Northeast Cluster Health First Family Care Center

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Northeast ClusterHealth First Family Care Center

• Franklin, New Hampshire
• 5 Providers including Physicians, Nurse
  Practioners and Behavioral Health Specialist
• Programs offered at center prenatal, family
  practice medicine, comprehensive care
  management, prevention programs, community
  /public health iniatives.
• Population Served
• 149 of 3,357 (4.4) of total patients have
  diabetes
• 33 of clients in center uninsured
• 97.5 White/Non-Hispanic .2 Black or African
  American .8 Hispanic .3 Asian and 1.4 Other

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Team Members

• Name Title Role on Team
• Richard Silverberg Director CEO
• Richard Young ARNP Physician Champion
• Liz Kantowski Admin Key Contact
• Peter Loeser MIS Clinical/Technical Expertise

Team Leader Contact Emailrsilverberg_at_healthfirstf
amily.org Telephone [phone]
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Aim

• Health First Family Care Center will implement a
  disease management care model through the
  redesign of office practice processes that will
  result in the average hemoglobin A1C lt7.0 for
  the diabetes registry population, 90 of diabetic
  patients having had pneumonia vaccine and 90 of
  the diabetic registry population having a
  monofilament foot exam annually.

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Population of Focus

• 149 diabetic patients
• All diabetic clients in Center
• From general population of the Center across all
  providers

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Key Diabetes Measures
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GRAPHS
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GRAPHS
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Support From Senior Leadership

• CEO is active member of team
• Small health center, CEO is also clinical
  director
• Full support from MIS on development of registry
  and reports all completed and tested
• Senior leadership had education and planning
  sessions with Board of Directors. Diabetes plans
  now part of Centers Community Health Care Plan

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Registry

• Registry used at our Health Center will be
  Customized graphical encounter form and report
  from EMR Medical Logic Logician/Centricity EMR
• EMR used for all office visits since January
  1999. Patient data into registry is part of
  existing office practice
• Patients identified to be part of registry by
  diagnosis, key measures and clinical review . .
  . . .
• No chart abstraction process require all data in
  EMR
• New patients with diabetes marked in EMR at
  registration for inclusion
• New data on patients entered at time of encounter
  directly into Logician which is now programmed
  to automatically update registry
• All clinical staff members are responsible for
  maintaining data entry as part of patient
  encounter in EMR at time of visit

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PDSA Cycles Completed During Prework

• PDSA cycles we completed
• Team selected and organized
• Aim statement written and approved
• Clinical measures chosen and reported
• Client population selected
• EMR graphical encounter form designed ,tested
  revised and implemented
• Registry and reports developed ,tested ,revised,
  now in active use

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Selected Clinical Measures

• Average HbA1c
• Patients with 2 HbA1cs in last year (at least 3
  months apart)
• Documentation of self-management goal setting
• Cardiac Risk Reduction Aspirin or other
  antithrombotic
• Patients with BP lt130/80
• Patients with LDL lt100

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Additional PDSA
Clinical Information Systems
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First Reports

• The initial data summary report was completed and
  transmitted on January 3rd
• To date, all 149 patients have been entered
• Internal reports, by provider used as tool to
  manage patient visits
• Office procedures/flow changed/improved

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Communication

• Staff heard about other health centers
  participation in the Health Disparities
  Collaborative from our involvement in ISDN with
  CHAN. They suggested they wanted to be involved
  nationally
• Line staff worked with CEO to write application
  and we jointly reviewed with BOD
• Upon receipt of participation notice everyone
  happily responded to now being part of a national
  group

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Key Partnerships That Will Help Our Work in
Health Disparities

• CHAN Community Health Access Network (Horizontal
  Community Health Center network)
• Pharmaceutical companies DAP ( Drug Assistance
  Program)
• State DCP
• Caring Community Network of the Twin Rivers,
  (Vertical network) community public health
  partnership including hospital, visiting nurse
  associations, faith based groups, mental health
  center,businesses, housing, citizen reps

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Climbing Diabetes Mountain
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Staff as Mountain Guides to Assist and Motivate
Clients Up Diabetes Mountain

• Challenges to surmount on journey up Diabetes
  Mountain
• Learning the new diet
• Taking blood sugar levels regularly
• Remembering to come into Center every three
  months for HbA1c
• Finding time in the day to exercise

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Techniques Used by Staff as They Guide Clients on
Their Journey Up Diabetes Mountain

• Coaching
• Reminder letters
• Telephone calls
• Individual client goals in care plans
• Follow-up of the staff
• Enthusiastic responsiveness from staff to clients
• Utilization of EMR, registry and reports to help
  clients manage their care

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And The Journey Continues..