Gaston Family Health Services Gastonia, NC

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Gaston Family Health ServicesGastonia, NC

• Southeast Health Disparities Collaborative

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Gaston Family Health ServicesSugar Babes

• Size
• 2 Medical Clinics and 2 Dental Clinics
• 5 Family Practice Physicians, 1 FNP-C, 2 PA-C, 2
  Dentists
• 90 Clinical and Administrative Staff
• Full-service pharmacy
• Population Served
• Number of patients served15,575, encounters
  42,129
• Number of patients diagnosed with diabetes 1637
• Number of homeless and migrant patients 0
• Ethnic mix 62 White, 27 Black, 4 Hispanic
• Programs Offered
• Diabetes Center, Podiatry Clinic, DM Eye
  Screening, Asthma Education Classes, Behavior
  Health, Medication Assistance Program, Pfizer
  Share the Care, HIV Case Management, Medicaid
  Managed Care, Industrial Health Primary Care and
  Care Management, Parish Nursing

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Team Members

• Robert Spencer Executive Director
• Shirley Ocloo, MD Medical Director
• Veronica Feduniec, RN, ND Chief Operating Officer
• Valerie Waddell, DDS Dental Director
• Leslie Ware, PA-C, M.Ed. Provider Champion
• Teresa Morris, RN, CDE Team Leader
• Kathy Vinson, MOA Clinical Support

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Aim Statement

• Gaston Family Health Services will redesign its
  system to provide improved care for our patients
  with diabetes. We will accomplish this through
  the implementation of the Care Model. This will
  be evidenced by
• At least 90 of patients will receive at least 2
  HgbA1cs 3 months apart within one year.
• An average HgbA1c less than 7.0.
• At least 70 of patients will have documented
  self-management goals.
• At least 80 of patients 40 years and older will
  take aspirin or another antithrombotic agent.
• At least 40 of patients will have a BP lt130/80.
• At least 70 of patients will have an LDL lt100.
• At least 70 of patients will have obtained a
  dental exam in the last year.

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Population of Focus

• Gaston Family Health Services population of
  focus (POF) will include
• Diabetes patients of one provider, Ms. Leslie
  Ware, PA.
• Initial size of our POF will be approximately 150
  patients.
• New diabetes patients of Ms. Wares will be added
  as they come into the practice and/or are
  initially diagnosed.
• Provider was chosen because of experience with
  disease management programming and openness for
  new opportunities to improve patient care.

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Key Diabetes Measures
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Registry

• The Registry has been populated at the time of
  the patients appointment. We are researching
  ways to populate the registry at one time.
• The Medical Assistant prepares a PECS Diabetes
  Flowsheet for the provider.
• The provider documents process measures on the
  PECS Diabetes Flowsheet and in the electronic
  medical record.
• The Medical Assistant enters the information into
  the PECS database.
• Currently, all data is entered into two systems.
  We hope to integrate these systems.
• Current number of patients in registry 40

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Key Partnerships

• Local podiatrists provide podiatry services to
  self-pay patients.
• Local ophthalmologists and optometrists
  participate in a diabetes eye screening six times
  per year. A NC Services for the Blind Social
  Worker is available during the screening to
  certify patients or make referrals to the local
  Lions Club.
• The GFHS Medication Assistance Program works with
  pharmaceutical companies to provide free
  medications to approximately 600 patients.
• Pfizer Share the Care program is available to low
  income patients providing medications at low-no
  cost through the clinic pharmacy.
• Blue Dot provides wheelchair maintenance for
  indigent patients.
• The Gaston County Health Department provides
  classroom space and various allied health
  services.