Gurabo Community Health Center

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Gurabo Community Health Center

• Location Gurabo is located in the central
  eastern region
• Population 36,743 (census 2000)
• Gurabo is also known as Town of Stairways

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Depression Conquest
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Northeast ClusterGurabo Community Health Center

• Gurabo, Puerto Rico
• Providers 7Family Physicians,1 Pediatric,1 ObGyn,
  2 Psychologist, 1 Dentist, 1 Optometry, 2 Social
  Worker, 1 Health Educator and 15 Nurses.
• Programs Emergency Room 24/7, SISMAD, SIVIF,
  Laboratory, X-Ray- , Pharmacy, Pediatrician,Dentis
  t, Ob-gyn,Ambulatory Clinics, Nutrition,
  Immunization, Family Planning, Home Visits,
  Obesity Clinic, Optometry,Nutrition.
• Population Served
• 120 patients with Depression.

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Team Members
Team leader Contact Email gchcsistemainf_at_aol.com
Telephone [phone]
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Aim

• To redesign the system of care to provide
  improved care to our patients with depression.We
  will accomplish this by making changes in the
  following areas at the patient visit we will
  provide a coordinated care plan integrating all
  aspects of depression management, revision of the
  depression protocol and implement PECS to collect
  our data and review the progress of the patient.
  Emphasize involvement of patient in their mental
  health care.

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Population of Focus

• 120 patients
• They are from the mental health program SISMAD
• They were selected to give them the benefit of
  receiving a coordinated care plan integrating
  themselves into their treatment.

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Key Depression Measures
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Senior Leadership Support

• I am involved in the ongoing process around
  assessment of quality improvement goals regarding
  the collaborative and our institution.
• I am working with providers, staff and mental
  health providers to determine concrete ways to
  expand access to mental health services,
  especially for the uninsured.
• I achieved the support of the Board of Directors
  by presenting the Chronic Care Model and our
  future benefits of a standardized care of the
  patients.

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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 our mental health
  program SISMAD.
• Chart abstraction process was completed by the
  nurse.
• Patient data was entered into the PECS registry
  by the secretary.
• The following staff members are responsible for
  maintaining data entry updated the secretary and
  MIS

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PDSA Cycles completed during Prework

• List the PDSA Cycles you completed
• Integrate the regular ambulatory clinics with the
  collaborative clinic.
• The administration of the PHQ9 for evaluation of
  progress of patient.
• Management of patients in crisis.
• Process of evaluation of no shows.
• Integration of psychiatric consultation.
• Develop a system to identify patients in
  collaborative.

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Communication

• The senior leader is in charge of providing
  information regarding the collaborative to the
  Board of Directors.
• All personnel of the health center has been
  informed through meetings and a committee was
  established to help us accomplish our goals.

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Key Partnerships that will help our work in
Health Disparities

• Pfizer Pharmaceuticals
• Humana Reforma
• Dr. Edgardo Prieto, Consultant Psychiatrist
• Quality Improvement Program
• Community Centers in Gurabo
• Club de Leones, Parroquia San Jose