REACHING FOR THE STARS''

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REACHING FOR THE STARS..

• A difficult task, yet an achievable one
• A story of a community health center in the
  collaborative

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In the beginning..

• We got together to try to determine what this was
  all about. We really didnt have a clue!!
• Decisions were based on what we thought was the
  right thing to do.

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The First Learning Session January 2000

• Needless to say, we were very OVERWHELMED!!!
• We couldnt see how anything like this could work
  without lots of staff, money, and time.

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Patient Population

• We only wanted compliant patients.
• We did not want to add the transient migrants.
• We did not want anybody that would skew our data.
• WRONG!!!!!

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We decided the purpose of the Diabetic
Collaborative.

• To help any person who has diabetes.
• To teach self-management to the diabetic patient.
• To empower the patient to care for him/herself.

• To monitor the diabetic patient closely.
• To give the patient the knowledge to understand
  his/her disease process.
• To release our control over their illness.

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So we added all patients with diabetes seen in
the last year -72

• Our average HgbA1c was 9.0
• We noted one thing immediately we needed
  documentation of what is actually done in the
  room EDUCATION!!

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Now we needed some magic!

• We had to get all patients into DEMS.
• We had to find a way to be assured of
  information getting documented.
• We had to remember all the changes!!

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Suddenly, we were so energetic..

• New ideas!
• The patients were actually making changes!
• Our numbers were improving!

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Our First Year!
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Then we lost our zap.

• Our clinic was rapidly growing.
• Our team members were leaving due to a rapid
  staff turnover.
• Our Diabetic patient load increased.
• Our transient migrants were in our DEMS causing
  our numbers to inaccurately reflect our local
  population.

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From January to July 2001

• We were unable to keep up with the diabetic
  collaborative. Our data input was way behind,
  and our staff were exhausted trying to keep up
  with all other requirements of the clinic.
• We just tried to maintain the changes that we had
  already implemented.

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Then in July 2001 a ray of sunshine came to the
clinic!!

• We hired an Advance Nurse Practitioner.
• She came to us with so much energy and oodles of
  ideas.
• She became our champion!!

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We became organized, activated!

• We developed standing orders.
• We re-started our regularly scheduled team
  meetings.
• We reviewed what we had already done, and what
  needed to be done.

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Rising from the ashes.
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Our achievements! We were so proud of our
patients ourselves!

• Average HgbA1c was 7.8!
• The patients with 2 or more HgbA1c in last 12
  months, 3 months apart, rose from 24.4 to 68.9!
• The documented self-management goals rose from 6
  to 86!
• The patients with at least one lipid screening
  rose from 36 to 88.

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Then we decided to spread.

• Dont you wish it was this easy???
• We had two meetings with our Lewisville clinic
  and brought them on board in the diabetes
  collaborative January 2002.

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And to keep things interesting

• We decided to get started in the CVD
  collaborative without any learning sessions. We
  asked for the goals from WCC staff and just
  plunged ahead!
• Talk about not knowing what we were getting
  into!!

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Did you know??

• We had over 200 HTN patients in addition to the
  patients with diabetes!!
• We had to implement the planned care model with a
  new disease process with so many patients.
• We began to panic again..

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We had to regroup!

• We decided to stay calm.
• We believed we could still keep things going.
• We relied on each other for support.

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And we continued to spread

• We just couldnt allow ourselves to become lazy
  our patients suffer.
• Lewisville came on board with the CVD
  collaborative May 2002.
• Amity came on board with the diabetes
  collaborative June 2002.

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Now you are probably wondering what is happening
to the patients?!

• They were learning.
• They were understanding.
• They were thinking we just wanted a whole lot of
  their sweat and blood!

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Just when things are going smoothly

• We got some bad news, our champion was leaving.
• But, we hired her sister another Advanced
  Practice Nurse. So it wasnt so bad..

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It is amazing what new brain waves will come up
with!

• The new APN had lots of new ideas and questions.
• Was our data up-to-date and accurate? We
  immediately said YES, of course
• But guess what! It wasnt. So we pulled all our
  charts updated our system info.

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Looked at what happened!
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Our Cardiovascular Collaborative
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The Continual Challenges

• The poverty, literacy, transportation barriers
  in our community.
• The rapidly growing patient load and limited
  clinic staff.
• The difficulty in maintaining data input into the
  PECS.
• The need to continue to spread to other CABUN
  clinics and disease processes.
• The need for support and understanding.

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The Future!!

• We will spread to the remaining 3 clinics within
  CABUN by March 2005.
• We will continue to spread to other disease
  processes.
• We are going to help our patients reach for the
  stars!