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Beulah, North Dakota
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Background Information
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Team What happens at a meeting? Meet how
often? How do you make decisions? May use
additional slide if necessary.
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Organization of Health Care

• How are the Collaboratives supported by
  leadership? We have a board member on our team
  as well as our Champion Physician, and our
  CFO/COO. They attend the weekly Collaborative
  meetings and give input.
• Who does the day-to-day leadership for continued
  clinical improvements? Dr Garman and Mary.
• Are the Collaboratives part of your Quality
  Improvement program? Yes Business plan? Yes
  Performance Improvement program? Yes

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Delivery System Design

• Protocols in place for staff role/duties/tasks
  during pt. visit? Yes
• Proactive staff, not reactive staff? Proactive
• Who does follow-up? Nursing, Chronic Care
  Coordinator, Dietician/Diabetic Educator.
• Case management? We dont do Case Management, at
  this point.
• How do you meet patients special needs? We have
  sample medications that we can supply our
  patients with, we also have the Indigent Programs
  and Womens Way.
• Do you do group visits? Yes
• Any work flow studies at your center? We have
  done work flow studies in lab, front desk,
  nursing and Providers.

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Clinical Information System

• How do you use your data? To capture information
  for our Providers, for reports as well as for
  Grants and BXBS.
• How do you do patient recalls? Every 6 weeks I
  pull names from the PECs system that are due for
  anything from labs to seeing our Dietician and
  send out a letter to those patients in need. We
  started this 6 week program in December.
• How do you do handle data entry? Data entry is
  done on a daily basis for visits as well as when
  lab or other pertinent information becomes
  available to enter.
• How do you prompt providers (PECS sheet or
  Reminder sheet)? Reception places the PECs sheet
  on the front of the chart for each visit and the
  Providers use it as their encounter note.

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Self-Management

• How do you help the pt. set a goal? We usually
  give the patient some direction as far as where
  to start daily exercise, checking blood sugars,
  losing weight, etc. and let them pick an area
  they can achieve success.
• What tools do you use? A self-management goal
  sheet.
• How do you follow-up and monitor goals? When the
  patient comes in for an appointment, Group Visit
  or to see our Dietician, the Provider or nurse
  look at their goal sheet and ask them how are
  they doing with their current goal and/or do they
  want to look at setting an additional goal.
• Do you use community resources to achieve goals?
  I put together a colorful flyer with all the
  exercise opportunities available in our community
  along with pricing/address/phone numbers. It was
  hung in each exam room, the waiting room and is
  available to hand out to our patients.

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Community

• Do you have community partners to help with
  medication costs? Our local drug store
  partnerships with us in a program called Sliding
  Fee Scale which is based on the patients annual
  income. They can receive a substantial savings
  on everything done at the clinic as well as on
  their prescriptions.
• Education? Group Visits for our patients and we
  also encourage family and friends to join us.
  
• Materials? We have a large selection of
  brochures that are available for our patients.
• Support groups? Our continuing Group Visits and
  Smoking Cessation classes sponsored by our local
  hospital.
• Awareness? Relay For Life, Providers that go to
  the local plants/mines.
• Outreach? Our Providers have given talks at Peer
  Youth, Wellness Programs, and Community Events.
• Have you been awarded any grants? We have
  received grants from Wal Mart and MDU (Montana
  Dakota Utilities) both in Bismarck, ND. Nothing
  local.

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Diabetes Measures

• National Goal
• Average HbA1C 7.0
• At least 2 HbA1C in the last 12 months (gt90 days
  apart) 90
• Self-Management goal in last 12 mo. 70

• Your Clinic
• Average A1c is 7.3
• 41.2
• 32.1

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Another Conditions Measures

• National Goal
• Patients with Blood Pressure less than 130/80

• Your clinic
• 32.8

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Showcase your most challenging graph 33.8
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Showcase your most successful graph 67.8
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Questions from the audience?