NORTHEAST CLUSTER PROJECT SAMARITAN HEALTH SERVICES, Inc' DIABETES STORYBOARD

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NORTHEAST CLUSTERPROJECT SAMARITAN HEALTH
SERVICES, Inc.DIABETES STORYBOARD

• Location Damian Family Care Center, Jamaica, NY
• Size 17,550 visits per year. Total
  medical/dental providers 5.6 FTE's (2.0 FTE's
  are PCP)
• Scope of Services Primary medical care,(Adult
  Peds) GYN, Dental, Psychiatry, Optometry,
  GI/Hepatology and Podiatry.
• Special Programs HIV and Hepatitis C
• Population Served -70 registered Diabetics who
  meet the selection criteria for POF.
• Ethnic mix 39.3 African-American, 25 Hispanic,
  14.3 Asian, 14.3 Caucasian, Other 7.1

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Team Members

• Name Title Role on Team
• M. Gebhardt CEO Senior Leader
• P.Wylie-Kennedy COO Senior Leader
• K.Begum MD Provider Champion
• S. Pierre, RN Nurse Manager Day-Day Leader
• J. Roscoe RN QI Facilitator Clinical/Tech
  Support
• C. Pocasangre Adm. Asst. PECS Data Maintenance
• Asif Ahmed MIS Specialist MIS Contact

Team Leader Contact Email Prohlt53_at_aol.com
Tel [phone]
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Aim

• The Diabetic health care team at Project
  Samaritan Health Services will apply the six
  components of the Chronic Care Model to
• Ensure the application of evidence-based
  practices for all Adult Diabetic patients.
• Promote optimum clinical outcomes in the POF for
  all clinical measures over the next year through
  planned visits and timely follow-up procedures.
• Provide strong support and guidance for patient
  self-management and establishment of
  self-management goals.
• Redesign existing documentation tools to
  facilitate and guide the plan of care at each
  encounter.

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Population of Focus

• Registry Size 68-100
• We will include in our POF all Adult Diabetic
  patients at our CHC in Jamaica Queens, NY who
  have had at least one visit in the past calendar
  year with Drs. Pulido, Begum Kaufman and F.
  Khan RPA.
• These are our three(3) Primary Care Providers at
  this CHC.(2.0 FTE)

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Choose the one slide on core measures that
pertains to your condition of focus.
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Key Diabetes Measures
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GRAPHS

• Print out and bring a copy of your EXCEL FILE
  graphs showing your initial prework for Diabetes
  and Depression

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Senior Leadership Support

• Our COO/Senior Leader is present at every team
  meeting and thus actively engaged in supporting
  the team. She continually facilitates allocation
  of staff resources necessary to implement the
  change processes.
• Our one middle management staff member at this
  CHC is our Day-to-Day Leader and a role model for
  the entire team.
• Our CEO/Executive Director initiated the
  application preparation process by (a)
  Enrollment in a CHCANY program for HDC
  preparation, (b) Obtaining a BOD resolution in
  July 2004 to support PSHS participation in this
  collaborative.

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Registry

• Registry used at our Health Center will be PECS
• How we populated/entered patient data into
  registry by Feb 2005
• We identified patients by ICD-9 codes and lists
  printed from our Health Pro information system.
• Chart Abstraction process is a work in progress
  to be completed by assigned clinical staff by
  1/31/05. Regional Nurse Managers from our other
  CHC's are assisting in the abstract process.
• Patient data was entered into the PECS registry
  by our team member--Carmen Pocasangre, PECS Data
  Maintenance.
• The following staff members are responsible for
  maintaining data entry updated C. Pocasangre.

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PDSA Cycles completed during Prework

• PDSA 1 Time resource requirements for intial
  data entry into PECS.
• PDSA 2 Methods for flagging charts of patients
  in POF.
• PDSA 3 Abilty to export data from PECS to
  Excel Diabetes Summary Report.
• PDSA 4 Tested re-formatting Diabetes Encounter
  form to guide plan of care for all core measures.
• PDSA 5 Tested various options to determine
  resources needed to complete chart abstracts.
• PDSA 6 Tested how much time and staff
  resources were required to transfer existing
  charts into new color coded binders to flag POF.
• PDSA 7 Outcome of didactic and interactive
  educational program for provider staff.
• PDSA 8 Selection of a patient Self-Management
  tool.

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Communication

• How was BOD and staff informed about the health
  centers participation in the Health Disparities
  Collaborative?
• BOD informed by CEO/Executive Director at BOD
  meeting in July 2004. BOD resolution passed at
  this meeting in support of participation in HDC.
  In Sept. 2004 several BOD members attended an
  orientation program for HDC and all were informed
  when PSHS was accepted for this Collaborative.
• QI committee informed in July 2004 that
  application was being filed in September that
  we were selected.
• All other PSHS staff informed during regular
  staff meetings.This included staff at our other
  clinic locations in Bronx, Manhattan Ulster
  County , NY.

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Key Partnerships that will help our work in
Health Disparities

• Samaritan Village
• Palladia
• Chem RX Pharmaceutical company
• PSI AIDS Services, Inc., ADHC COBRA programs
• CHCANY