Schenectady Family Health Services Inc'

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Schenectady Family Health Services Inc.

• Schenectady, New York
• City That Lights and
• Hauls the World
• (Birthplace of GE and American Locomotive)

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Schenectady Family Health Services

• Our Staff Ten Medical Providers, six Dental
  Providers, Podiatrist and Optometrist
• Circle-Of-Service Primary, Dental and Wellness
  Care OB/GYN, pediatrics, adolescent and teen
  services, adult and geriatric care, podiatry,
  optometry, nutrition counseling, social work
  counseling, 340B Drug Program, HIV / AIDS testing
  and counseling, WIC, laboratory services and
  24-hour on-call coverage

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Population Served

• 2004 More than 50,000 patient encounters,16,000
  registered patients
• Half live at 200 or less of the Federal Poverty
  Level (FPL), including nearly 12,000 children.
• About 60 are enrolled in Medicaid more than 20
  have no health insurance.
• Culturally diverse -- three in 10 citizens
  identified by the U.S. 2000 Census as Black,
  Hispanic or other race.

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Selected Diagnoses (2003)

• Diabetes 1,268 (13.47)
• Child Health Supervision 1,886 (20.02)
• Asthma and Bronchitis 1,219 (12.94)
• Immunizations 1,268 (13.47)
• Hypertension 911 (9.67)
• PAP Smear 636 (6.75)
• STDs 377 (4.01)
• Teen Services 245 (2.6)

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Team Members
Name Title Role on Team John Silva President
CEO Leadership Lily Kam, M.D. VP of
Medical Leadership John Pramenko M.D. Medical
Provider Provider Champion Jaclyn Hoyt PI
Coordinator Day-to-Day Leader Joy
France Nursing Manager Clinical / Technical
Expert Angella Timothy VP Health
Services Clinical / Technical Expert Rod May VP
Administration MIS Contact William Down D.D.S. VP
Dental Services Dental
Team Leader Email jhoyt_at_sfamilyhealth.org Teleph
one 518-370-1441 Extension 176
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Goals

• To improve glycemic control and reduce
  complications of diabetes by reorganizing
  healthcare service delivery enlisting patient
  support for self management, utilizing community
  resources and improving clinical information
  processing and access to disease and care data.
  In doing this our organization will
• Increase the percentage of patients with self
  management goals by 50.
• Have 90 of our diabetic patients receive two
  HbA1c tests annually, at least three months
  apart.
• Increase the number of diabetic patients who show
  a reduction in their HbA1c by 50 within the
  year.
• The collaborative will begin with at least 100
  registered patients and two participating
  providers. As the process moves forward we will
  expand the collaborative to include more
  providers and at least another 100 patients.

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Target Population

• The starting number is 100 patients
• Patients will be split between two providers at
  our main site.
• Our facility has a high number of diabetic
  patients
• from a diverse ethnic background (42.68 White,
  31.09 Black, 13.54 Hispanic, .90 Asian,
  .28 Pacific, .23 Indian and 11.29 Unreported
  ).

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Key Measures of Diabetes
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Senior Leadership Support

• Senior Management allocates significant
  resources meetings, training and seminars,
  collaboration visits, support for strengthening
  community linkages
• Middle management provides the foundation
• Nursing staff Provides education, patient
  follow-up care, chart reviews.
• Health Information Provides timely patient
  record data and statistics.
• Front desk Provides vital follow-up
  appointments scheduling / monitoring.
• Dental Separate contact to diabetes patient
  urging follow-up care.
• Board of Directors
• Recognizes the priority and importance of our
  diabetes practice, patient need and the role of
  the Diabetes HDC
• Received education about the Diabetes HDC and how
  SFHS will be involved focusing on eliminating
  health disparities, reducing complications of
  diabetes, improving patient outcomes.
• The SFHS Board voted unanimously to approve the
  facilities participation into the collaborative.

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Registry

• Patient Electronic Care System (PECS)
• Our process for entering patient data into the
  Registry (finished February 2005)
• Patients identified by diabetes diagnosis.
• Chart Abstraction process -- Completed January
  20th.
• Patient data entered into PECS registry --
  Completed January 31st.
• Staffers responsible for updating and overseeing
  data entry
• Jaclyn Hoyt
• Lily Kam M.D.
• John Pramenko M.D.

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Communication

• The Board of Directors was informed of our
  acceptance into the Diabetes HDC by our CEO at
  the monthly board meeting.
• SFHS employees were informed of our acceptance
  into the Diabetes HDC at our monthly staff
  meeting by our Vice President of Medical
  Services.
• All staff received a brief overview of the
  Diabetes HDC and were able to ask questions.

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Key Partnerships Supporting Our Work in the
Diabetes HDC

• St. Clares Hospital
• Ellis Hospital
• Pharmaceutical Companies
• American Diabetes Association
• Community Action Groups
• Local Churches
• Schenectady County Public Health Services
• HMOs (MVP, CDPHP, Fidelis Healthcare, Blue Cross
  / Blue Shield)