Instructions

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Instructions

• A few of the slides you created for your previous
  storyboard might remain consistent, (i.e. Aim
  Statement, list of key measures, list of team
  members.) The exception would be if the
  directors provided comments/edits to any of these
  areas on your monthly report. You need to
  remain consistent and have the AIM statement,
  list of key measures, etc as they appear on your
  monthly report.
• You will have submitted two monthly reports by
  learning session two. You are either TESTING
  ideas under each component of the Chronic Care
  Model and/or have already IMPLEMENTED changes
  under the components of the Care Model.
  (remember, that means that the change would not
  go away in your organization if you ended
  participation in the Collaborative process
  today!!) The tests of change and changes
  implemented is the new information you will be
  sharing at learning session two. Most of the
  information youll need is already in your
  monthly report. Keep the description short and
  to the point but with enough description that the
  reader can get the major points from your
  storyboard.
• Update your data and insert the graphs from your
  excel file on slides as demonstrated on slide 13
  and 14. Make the graphs large enough so that
  they are easy to readno more than 2 to a page,
  if possible. Therefore, you will need more than
  2 slides to display your progress for all
  measures that you are tracking. DO NOT SUFFER
  IN SILENCE ! Please post a ticket to the Help
  Desk on SharePoint as soon as possible if you
  need help accomplishing this step.

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Learning Session 2May 12-14, 2005Atlanta,
Georgia
Cluster NORTHEAST CLUSTER
Project Samaritan Health Services
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PROJECT SAMARITAN HEALTH SERVICES

• Location Damian Family Care Center, Jamaica, NY
• Size 17,550 visits per year. Total
  medical/dental providers 5.6 FTE's (2.0 FTE's
  are PCP)
• Scope of Services Primary medical care,(Adult
  Peds) GYN, Dental, Psychiatry, Optometry,
  GI/Hepatology and Podiatry.
• Special Programs HIV, Hepatitis C Homeless
• Population Served -75 currently registered
  Diabetics who meet the selection criteria for
  POF.
• Ethnic mix 36.2 African-American, 29 Hispanic,
  13 Asian, 10.1 Caucasian, Other/unspecified
  11.5

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Team Members

• Name Title Role on Team
• M. Gebhardt CEO Senior Leader
• P.Wylie-Kennedy COO Senior Leader
• K.Begum MD Provider Champion
• S. Pierre, RN Nurse Manager Day-to-Day Leader
• J. Roscoe RN QI Facilitator Clinical/Tech
  Support
• C. Pocasangre Adm. Asst. PECS Data Maintenance
• Asif Ahmed MIS Specialist MIS Contact

Team Leader Contact Email
Prohlt53_at_aol.com Tel [phone]
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AIM Statement

• AIM The Diabetic health care team at Project
  Samaritan Health Services will apply the six
  components of the Chronic Care Model to
• Ensure the application of evidence-based
  practices for all Adult Diabetic patients.
• Promote optimum clinical outcomes in the POF for
  all clinical measures over the next year through
  planned visits and timely follow-up procedures.
• Provide strong support and guidance for patient
  self-management and establishment of
  self-management goals.
• Redesign existing documentation tools to
  facilitate and guide the plan of care at each
  encounter.

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Selected DM Measures

• Average HbA1c lt 7.0
• gt 90 DM Patients with Two (or More) HbA1c in
  Last 12 Months (gt90 days apart)
• gt 70 DM Patients with SM Goal Setting in Last 12
  Months
• gt 40 DM Patients with BP lt130/80
• gt 70 DM Patients with LDL lt100
• gt 70 DM Patients who had a Dental exam in past
  12 months
• Cardiac Risk Reduction Option 3 gt 80 DM
  Patients, age 40 or older, on Aspirin or
  antithrombotic agent
• Optional Measures
• gt 70 DM Patients who had a dilated eye exam
  done in last 12 months

7
Self-management

• Currently Testing
• Effectiveness of Self-management form in helping
  patients establish realistic SM goals.
• Dental Self-Management form with goals specific
  to dental care.
• Implemented into our Delivery System
• Form titled, Diabetes Self-Management
• Processes for (1) Use of 5 A's for SM to
  assist patients in establishing hopefully
  achieving written goal(s), (2) Keeping a SM form
  in chart as part of permanent record to be used
  by providers as flow sheet for tracking SM
  outcomes at follow-up visits.
• A system to communicate patients specific
  self-management goal(s) to PECS staff for entry
  into registry on to PECS Encounter form.

8
Community

• Currently Testing
• Partnering with local hospital to refer PSHS
  patients to their Diabetes support group
  programs.
• Partnering with Faith based organization for
  additional community outreach services.
• Implemented into our Delivery System
• Relationship established with NYSDOH for various
  support systems, i.e. patient educational
  materials, patient support services, testing
  equipment, community outreach programs.
• Relationship with CHCANYS well-established
  excellent source for networking.

9
Healthcare Organization

• Currently Testing
• Development of Orientation package for all
  employees on the collaborative models.
• Implemented into our Delivery System
• Care Model and Model for Improvement is fully
  integrated into our organization-wide performance
  improvement program.
• Collaborative report presented at each BOD and
  Quality of Care Council meeting. Includes summary
  of monthly narrative report and Excel charts.

10
Decision Support

• Currently testing
• A system to obtain verification reports from
  external providers on dental optical exams.
  (This pertains to services that are not a result
  of PSHS referrals. System already in place if
  referral made by PSHS staff.)
• Implemented into Delivery System
• RN staff, at end of each visit, use PECS
  encounter form to record communicate data to
  PECS staff for entry into registry.
• Continued use of Diabetes Flow sheet( developed
  2003) as the primary documentation tool for
  providers. This form has all best practice
  gudelines for DM embedded in its design and has
  been tested as successful in guiding the plan of
  care.
• A system for communicating lab/diagnostic results
  to PECS staff that are received post visit.
• Didactic interactive educational programs for
  medical/dental providers support staff on care
  model, key measures, practice guidelines, SM,
  PDSA tests, process redesign implementation.
• A questionnaire to determine if DM patients, who
  have not had a dental and/or optical visit at
  PSHS, are receiving these services from external
  providers.

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Clinical Information System

• Currently Testing
• Computer installation in clinical work areas to
  provide team with immediate access to data in
  PECS registry and to HDC network. Training is in
  progress.
• Implemented into Delivery System
• Use of the PECS registry to track, report and
  communicate results for the POF. Reports printed
  by PECS staff distributed to HDC team.
• Excel Reporting working very effectively. Reports
  used effectively to evaluate performance .
• Use of the registry to identify patients that
  require follow-up for appointments, testing.

12
Delivery System Design

• Currently Testing
• No Activity at present
• Implemented into Delivery System
• Green colored binders used to identify charts of
  DM patients.
• A System for flagging newly diagnosed patients
  which includes
• An RN reviews all patient records post visit.
  (P/P since 2001)
• If patient is diagnosed with Diabetes, the RN
  reviewer communicates this to clerical staff.
  Clerical staff will place chart in color-coded
  binder.
• Day-Day Leader or designee prepares chart
  abstract forwards to PECS staff for entry of
  new patient into registry.
• A process system for ensuring that
  lab/diagnostic results received post visit are
  sent to PECS staff. This includes
• PECS Encounter form is held in the pending lab
  folder.
• When test results are received/reviewed the RN
  will enter the test values onto the PECS form,
  which is then forwarded to PECS staff.

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Functional and Clinical Outcomes
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National Key Measures
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Project Samaritan Health Services Key Measures
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Project Samaritan Health Services Key Measures
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Project Samaritan Health Services Key Measures
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Project Samaritan Health Services Key Measures
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Senior LeadershipMaking the Case for Change

• What information did you share with your ED/CEO
  and/or Board of Directors to encourage them to
  make improvements in the management of Diabetes?
• Slide presentations on the collaborative model at
  special meetings of the BOD.
• BOD resolution was obtained by CEO in support of
  submitting HDC application and BOD participated
  in the HDC interview process.
• BOD was already introduced to the concepts of
  this process pursuant to PSHS participation in
  (2) NYCDOH collaboratives in 2002 -2004.
• How did you promote the work?
• Monthly Narrative Reports These are very
  effective for reporting teams progress to ED/CEO
  BOD..
• Excel Reports/Graphs Distributed and discussed
  for each key measure. PSHS actual compared to
  national target goals.

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Communication Plan (How are you communicating
your progress at the center level and within your
community)

• At the center level
• BOD meetings ( Community members are on BOD)
• Quality of Care Council meetings
• Staff meetings( Includes medical/dental
  providers)
• Management meetings
• Special Educational programs.
• Storyboard posted in clinic for staff
  community.
• At the Community level
• Through partnerships that we are establishing
  with community
• outreach programs. (includes NYSDOH CHCANYS)

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Anticipating Barriers and Issues
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A story to share.the patient

• 42 year old male with new onset Diabetes
  diagnosed in October 2004. He was consistently a
  no showfor scheduled visits with PSHS dental
  optometry. At a recent visit with the PCP, our
  Day-Day team leader identified this via review of
  the PECS encounter form. Educational session held
  with patient to discuss importance of dental
  eye care in preventing complications of Diabetes.
  SM plan established with patient. He has since
  kept appointments with dental optometry and
  continues to work on setting new goals. Our
  teams heightened awareness to the key DM
  measures and these components of the care model
  have now spread to all DM patients.

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A story to share.our staff

• We do not have one story to share but rather an
  overall observation of the impact we have seen to
  date with our PSHS staff. Our medical providers
  for POF, nursing staff and even our clerical
  support staff are working closely as a team and
  demonstrating a more seamless approach in the
  care of our POF. Better still we are beginning
  to see the concepts of the collaborative care
  model infiltrating their care approach for
  other populations. The clinical staff, in
  particular, has a heightened awareness of total
  patient needs and is demonstrating the ability to
  look at the bigger picture. We are seeing a
  focus on caring for the whole person rather
  than just treating a disease.

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A story to share.the organization

• GREAT STUFF HAS HAPPENED!!
• Timeline for EMR and Practice Management system
  moved from 2/3 years to within one year. System
  selected and approved by BOD.
• Installation of computers with Internet
  connection in clinical areas.
• Applying the concepts of the collaborative care
  model and PDSA testing into our performance
  review process system-wide. This has been fully
  integrated into our organizational quality
  improvement program.
• Incorporating the self-management model into
  other populations services, Ex. Asthma,
  Depression Dental care.
• Use of Diabetes Encounter form system-wide.