Innis Community Health Center

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Innis Community Health Center

• West Central Cluster Summit
• Moving Ahead With Spread
• November 8-10, 2004
• Dallas, TX

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SPREAD SPLENDA IN LIVONIA

• Satellite Clinic of the Innis Community Health
  Center
• Main site 2 providers for Innis
• Satellite 1 provider for Livonia
• Rural

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AIM Innis Community Health Center will
redesign its system to provide a comprehensive
case management approach for those patients
with diabetes. A defined chronic care model
focusing on a specific patient population within
the total identified diabetes patients will be
implemented demonstrating a pro-active management
of this chronic disease. Evidenced based care in
a team approach will aid these patients in
taking more responsibility in their plan of care
and assist the providers in coordinating care
more effectively and efficiently.
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Innis CHC Team

• Linda Matessino, RN, Executive Director
• Dr. Harry Kellerman, Medical Director
• Dedra Newton, RN, Family Nurse Practitioner
• Sandra Finch, RN, Clinical Coordinator
• Jeanene Thibaut, RN, Case Manager
• Rachel Nelson, HIM/Billing Specialist
• Casandra Dixon, PECS Data Specialist
• Dr. Kenny St. Romain , DDS
• Team Leader Key Contact Info Team Leader Linda
  Matessino, 225-492-3775
• E-mail Linda_at_inchc.org or
  Nursing_at_inchc.org

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IN THE BEGINNING

• Chapter 1 God created the Innis CHC in 2001
• Innis participation in HDC 2003
• Focus Diabetes
• 100 patients identified ICD -9
  (250.00 250.01)
• Chapter 2 He created partners Patients Staff
  in 2003/04
• Diabetes Collaborative
• 207 Patients in PECS
• Patient specific measurments
  quality monitoring
• Care is better today than last
  year proven
• Chapter 3 He said Go and spread the word
• Livonia Satellite clinic opening 1st qtr 2005
• 1 Provider
• 100 patients in PECS to be identified

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Spreading Splenda to Livonia Collaborative
Movement

• Livonia Clinic opening 1st qtr 2005
• 1 provider
• Population of focus - 100 patients

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The Best in Innis

• Establishing Standing order protocols for
  automatic referral to Dental and Ophthalmology
  for annual exams.
• Completing foot checks at every visit.
• Practitioner trimming nails as needed with
  referrals to Podiatry as needed.
• Creating Bring your Meds to the Visit
  campaign. Giving patients the Partners in Care
  Bag to bring meds .
• Negotiated a reduced rate with local
  Ophthalmology Providers for un-insured in order
  to get the annual retinal exam. Establishing
  voucher system for payment.
• Purchased the DCA 2000 machine for clinic to
  perform HgBA1c.
• Diabetic Teaching Review of Goals with RN _at_
  every visit.

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Lessons Learned

• Learned the Quality process PDSA cycles
• The value of the chronic care model
• For change to be permanent all must own the
  change !
• The Collaborative is a journey not a final
  destination or ending.
• Importance of patient self management goals for
  patients to take ownership of their disease.
• The collaborative is everyone in the Center not
  just the clinicians on center stage.it takes the
  whole team to win.

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Hurdles

• Using the encounter note as the progress note for
  the visit. Still a problem
• Provider buy in on the Collaborative -
• Conquered with Education
• Really using PECS and understanding its value in
  data management quality monitoring.
• Improved learning but not yet there.
• Having time and man-hours to enter data into
  PECS. Conquered- PECS Data Coordinator
• Creating more time for the pt. visit in a busy
  clinic. Conquered
• Realizing we were under-coding our visits with
  these patients. Conquered with education

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Next Steps

• Spread to the Livonia site Diabetes
• Explore spreading to Preventive Diabetes
• Explore spreading the Chronic care model to
  obesity.

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Mrs. Ruthie Coston 59 Yrs. Black female , DX
Diabetes 8 yrs, followed at Public clinic prior
to our clinic. Started _at_ Innis Clinic in May
2004 Wgt 219 Blood sugar 273 Micro-alb 75
HgBA1c 8.6 B/P 180/80 October 2004 Wgt
230as a result of her reading she found
information on her medication that stated it
could influence the weight gain. She planned to
discuss with MD _at_ next visit. Blood sugar
100 HgBA1c 6.6 Micro-alb 20 Sugar checks
report daily for 1 month range 158-90 B/P
128/82 last visit. Mammo, Pap , Nutrition
consult, Dental visit , Retinal Exam, Lipid
profile and Pneumovax all completed since May ,
2004 Self Management goals set for reducing fat
in diet and exercising with walking. Drives 43
miles one way to come to our clinic because of
our Diabetes Program. If we ask her to do it she
does it. Her compliance has been tremendous.
Many kudos' go to Mrs. Ruthie for her commitment
to take responsibility for her Diabetes.
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