exam
  for 50.00. The patient pays 10.00 and the
  additional 40.00 is covered under our voucher
  program
• St. Michaels Hospital- Supplies an additional
  van and driver for our Summer Mobile Outreach
  Unit
• UW Systems- Provides us with Family Nurse
  Practitioner Students to staff our Mobile
  Outreach Unit