Jagruti Shukla, MD, MPH

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• Jagruti Shukla, MD, MPH
• Medical Director
• September 9, 2008

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San Mateo Medical Center Main Campus Primary Care
Clinic

• 11 San Mateo County Clinics, FQHC
• 9 Physicians 6 FTE, Approx. 20,000
  visits/year
• Patient Population

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Chronic Care Model Past Experience

• One Provider Team in SNI Collaborative in 2004
• Introduction of CDEMS Registry
• Chronic Disease Management
• Improvements in Clinical and Process Measures
• Success working as a team

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TOOLKIT INTERVENTION

• Introduced by Administration
• Random division of providers into Intervention
  and Control Groups
• Formation of MD-MA-Clerk teams
• Jointly set goals 10 parameters total
• Data transfer for all Diabetic patients into CDEMS

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MAJOR ACCOMPLISHMENTS

• Working together as teams
• CDEMS data sheet used as the Progress Note
• Chronic disease education at each visit
• Monthly group visits for all providers
• Some Population Management ( No labs 1 yr)
• Improvements seen in both process outcome
  measures

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Reflections What worked well

• Experience of our pioneer team with CDM
• Formal structure, timelines, reporting
• Coaching Support
• Weekly meetings - time allocation for
  brainstorming and reporting
• Toolkit references
• Targeted Interventions Pneumovax

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Reflections Challenges

• Time commitment for data input, reports, and
  meetings
• Integration of CDM into usual workflow
• Significant amount of front-end work prior to
  seeing benefits
• Active communication with staff not involved
• Sustaining and spreading successful ideas
• Interpretation of the variation seen in the
  MDs data reports

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Next Steps

• Establish patient care teams for all providers
• Identify all clinic patients with DM and
  populate CDEMS Registry
• Further develop role of MA, Clerk, and RN
• Monthly group visits for all providers
• Add Pharmacist and LSW into the clinic
• Continue to monitor and discuss measures

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San Mateo Medical Center Main
Campus Primary Care Clinic
Questions?