Learning Session

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Learning Session 2May 12-14, 2005Atlanta,
Georgia
Cluster Southeast
Metro Public Health Downtown Clinic for the
Homeless
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Metro Public Health Department

• Location
• 526 8th Ave. So Nashville, TN 37203
• Size of Clinic Seventeen Staff Members
• Clinic Director, Medical Director, 2 Nurse
  Practitioners, 2 Clinical
  Nurses, Diabetes Educator/Clinic Manager, Mental
  Health Specialist, 2 AD Counselors, 2 Social
  Workers, Office Support Staff, and Courier
• Programs offered at our center
• Primary Care, Alcohol Drug, Mental Health
  Dental, Social Services, Transportation

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Team Members

• Scott Orman, Clinic Director, Senior Leader
• Ida Self, RN,CDE, Team Leader
• Dr. Keith Junior, Medical Director,
• Tracy Beadle, APRN, FNP-BC
• Diane Campbell, APRN, FNP-BC
• Chuck Holmes, Information Services

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Aim

• Metro Public Health Department Downtown Clinic
  serving the needs of the homeless will redesign
  the clinical systems to improve provide the care
  to our patients with Diabetes Mellitus. This
  will be accomplished through implementing the
  components of the chronic care model.

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Key Diabetes Measures
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Self-management

• Currently Testing
• Self Management contracts at 1st or 2nd visits
• Dental Referrals at 1st visit
• Implemented into our Delivery System

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Community

• Currently Testing
• Referral to MNGH for opthalmalogy
• Medications using Needy Med.com and other PAPs
• Implemented into our Delivery System
• Retinal Eye examinations _at_ UNHS Clinic on
  referral
• Partnered with Health Promotion project to
  provide culturally appropriate health education
  series

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Decision Support

• Currently testing
• After entry into registry and after every visit,
  encounter note is printed from PECS to identify
  measures, labs and educational needs ( see flow
  sheet below).
• Standing orders for missing labs and referrals
  for use by nursing staff
• Implemented into Delivery System
• Currently use established flow sheets and
  presently integrating into PECS encounter form to
  better obtain measures.
• Use pocket guides to embed guidelines for
  medication and treatment into daily practice
• Establish criteria for referral of patients to
  Orthopedic, Ophthalmology and assure that PCPs
  have access to expert support from specialists
  for consultation

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Healthcare Organization

• Currently Testing
• Board Member attend team meeting once every 2
  months
• Optimizing CPT Coding for comprehensive visit by
  NP who is also CDE
• Orientation package for all employees on the
  collaborative models
• Implemented into our Delivery System
• Care Model and Model for Improvement part of our
  performance improvement program
• Collaborative report submitted to BOD on monthly
  basis and team presents quarterly to the board

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Clinical Information System

• Currently Testing
• Easy access for providers to clinical information
  from the registry. Computer with access to
  network placed in provider work station
• Nursing close-out visit using PECS registry flow
  sheet at end of visit
• Implemented into Delivery System
• Appointment system flags patients in our registry
• Develop guidelines for creation and use of
  registry including designating personnel for
  tasks and registry maintenance
• Use the registry to track, report and communicate
  results and outcomes of care effectiveness over
  time and across providers and populations

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Delivery System Design

• Currently Testing
• Assure that appointment systems support the needs
  of our patients including follow-up activities
  and multiple appointments on same day
• Implemented into Delivery System
• Use outreach workers to connect with patients
  outside office for connecting with community
  programs, follow-up on self-management goals.
• Primary Care Patient Care Teams made up of
  provider, nurse and medical assistant. Using
  team huddle prior to start of session for planned
  patient interventions.

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Functional and Clinical Outcomes

• Measures Goal as of 10/2002
• 2 HbA1cs in last yr gt90 22
• Average HbA1c lt7.0 8.2
• Documented self gt70 ----
• management goal setting
• BP lt 135/85 gt70 56
• ACE inhibitor for pt over age 55 gt75 69
• Dental exam in past year gt70 25
• REGISTRY SIZE 123 90

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National Key Measures
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National Key Measures can't
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Additional Measures
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Additional Measures
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Senior LeadershipMaking the Case for Change

• What information did you share with your ED/CEO
  and/or Board of Directors to encourage them to
  make improvements in the management of
  Diabetes/Depression? i.e., graphs, data, patient
  stories, articles, etc.
• How did you promote the work? i.e., speak at
  meetings, talk with particular people, write
  articles, produce a video, etc

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Communication Plan (How are you communicating
your progress at the center level and within your
community)

• At the center level
• At the Community level

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Anticipating Barriers and Issues
Those that the team can resolve
Those that leadership needs to address

• Clinical decision making
• Staff responsibilities
• Education for additional staff

• Information systems
• Scheduling systems
• Resources for time and equipment

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A story to share.the patient

• Please share a new story relating to the impact
  the collaboratives have had on your patients

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A story to share.our staff

• Please share a new story relating to the impact
  the collaboratives have had on your staff

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A story to share.the organization

• Please share a new story relating to the impact
  the collaboratives have had on your organization