Health Center Name

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Valemount Health Center

• Diagnostic and Treatment Center
• Rural area
• Catchment area of 2500
• 2 physicians
• Pilot project
• 29 diabetes patients

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Team Members

• Dr. Wayne Dong
• MOA Teena Storoschuk
• Nurses Mia Dong (maternity leave), Ramona Kowch
  (replacement), Susie Taylor,
• Marie Hasper (diabetic educator) resigned

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• Aim and Key Measures

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Clinical Information Systems

• Status of Toolkit
• pilot 29 diabetic patients now there are 70 pts
  in the toolkit
• all support staff type in data into our EMR
  MOIS and then transferred into the tool kit
• Use of the Toolkit in planning care
• Use of recall system every 2 wks
• transfer of data q2wks from MOIS

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Decision Support

• PDSA cycles implemented
• nurse does a diabetic foot check
• All Office staff input data into MOIS EMR
• office staff (MOA) check their BMI, status of
  their immunizations for influenza and
  pneumococcal and last eye check up
• Physicians review the issues on the flowsheet

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Delivery System Design

• PDSA cycle implemented
• MOA call pt to get blood work done before clinic
• Standing orders for HgA1c q3mo and f.chol. Ast,
  alt, ck, MAC, lytes, bun, cr annual with lab
• Diabetic clinics are on Tuesday afternoons
• Print out flowsheets from the toolkit before
  clinic
• We have 4 patients per hour for 2 sessions
• Pts are rotated and see the physician, MOA and
  nurse

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Self-management

• PDSA cycles implemented
• Pt handout about why certain blood tests are done
• Goal setting eg weight loss or quit smoking
• the challenges or barriers overcome
• Patient acceptance of new way of managing their
  diabetes clinic calls them in and visit is just
  for diabetes

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Community

• Community care is very poor, as we have few
  support groups for anything. We are hoping to
  involve patients in leading some of the support
  groups such as the beginner walking group which
  we hope to start

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Spread of Diabetes Management in our office

• Dr. Markham has started the diabetes clinics
• Follows the same protocols that we have set up
• Challenges
• Time (other priorities in the clinic)
• Motivation to get clinics done

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HgA1c
Valemount BC Coll.
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HgA1c
Valemount BC Coll.
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Blood pressure
Valemount BC Coll. Goal
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Blood pressure
Valemount BC Coll.
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LDL
Valemount BC Coll.
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Eye exam
Valemount BC Coll. Goal
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Albumin to Creatinine Ratio
Valemount BC Coll.
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Lower extremity exam
Valemount BC Coll. Goal
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Self Management
Valemount BC Coll. Goal
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Yet to be done

• Organizing meetings with dietician with video
  telehealth
• Try out different patient information sheets
• Teach all the nurses how to do diabetic foot
  check
• Organize binders for individual patients

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Challenges and barriers in sustaining the changes
made

• Staff enthusiasm and diligence
• Manpower issues
• No diabetic nurse educator
• Have not had diabetic clinics in the past two
  months because of no nursing support
• System is still not self sustaining large part
  of maintenance done by one person

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Possible Solutions

• Regular staff meeting
• Encouragement
• Reinforce roles and duties
• Resolve any problems
• Address manpower issue with management
• access Telehealth for dietician