Learning Session

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Learning Session 2May 12-14, 2005Atlanta,
Georgia
Cluster Northeast
Betances Health Center
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Northeast ClusterBetances Health Center

• 280 Henry Street, New York, NY 10002
• Betances Health Center is a multi disciplinary
  clinic that accomplished 50,000 visits in 2004.
  It employs 9 full time medical providers and a
  part-time consultant staff of 11.
• Services offered at the center include Family
  Practice, Pediatrics, Internal Medicine, HIV
  medicine, Obstetrics/Gynecology, Ophthalmology,
  Podiatry, Acupuncture, Cardiology, Audiology,
  Physiatry, Physical Therapy, Psychiatry, Social
  Work, Nutrition and Dentistry.
• With an active census of 6000 patients,
  approximately 500 are diagnosed with diabetes.
  The patient population is 65 Latino, 15 Black,
  10 Asian and 7 White.

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Team Members

• Name Title Role on Team
• Wanda Evans, Executive Director Senior Leader
• Caron A. Houston, MD Medical Director Senior
  Leader, Day to Day Leader
• Dina Louie, PA Physician Assistant Provider
  Champion
• Theresa Kinsella, MS, RD, CDN Director of
  Nutrition Clinical/Technical Expert
• Orlando Perez Director of MIS Information
  Systems Specialist (MIS)
• Yuderka (Judy) Goris, RN Supervisor
• Kesha Bright, MA Patient Care Technician
• Josue Nolasco Diabetes Case Manager
• Lisa Perez Executive Assistant

Team Leader Contact Email chouston_at_betances.org
Telephone [phone] ext. 137
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AIM Statement

• The Betances Health Center Disparities
• Collaborative has committed to improve
• diabetes care by
• Creating a Diabetes team with a Diabetes case
  manager.
• Tracking and monitoring outcomes.
• Focusing on provider and patient behavior change
  with a more preventative and proactive approach
  emphasizing patient education and
  self-management.

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Key Diabetes Measures
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Self-management

• Currently Testing
• 60 day intervention cycle in which patient
  elects behavioral change in one of four area
  diet, exercise, smoking cessation, home glucose
  monitoring. Interventions will include
  structured programs and incentive awards. Group
  sessions will convene for exercise and smoking
  cessation program. Individual systems will be
  held for diet and glucose monitoring cycles.

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Community

• Implemented into our Delivery System
• Utilization of NYC Smoking Cessation programs
  (free nicotine gum, patches, and counseling.)
• Built relationships with Pharmaceutical companies
  such as Novo Nordisk and Aventis.
• Partnered with New York Diabetic Supply Co.,
  which offers glucometer training to patients at
  their home and provides us with feedback.
• Working with United Way/ Food Bank, and they
  contribute food for DM and Obese patients.

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Healthcare Organization

• Implemented into our Delivery System
• Diabetes case management based on the chronic
  care model is reported monthly to medical staff
  and quarterly to CQI committee.
• Collaborative report submitted to senior
  management and board of directors on a monthly
  basis and to center-wide staff meeting Q 6 weeks.

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Decision Support

• Currently testing
• Monthly health education lectures on the
  following know your numbers, complications, eye
  care, foot care, sick day care, medications, oral
  health stress management.
• Patient education library filed electronically on
  center wide intranet.
• Implemented into Delivery System
• Charts previewed by case manager who updated PECS
  and prompts providers to complete outstanding
  work.
• Data elements expanded beyond key measures and
  include tracking of Podiatry, Ophthalmology,
  Dental, Social Work, Nutrition and Self-
  Management visits.

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Clinical Information System

• Currently Testing
• Mail merge applications to recall patients with
  LDL gt100 and BP gt 130/80
• Implemented into Delivery System
• Outcome reports presented to collaborative team
  and medical staff monthly.
• Individual progress reports outlining provider
  performance on key measures.
• Data elements expanded beyond key measures.

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Delivery System Design

• Currently Testing
• Diabetes case manager duties to include patient
  education.
• Social Work, Podiatry and Dental team will track
  DM patients who access their services.
• Real time data entry into PECS by medical
  assistants at point of visit.
• Implemented into Delivery System
• Case manager dedicated to diabetes care.
• Nutrition team tracks diabetes patients who
  receive their services.

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Functional and Clinical Outcomes

• Measures Goal as of 4/2005
• 2 HbA1cs in last yr gt90 35.9
• Average HbA1c lt7.0 7.4
• Documented self gt70 ----
• management goal setting
• BP lt 130/80 gt70 28.8
• ACE inhibitor for pt over age 55 gt75 72.0.
• Dental exam in past year gt70 ----
• REGISTRY SIZE ---- 181

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National Key Measures
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National Key Measures
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Communication Plan

• At the center level
• Regular reporting to Medical Staff, All Staff,
  Senior Management Team, CQI Committee and Board
  of Directors.
• At the Community level
• Introduction of collaborative at community
  leadership, faith based organizations and senior
  outreach events.

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Anticipating Barriers and Issues
Those that the team can resolve
Those that leadership needs to address

• Translating information in all 3 languages.
• Change in our Champion Provider.
• Cross-training for additional staff.

• Assess feasibility of hemoglobin A1c point of
  care testing.

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A story to share.the patient

• G.L is a 35y/o Male from China, monolingual, S/P
  MVA 2/04 with a Hx of Diabetes, Heart Disease,
  and Cancer. He presented this fall complaining of
  knee pain. He is clinically obese with a BMI of
  30, 59, 201 lbs. His BP was 140/90. A fasting
  lipid profile revealed TGs 666, Glucose 247,
  Cholesterol 237, HgbA1c 7.0. He was started on
  Actos, referred for nutrition and rehab.
• The collaborative has allowed us to track and
  monitor this patients progress. He has been
  educated in the DASH diet, weight loss, and
  portion control. His last BP was 116/74. He is
  also scheduled for monthly nutrition classes.
  Although his weight has not significantly
  decreased he seems more hopeful and has kept his
  last appointments.

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A story to share.our Community

• The collaborative has made a significant
  difference in how we approach our DM patients. On
  April 26, 2005 we had a Focus Group on exercise
  to help us with our Self-Management and these are
  some results
• Walking and aerobics/dance were the most popular
  choices.
• Participants wanted music to be involved somehow.
• Walking someplace or taking a field trip really
  interested them.
• We also want to offer incentives for those who
  attend our exercise program, metro cards and
  diabetic socks were the most popular choices.
  Also requested were, Equal or Splenda, fruit and
  vegetable packages, hat with visor to protect the
  walkers from the sun, T-shirts, and shoes. The
  overwhelming response for keeping themselves
  motivated was if they could monitor their weight
  and watch it go down. Participants stated they
  were likely to come once to twice a week

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A story to share.our partners

• We have collaborated with Pharmaceutical
  companies to enhance our lifestyle modification
  programs. Bayer, Aventis, Merck and Lilly have
  all offered their enthusiasm and support. We are
  especially thankful to Merck and Aventis for
  supplying pedometers for our walking program. We
  have also received patient information in English
  and Spanish. We have established relationships
  with our reps and will continue to utilize their
  resources to help us improve care and empower our
  patient population.