Valley Community Health Centers

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Valley Community Health Centers

• West Central Cluster

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Valley Community Health Centers

• Location Northwood and Larimore, ND
• Size 1 MD, 3 FNPs, 2800 patients
• Services Primary Healthcare, Family Medicine,
  Well Child Checks and routine Pediatric care
  including ADHD, Prenatal Care, Chronic Disease
  Care, Cancer screening, Adult Preventive Care,
  Geriatric Care, Nursing Home Care, Emergency
  Services
• Population Served 73 of all patients 65

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Team Members

• Name Title/Role on Team
• Sharon Ericson CEO/Team Leader
• Condetta Ness, FNP/PA-C Provider Champion
• Laurel Johnson, LPN Clinical/Technical
• Wendy Nygaard Clinical/Technical

Team Leader Contact Emailsharon.ericson_at_valleych
c.org Telephone [phone]
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Aim

• We will redesign the current care system for
  patients with diabetes, using the Care Model as a
  guide. By doing this we hope to achieve the
  following results 90 of our patients have an
  HbA1c twice in the next year and have the average
  value of HbA1c equal to or less than 7.0

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Population of Focus

• Valley Community Health Centers population of
  focus will be the 120 patients with a diabetes
  diagnosis seen within the last year will be
  followed for ongoing primary care. New patients
  that are identified with diabetes will be added
  as they come into the practice and/or are
  initially diagnosed.

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Key Diabetes Measures
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Senior Leadership Support

• Valley Community Health Center has been involved
  in Clinic Redesign and another translation
  research project which focused on diabetes. The
  Health Disparities Collaborative was a natural
  next step. The CEO is the team leader and the
  board is very supportive of efforts to improve
  care to our 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 finding all patients
  with diagnosis 250.x seen in the past year.
• Each chart was pulled to find any information for
  services provided in the past year to patients
  with Diabetes.
• Patient data was entered into the PECS registry
  by our clinical support person. By February, we
  expect to have PECS available on our network to
  all care team members.
• The following staff members are responsible for
  maintaining data entry updates Wendy Nygaard.
  Additional team members will be trained in the
  near future.

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PDSA Cycles completed during Prework

• Organization of Healthcare (12/22/04) A meeting
  with all providers was held to outline the HDC
  models and describe PECS. Staff is attempting to
  digest changes and transition from a previous
  registry. Some difficulty with size of form,
  lack of electronic input.
• Delivery System Design Adoption of the flow
  sheet occurred 1/15/05.
• Clinical information systems (December, January)
  Data entered into PECS. Flow sheets were will
  be hung in charts beginning January 15.

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PDSA Cycles completed during Prework

• Delivery System Design (January 15, 2004) All
  charts will reflect height in order to calculate
  BMI
• Delivery System Design (January 15, 2004) All
  charts will document whether a glucometer is used
  and what type

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Communication

• The Board was approached about Health Disparities
  Collaborative prior to application.
• Staff was informed after the board.
• Health Disparities Collaborative information is
  provided at each board and staff meeting.

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Key Partnerships that will help our work in
Health Disparities

• Northwood Deaconess Health Center, local CAH,
  will provide lab, x-ray, diabetic education.
  Also working on group visits for all joint
  services.
• VCHC is part of the State Diabetes Collaborative.
• VCHC is part of the local Healthy Communities
  Access Program which has a focus on Diabetic
  improvement, provides funding for prescription
  assistance and diabetic supplies