University Medicine Governor St大学医学院. Primary Care ctc .pptVIP

University MedicineGovernor St. Primary Care Diabetes and A1c Control Dr. Michael Johnson Maureen Claflin Governor St. A1c Metric Over Time Team Based Care Team Physician Nurse Care Manager Medical Assistant Nutritionist Behavioral Health Patient Caregivers Pharmacist Protocols Pre-visit planning – determine need for A1c At visit – MA will do an in-house A1c if not done in last 3 months when patient is being roomed A1c results 8.5 referral to NCM or nutritionist All newly diagnosed patients and patients new to Insulin are referred to NCM for teaching CSI Quality Improvement Team Meets bi-weekly All providers, NCM, practice manager, QI assistant and MA’s from each pod Review provider level data monthly Process/systems improvements discussed PDSAs Rollout to practice Patient Self-Management Patients are integral to their care Education happens at each visits Ophthalmology f/u Podiatry f/u Neurology f/u if necessary Short and long term SMG established Internal resources/External resources Reinforcement of patient teaching and goals Community Partners Team Works educational sessions Community CDOEs VNA and Home Care Diabetic Educators YMCA program for diabetics Nutritionists Behavioral health Challenges Patient activation – especially for poor control Obesity epidemic Coordinating patient care with Endocrinology groups Elderly population with multiple co-morbid conditions