Hamilton Community Health Network

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Hamilton Community Health Network
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Hamilton Community Health Network
Got Sugar?

• 4001 N. Saginaw St., Flint, MI 48505
• Two Providers Dr. Shortt and Dr. Carlis
• Programs Offered at Hamilton
• Adult Primary Care Lab Services
• Physical Exams Cancer Screening On-Site
• Wellness/Health Screenings Family Independence
  Agency
• Case Management Genesee Health Plan
  Enrollment
• Treatment of Chronic Disease Pediatric
  Dentistry
• Acute Care Services OB/GYN Services
• Minor Office Surgeries
• Counseling/Health Education
• Referrals

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POPULATION SERVED

• Total Number of Patients Served Approximately
  13,000
• Number of patients diagnosed with diabetes
  Approximately 700 from all three medical sites
• Number of homeless patients Approximately 1,150
• Ethnic Mix African-American 8,471
• Caucasian 3,827
• American Indian 16
• Asian 39
• Hispanic 178
• Unreported - 417

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Team Members
Reuben Pettiford, CEO
Sue Siwek, COO, Senior Leader
Dr. Sandra Shortt, Physician Champion
Christina Aplin-Kalisz, Team Leader
James Wilmot, Technical Expertise
Debbie Uhlian, Health Information Manager
Tawanna Morgan, Administrative Support
Delena Robison, Medical Assistant
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AIM STATEMENT
Hamilton Community Health Network will redesign
our system to provide improved care for all
patients with the diagnosis of diabetes. We will
accomplish this through implementation of the
Care Model and this will be evidenced by our
tracking of objectives to follow
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POPULATION OF FOCUS
Hamilton Community Health Network will focus o
the patients of two of our providers (Dr. Shortt
and Dr. Carlis) at our Main site. This includes
approximately 100 patients with diabetes who have
been identified as active clinic patients of Dr.
Shortt and Dr. Carlis. New patients will be
added as they come into the practice.
Dr. Sandra Shortt
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KEY DIABETES MEASURES  
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Self-Management

• Currently Testing
• Self-Management Tool
• Dental Questionnaire
• Patient Orientation Notebook
• Implemented into our Delivery System
• Chart identifier for patients in collaborative
  (round purple sticker on outside of chart)
• Chart identification system (color coded)
• 1. Provider identification
• 2. Referral identification
• 3. PECS identification

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COMMUNITY

• Currently Testing
• Local hospital providing intense Diabetic
  Education
• Implemented into our Delivery System
• Collaborative Team Member has joined the Greater
  Flint Health Coalitions Diabetes Task Force
• Faith Access to Community Economic Development
  (FACED)
• Collaborative Team Member teaches a eight week
  diabetes education series twice a year at local
  Community Mental Health facility.

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Healthcare Organization

• Currently Testing
• Medical Assistants received training on a new
  testing device to check patients A1c right in the
  clinic
• Sharing written information monthly to our staff
  and patients regarding the diabetes collaborative
• Implemented into our Delivery System
• Purchased A1c Now meters for each site for
  immediate access of patients A1c level
• Developing a diabetic news letter patients and
  one for staff regarding diabetes collaborative

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Decision Support

• Currently Testing
• Lab tracking tool for abnormal lab work
• Referral tracking tool
• Implemented into Delivery System
• Created a lab tracking tool to ensure follow-up
  on any abnormal lab work
• Tool created to make sure referrals are being
  processed and patient receives access to
  specialist.

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Clinical Information System

• Currently Testing
• Adding PECS access to Team Leader Lap top for
  additional access opportunities
• Added Medical Assistant as data entry personnel
  to help input current data
• Implemented into Delivery System
• Added a flag system to ensure charts are routed
  to data entry personnel
• Redefined and redistributed workload within the
  collaborative personnel for task and registry
  maintenance
• Using registry to track, report and communicate
  results and outcomes of care effectiveness over
  time and across providers and populations

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Functional and Clinical Outcomes

• Measures Goal As of 5/5/05
• 2 HbA1cs in last year gt90 37.6
• Average HbA1c lt7.0 8.3
• Documented self-management gt70 24.8
• goal setting
• BP lt130/80 gt40 31.3
• ACE inhibitor for pt. over age 55 gt80 68.8
• Dental exam in past year gt70 2
• Foot exam in past year gt90 45.5
• Patients with LDL lt100 gt70 38.6

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SENIOR LEADERMaking the Case for Change

• Each month at the board of directors meeting, the
  board receives a written and verbal update on the
  collaborative. The Medical Directors report
  also contain information pertaining to the
  collaborative. The Board is very supportive of
  this change in practice and encourage management
  staff to include in any mailings or informing
  them of any classes, fairs, etc., that they can
  attend.
• The storyboard has been shared with the
  management ream and monthly the team is invited
  to Executive Management Team meeting to talk
  about the collaborative.
• The first promotion for the collaborative is to
  our staff in our other clinics. Staff meetings,
  news letters and the new Diabetes Newsletter are
  given to the staff, identifying the changes and
  activities at our main clinic.
• HCHN promotes the collaborative through the
  involvement of partners and activities with
  community based programs, health fairs,
  committees, and networking with programs like
  ECDON (East Central Diabetes Outreach Network).
  The drug reps that are in our clinics daily are
  excited to participate in the collaborative by
  providing us with educational materials and
  handouts that provide additional support to the
  patients.

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A story to share.the patient

• The impact of the collaborative has helped our
  patients by making staff more aware of some of
  the things we need to make sure we check when a
  diabetic patient comes into the clinic. For
  example, we make sure our diabetic patients get
  their feet examined by the doctor at every visit.
  All of our diabetic patients are working on
  their diabetic goals. We are also learning more
  effective ways to help our patients take care of
  themselves. The patient is shown how to take
  better care of their feet and the importance of
  checking their blood sugar on a regular basis.
  All diabetic patients are given a glucometer
  machine so they can check their blood sugar every
  day at home and log them into a log book. The
  patient is encouraged to bring their log book
  with them to each appointment so we can see how
  their blood sugar has been doing over a period of
  time.

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A story to share.our staff

• The diabetic collaborative has affected the staff
  in different ways. Overall, the collaborative
  has been a wonderful addition to our clinic. The
  majority of the staff feel the collaborative has
  allowed them to get to know their patients
  better, by reviewing the charts it allows the
  staff to relate to the patients and to feel
  sympathetic with regards to the challenges the
  patient may be facing with regards to managing
  their diabetes. Some staff feel the
  collaborative has created additional work. When
  a known diabetic comes into the clinic they are
  required to remove their shoes and socks to have
  their feet examined by the physician and they are
  also required to complete a diabetic
  self-management tool. The above two requirements
  has given the staff more responsibilities. With
  regards to the physicians, the collaborative has
  allowed them to better manage their diabetic
  patients. The physicians are more focused on
  educating the patients with regards to diet,
  nutrition, hemoglobin A1c, exercise and good foot
  care.

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A story to sharethe organization
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Communication Plan

• At the center level
• Monthly newsletter specifically for patients and
  staff
• Plan to discuss data monthly with all providers
  at monthly provider meeting to identify potential
  changes in treatment
• At the community level
• Plan to hold diabetes education series open to
  the community
• Continue to be a part of area health fairs and
  community diabetes forums

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Anticipating Barriers and Issues

• Those the team can resolve
• Ongoing clinical decision making
• Ongoing staff responsibilities
• Ongoing education for staff
• Those leadership needs to address
• Information systems
• Scheduling systems
• Resoucrces for time and equipment

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• KEY PARTNERSHIPS
• Hurley Medical Center
• Genesee County Community Mental Health
• Genesee County Health Department
• Greater Flint Health Coalition
• Genesee Health Plan
• Salvation Army
• Odyssey House
• REACH
• Clio Pharmacy/Pfizer Sharing the Care