Autaugaville Family Health Center

1
Autaugaville Family Health Center

• Southeast Health
• Disparities Collaborative

2
Health Services, Inc.(alpha-bamians)

• Autaugaville, AL
• 1 physician 1 each LPN, nursing asst, pt.
  rep.
• Podiatry and CDE once a month
• Population Served
• Approximately 820 in town limits.
• Approximate 101 diabetic patients.
• No homeless. Migrant number unknown.
• Black (66.0, White (32.3), two or more
• races (1.2), Hispanic (1.0).

3
Team Members

• C. Bernell Mapp, CEO, Senior Leader
• Julian E. McIntyre, M.D., Medical Director
• Ace Anglin, DPM, Team Leader
• Olu Adediji, M.D., Physician Champion
• Kathy Cunningham, RN, Director of Nursing
• Linda Cates, RN, Special Operations/QA
• Rhonda Overton, RN, CDE
• Felicia Greer, LBSW
• Jimmy Madden, IS

4
Aim

• Autaugaville Family Health Center will redesign
  its system to provide improved care for our
  diabetic patients. We will utilize the Care
  Model to implement this process. Results of this
  process will be shown by
• At least 90 of our patients will receive at
  least 2 HgbA1cs, 3 months apart, within one
  year. 
• An average of 75 of our patients will have an
  HgbA1c between 6.5-7.0.
• At least 80 of our patients will have documented
  self-management goals.
• At least 75 of our patients will have current
  prescriptions to ACE Inhibitors or ARB
  medication. 
• At least 75 of our patients will have BP
  lt130/80. 
• At least 75 of our patients will have LDL lt100.
• At least 60 of our patients will be referred for
  an annual dilated eye exam. 
• 65 of our patients will receive a foot exam
  annually. 
• Urine protein testing will be done annually on
  75 of our diabetic patients.

5
Population of Focus

• Health Service, Incs. population of focus will
  be all the patients of Dr. Olu Adediji at the
  Autaugaville Family Health Center, Autaugaville,
  AL.
• The initial size of our Population of Focus will
  be approximately 100 patients and new patients
  identified with diabetes will be added as they
  come into the practice and/or are initially
  diagnosed.

6
Key Diabetes Measures
7
Optional Measuresif applicable

• 65 of all diabetic patients will have a
  comprehensive foot exam annually.

8
Registry

• QA RN gathers data from the diabetic encounter
  form. (The encounter information will be
  forwarded to the data entry clerk by the
  physician, after the initial patients are
  entered.)
• Data entry clerk enters information into PEC.
• 76 patients currently in registry.

9
Key Partnerships

• ADPH
• Aventis, Novartis, Pfizer, Glaxo Wellcome, Foster
  Drugs
• Alabama Medicaid
• Community Care Network
• Community churches