McBride Family Practice

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McBride Family Practice

• A 2 physician practice
• Number of Patients with Diabetes
• Location Northern BC

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Team Members

• Dr Herman Venter
• Dr Michael Jackson

Team Leader Key Contact Info Name, Phone, email
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AIM and Key Measures

• AIM
• To identify individuals or family units with DM
  and involve as many as possible in the Chronic
  Care Model.
• To create an office environment where chronic
  care is proactively practiced.

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• Key Measures
• gt90 of patients with Diabetes will have an A1C
  test every 3 months 
• gt70 of patients with Diabetes will have an A1C
  of lt7.0.
• gt90 of patients with Diabetes will have a BP
  test every 3-6 months
• gt40 of patients with Diabetes will have a BP of
  lt130/80
• gt70 of patients with Diabetes will have an LDL
  done annually.
•  gt100 of patients with Diabetes will have an
  annual dilated eye exam.
•  gt50 of patients with Diabetes will have an
  annual ACR.
•  gt90 of patients with Diabetes will have an
  annual lower extremity exam.
•  gt70 of patients will have a self-management
  goal documented annually.

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Clinical Information Systems

• Status of Your Registry
• Number of patients in your registry
• Dr Venter 16
• Dr Jackson 15
• Persons trained to enter data Physicians
• Use of the Toolkit in planning care
• Small number of patients
• Monthly Recall reports generated
• Flow sheet printed before patient arrives
• Data entered after each visit
• Run charts monthly to see areas where improvement
  is needed
• Aims and targets posting within sight

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Self-Management

• PDSA cycles tested
• Letter to patients about the diabetes
  collaborative
• Letter to patients re what they are due for
• Italian Handouts
• Discussions with patients
• Small changes, gradual
• What worries you the most? motivational tool
• What have you been successful with?
• Help them feel responsible for their health and
  feel control over what they can personally do to
  improve it
• Small townsee them on the street

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Highlights of the letter

• We want to know how you feel about diabetes
• We want to know if anything about this disease
  upsets or worries you
• We want to know what you personally feel you can
  do about diabetes to help yourself
• Work together on your goals for better control of
  your diabetes

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Functional and Clinical Outcomes
68
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Key Measures
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Key Measures
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Key Measures
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Key Measures
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Key Measures
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Key Measures
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Summary of Current Status

• What have you accomplished in the second Action
  Period?
• What challenges and/or barriers have you faced?
• What are you planning to test next?