Oakhurst Medical Centers

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Oakhurst Medical Centers

• Southeast Cluster

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Oakhursts Mission

• "The mission of Oakhurst Medical Centers is to
  meet the needs of our community by providing
  culturally sensitive, quality, affordable,
  comprehensive and accessible health, care for the
  residents of DeKalb County and surrounding
  communities in collaboration with our partners. "
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Oakhurst Medical Centers

• FQHC located in DeKalb County, GA
• Stone Mountain, GA (main site)
• Satellite office Decatur, GA
• Services offered
• Internal/Family Medicine
• Pediatrics
• Obstetrics/Gynecology
• Social Services (WIC/Medicaid certification)
• Population Served
• 5, 965 patients (2003)
• 815 diabetes mellitus encounters (2003)
• Ethnic Mix 86 Black/African-American 6
• Hispanic/Latino 4 White 4 Other

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Team Members

• Dr. Raulnina Uzzle, MD (Medical Director / Team
  Leader)
• Tim McNeill, RN/MPH, Director of Nursing (Team
  Leader)
• Talayah Jackson, Coordinator of Research
  Collaborative Services (Team Member)
• Virginia Matthews, Referral Coordinator (Team
  Member)

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Aim

• Oakhurst Medical Center is currently implementing
  a Chronic Care Initiative designed to
  strengthen and improve chronic care for all of
  our patients. With an initial focus on diabetic
  patients, we will redesign our system of care
  based on all of the Care Modes six components.
  Accomplishments will be evidenced by

• Average HbA1c level for patients lt 7.0
• gt 90 of patients with 2 HbA1cs in last year
• gt 70 of patients w/ documented self-management
  goals in the last year
• gt 75 of patients prescribed a ACE inhibitor or
  ARB medication
• gt 40 of patients with B/P less than 130/80 in
  the last year
• gt 70 of patients w/ fasting LDL less than 100
  in last 12 months

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Optional Measures

• gt 70 of patients with a dental exam and
• dilated eye exam in past year
• gt 90 of patients with comprehensive foot exam in
  past year
• gt 30 of patients w/ BMI gt25 who have lost 10 lbs
  in past year
• gt 60 of patients w/ a current statin
  prescription
• gt 80 of diabetic patient 40 years and older w/ a
  current aspirin or antithrombotic prescription

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Population of Focus

• of patients 200
• Includes identified patients of all providers at
  Stone Mountain site who are diagnosed with
  diabetes
• Representative sample of patient population
  across 3 clinics

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Registry Summary

• of patients 129
• Pts w/1-2 visits 71.3
• Sex 69.8 Female
• Age 94.6 gt 30 years of age
• Race 65.1 African-American
• Insurance 66.4 Uninsured

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Registry Summary (Key Diabetic Measures)

• Average HbA1C 9.4
• Self-management goal setting 0
• BP lt130/80 18.9
• LDLlt100 20.9

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SAMPLE PDSA Cycles

• 2/21/05 Created process flow for PECS encounter
  note collection and data entry. Tested process
  on 5 diabetic walk-in patients for 2 days.
• 3/1/05 Tested new patient check-out procedure
  medical assistants will collect encounter and
  schedule follow-up appointments for patient
  instead of front-office staff in all departments
  (internal medicine, OB/GYN, and Pediatrics)
• 3/24/05 Engaged local community pharmacy to
  discuss contracting 340B pharmacy services -
  contracted services ensures availability of
  medication for patients versus relying on samples
  and donated meds

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SAMPLE PDSA Cycles Continued...

• 3/7/05 Implemented new clinical model to include
  an LPN in each department and a lead LPN to
  oversee all clinical departments daily operations
  
• 3/25/05 Expanded clinic hours to better serve
  patient population now operating M-F 8 am 5
  pm and Saturday 9am 2 pm (Stone Mountain
  location only)