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Location: San Angelo, Texas

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... HEALTH AND DENTAL CENTERS WILL REDESIGN ITS SYSTEM TO PROVIDE IMPROVED CARE FOR OUR PATIENTS. ... New patients identified with diabetes will be added as ... – PowerPoint PPT presentation

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Title: Location: San Angelo, Texas


1
Esperanza Health Center
  • Location San Angelo, Texas
  • Size 5 full-time,5 part time providers
  • Programs offered at center
  • Case Management
  • Community Educator
  • Social Service Coordinator
  • Population Served
  • Number of Patients Diagnosed with Diabetes 1048
  • Ethnic mix
  • 5 African American
  • 62 Hispanic
  • 33 White

2
Team Members
  • Name Title Role on Team
  • LUIS RODRIGUEZ MEDICAL DIRECTOR
    CHAMPION LEADER
  • MIKE CAMPBELL C.E.O
    EXECUTIVE DIRECTOR
  • BECKY REYES DON
    DAY-TO-DAY
    LEADER/CONTACT
  • MARICELA ALMAZAN LAB SERVICES COORD.
    PECS DATA ENTRY
  • LONNIE FRAZIER CASEMANAGER
    CLINICAL/TECH. EXPERTISE
  • HORTENCIA JACOBO EDUCATOR
    CLINICAL/TECH. EXPERTISE

Team Leader Contact Email BeckyReyes_at_esperanzahe
alth.org Telephone325-658-5339
3
Aim
  • ESPERANZA HEALTH AND DENTAL CENTERS WILL REDESIGN
    ITS SYSTEM TO PROVIDE IMPROVED CARE FOR OUR
    PATIENTS. WE WILL ACCOMPLISH THIS THROUGH
    IMPLEMENTATION OF THE CARE MODEL. THIS WILL BE
    EVIDENCED BY
  • -AT LEAST 90 OF OUR PTS. RECEIVING AT LEAST 2
    HBAICS 3 MONTHS APART WITHIN ONE YEAR.
  • -AT LEAST 70 OF OUR PTS. WILL HAVE DOCUMENTED
    SELF-MANAGEMENT GOALS.
  • -AN AVERAGE HBA1C LESS THAN 7.0.
  • -AT LEAST 60 OF OUR PTS. WILL HAVE CURRENT RXS
    FOR STATINS.
  • -AT LEAST 40 OF OUR PTS. WILL HAVE BPlt130/80.
  • -AT LEAST 70 OF OUR PTS. WILL HAVE LDLlt100.
  • ESPERANZA HEALTH AND DENTAL CENTERS WILL DEVELOP
    AND MAINTAIN A REGISTRY OF ALL OUR PTS. WITH
    DIABETES. WE WILL FOCUS ON ALL OF THE COMPONENTES
    OF THE CARE MODEL SYSTEM. TRAINING OF MEMBERS
    AND HIRING OF AN EDUCATOR WILL GUIDE THIS CENTER
    TOWARDS THE COLLABORATIVE GOALS. ONCE, THE CARE
    MODEL AND CHANGES HAVE BEEN IMPLEMENTED, THE
    OTHER PROVIDERS AND THEIR PANELS WILL BE
    INCLUDED.

4
Population of Focus
  • La Esperanza Health and Dental Centers population
    of focus will be all of the patients under Dr.
    Rodriguez care at the Chadbourne location that
    are active and have been diagnosed with diabetes.
    We curently have 521 patients. New patients
    identified with diabetes will be added as they
    establish care with Dr. Rodriguez and/or are
    initially diagnosed.

5
Key Diabetes Measures
6
Senior Leadership Support
  • How has leadership supported the team?ATTENDING
    CALL CONFERNCES, ATTENDING MEETINGS. C.E.O AND
    BOARD MEMBERS AGREED THAT ANY RESOURCES NEEDED
    WOULD BE AVAILABLE UPON REQUEST.
  • How has middle management been engaged to support
    the team? BECKY REYES, D.O.N HAS BEEN IN ALL
    CALL CONFERENCES AND KEEPING TEAM MEMBERS
    INFORMED OF COLLABORATIVE.

7
Registry
  • Registry used at our Health Center will be PECS
  • How we populated/entered patient data into
    registry by Feb 2005
  • We identified patients by running queries in our
    practice management system / billing system.
  • Chart Abstraction process was completed by
    medical records personnel pulling charts from
    medical records. List of DM patients was provided
    to medical records.
  • Maricela Almazan is entering patient data into
    the PECS registry.
  • Maricela Almazan is the primary staff member
    responsible for maintaining the PECS data entry.
    Manuel Del Real will provide back up support for
    data entry.

8
PDSA Cycles completed during Prework
  • List the PDSA cycles you completed
  • NONE
  • Are you sure about this. Did you identify
    patients by flagging the medical records with
    stickers or in the practice management system.
    What about how you came up with the process of
    abstracting information for the records and
    entering the data into PECS.

9
Communication
  • Our board of directors were informed of the
    collaborative by our CEO and our medical
    director. The clinical staff and providers gained
    knowledge of the collaborative through various
    staff meetings. Information about the
    collaborative was published in our clinics
    newsletter, The Hope Scope, to inform other staff
    members interested in the project.

10
Key Partnerships that will help our work in
Health Disparities
  • LIONS CLUB
  • P.A.P _at_SHANNON, CITY SOCIAL SERVICES
  • 55 PLUS-COMMUNITY
  • HHA
  • REFILL SYSTEM (340BETTER)
  • PROSPECTIVE-DM ASSOCIATION (LOCAL)
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