Download - This is NOT “Zach’s Diabetes Thing”
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Making the Montefiore Medical GroupMaking the Montefiore Medical GroupHealth Disparities Collaborative WorkHealth Disparities Collaborative Work
at Montefiore Medical Centerat Montefiore Medical Center
The MMG HDC TeamThe MMG HDC Team
Bronx CREEDBronx CREEDSeptember 30, 2005September 30, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
This is NOT “Zach’s Diabetes Thing”This is NOT “Zach’s Diabetes Thing”
Coordinated effort on the part of a lot of folks. This afternoon:
• Eleanor Larrier Introduction
• Me Introduction
• Nandini Deb: Clinical Information Systems
• Jennifer Klein: Diabetes Education
• CFCC: Judy Leuchter, Peer Educators
• FHC: April Evangelista, Health Ed PDSA
• WB: Sean Misciagna, M.D., FM Resident
• Nutrition: Helen Persovsky
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
““We don’t just talk about reducing health We don’t just talk about reducing health disparities . . disparities . .
we reduce ‘em!”we reduce ‘em!”
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
So . . . So . . . how do we reduce health disparities?how do we reduce health disparities?
‘THE COLLABORATIVE MODEL”
What’s so great about that model?
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
OLD QI METHODOLOGYOLD QI METHODOLOGY
“Swoop and Poop”
Do everything to everyone all at once. Punish whoever doesn’t have good scores. Create simplistic and token responses to
real problems.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
REAL PROBLEMREAL PROBLEM
Health care worker lack of comprehensive understanding of the dimensions of pain, pain control, addiction, emotional response to pain and end of life issues, etc.
Patients feel too much pain in the hospital, report being ignored, addicts turned away from pain treatments, etc.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
THE “SOLUTION” TO THESE COMPLEX AND MULTIDIMENSIONAL, REAL
PROBLEMS:
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Fix what is wrong, help clean the mess yourself.
Tests of change on small populations, then “SPREAD” to everyone - GRADUALLY
Realize that making mistakes is part of the process. Without mistakes no one learns.
Share senselessly, steal shamelessly
Collaborative Philosophy and Method
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Chronic Care ModelChronic Care Model
Can be applied to all chronic conditions:• Asthma• Depression• Hypertension• Coronary Artery Disease• HIV• Diabetes• Domestic Violence• Emergency Preparedness
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Six Elements of the Chronic Care ModelSix Elements of the Chronic Care Model
Medical Information Systems • the registry
• populated progress note
Self-Management (e.g., classes, health educators) Community (e.g., salsa classes) Delivery Systems Design (e.g., planned visit) Decision support (listserv guidelines) Organization of Health Care (spread to MMC)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
PDSAPDSA
Plan, Do, Study, Act Disciplined, results oriented method of
group discussion. Topic tracking and adherence. Track progress. Learn from failures. Over and over and over and over again.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Collaborative Sponsorships Collaborative Sponsorships of Montefiore Medical Groupof Montefiore Medical Group
• Bureau of Primary Healthcare/National Collaborative
• New York City Department of Health: Spread Collaborative
• Academic Chronic Care Collaborative (ACCC by American Association of Medical Colleges)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
What is the NationalWhat is the National Diabetes CollaborativeDiabetes Collaborative??
Made up of hundreds of health
centers from all over the country
Northeast Cluster
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
That’s all very special, so tell me, how That’s all very special, so tell me, how do you get collaborative stuff going?do you get collaborative stuff going?
Get blessed. • Great leaders, great support, wonderful energy, motivated people.• Where do they come from?• We pick them out.
Do something good with no money. Then write about it and present it to everyone every chance you have.
Get money. “Salvador Dali: With Gold You Get Gold.” Get going. Getting going is easy, thinking about getting
going is hard. Keep going (THE VERY HARDEST PART!)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
What were goals in first year What were goals in first year for MMG HDC?for MMG HDC?
1. Identify successes of FHC.2. Spread to CHCC, CFCC and WB in
Diabetes3. Establish working teams.4. Determine key measures for all sites.5. Establish uniform/compatible data
collection system for registry.6. Identify key measures needing
improvement and begin interventions.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #1Goal #1Spread to CHCC, CFCC and WB in DiabetesSpread to CHCC, CFCC and WB in Diabetes
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Medical Group Health Disparities Collaborative
FHC(DM)
CHCC(DM)
CFCC(DM)
Montefiore Medical Group Health Disparities Collaborative
WB(non 330)
DM
Bronx Community Health Network Sites
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal 2.0Goal 2.0
Create centralized working group/leadership team:• Facilitate, supervise, train, develop the sites.• Coordinate allocation of resources.• Plan for future • Communicate with larger Collaborative
organizations.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Medical Group:Montefiore Medical Group:Health Disparities CollaborativeHealth Disparities Collaborative
Senior LeadershipSenior Leadership Jon Swartz, M.D., Senior Leader Arnel Tirado, Senior Leader Victoria Gorski, Senior (Academic Leader) Jennifer Klein, Director, Health Education Nandini Deb, Information Specialist Arthur Blank, PhD Eleanor Larrier and Celia Alfalla, M.D., Bronx
Community Health Network Rita Louard, M.D., Joel Zonszein, M.D., Endocrine Clyde Schecter, M.D., Research Helen Persovsky, Nutritionist Zach Rosen, M.D., Project Director
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Bronx Defeat Diabetes ProjectBronx Defeat Diabetes Project(BDDP)(BDDP)
Bronx Community Health Network (Eleanor Larrier and Celia Alfalla)• Obtained $3 M grant/3 years for community
based initiatives – Diabetes Educators, Peer Educators, Diabetes Training, Specialty Care, etc.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #2.1Goal #2.1Establish working teams.Establish working teams.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
MMG HDC MMG HDC Multidisciplinary Multidisciplinary
Work TeamsWork Teams
•Administrative Director
•Medical Director
•Physician Champion
•Nurse or Nurse Manager
•Diabetes Educator
•Peer Educator
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Family Health CenterMontefiore Family Health CenterThe Bronx Diabeaters: The Bronx Diabeaters:
Ibis Castro, Health Educator, MFHC
Jose Delgado, Associate Director, MFHC
Wayne Joseph, MD, Attending, MFHC
Zach Rosen, MD, Medical Director, MFHC
April Evangelista, Diabetes Educator
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Williamsbridge Family Health CenterWilliamsbridge Family Health Center“The Sugarbusters”“The Sugarbusters”
• Sandra Barnaby, R.N. Staff Nurse• Noel Brown, M.D. Medical Director• Joanne Dempster, M.D. Team Leader• Blanche Doati Associate Director• Victoria Gorski, M.D. Academic Leader• Danette Ortiz Front desk
supervisor (day-to-day leader)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Medical Director Marta Rico, MD Physician Champion Chris Meserve, MD Team Leader Carol Lau, FNP, Associate Director
Team Members Carmen CintronLopez, Assistant Administrator
Joanna White, Administrative Nurse Manager Judy Leuchter, Health Education Manager
Bobbie Jamison, Health Educator
Jennifer Sanchez, PECS data entry Estelle Vargas, LCSW
Comprehensive Family Care Center Comprehensive Family Care Center (CFCC)(CFCC)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CHCC TeamCHCC Team
Joe Deluca, M.D., Team Leader and Physician Champion
Jennifer Santiago-Rivera Health Educator Donna Wade, Nurse Manager Erwin Duran, Data Entry Carmen Guerra , Nurse
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #3: Goal #3: Determine key measures for all sites.Determine key measures for all sites.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal Shared Core Measures
<8% Average HgbA1c
70% % of patients with BP< or = 130/80
70% % of patients with an LDL <100
90% % of patients who have had pneumococcal vaccine
90% % of patients with documented LEAP foot exam in the past 12 months
(90% % of patients receiving annual flu shots)
90% % patients on aspirin (or other anti-coagulant)
70% Signed self management contract in chart
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Other measuresOther measures
Smoking Passive smoking (asthmatics) Nutrition Exercise . . .
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #4Goal #4 Establish uniform/compatible Establish uniform/compatible
data collection system - Registrydata collection system - Registry
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #5Goal #5Identify key measures Identify key measures needing improvementneeding improvement
and begin PDSA’s and begin PDSA’s
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Pneumococcal Vaccine FHC: Percent of DM Patients with Pneumococcal Vaccine (10 years)(10 years)
Percent DM Patient with Pneumococcal Vaccine (10 years)
0%
20%
40%
60%
80%
100%
Perc
ent Removed patients
with no visit in one year
Latest Data as of September 1, 2005
PDSA
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FOOT EXAM PDSA (s)FOOT EXAM PDSA (s)
1. From registry get print out of all charts without pneumovax.
2. Pull charts and have provider review (some charts didn’t have it recorded but had pneumovax given).
3. Put yellow stickies in charts without pneumovax.
4. Combine fluvax and pneumovax forms.5. Etc. etc. etc.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
So where’s So where’s the data?the data?
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
DM Collaborative: Key Measures By SiteDM Collaborative: Key Measures By SiteMay 2004 – May 2005May 2004 – May 2005
Clinic
Number of
Patients with 1+ visits
% Patients with HbA1c
< 8.0
Average HbA1c for
DM Patients
% Patients with BP <=
130/80
% Patients with
LDL<100
% Patients on Aspirin
% Patients with LEAP exam (12 months)
% Patients with
Pneumoccocal vaccine
(ever)*
% Patients with Flu
Vaccine (12 months)
% Patients with Retinal Exam (12 months)
% DM Patients with SM Goal (12 months)
ACTIVE PT.
ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.ACTIVE
PT.ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.
FHC 760 60% 7.9 56% 54% 53% 60% 78% 40% 28% 33%CFCC 191 64% 7.8 47% 66% 59% 35% 54% 18% 31% 47%CHCC 273 64% 7.7 65% 57% 59% 38% 54% 35% 22% 15%WB 606 61% 8.0 46% 50% 38% 32% 69% 19% 22% 8%
TOTAL 1830 61% 7.9 53% 54% 50% 45% 69% 30% 25% 23%
70% 6.5 70% 70% 70% 90% 90% 70% 70% 70%Goal
Note: Data from FHC and WB are for patients with Pneumococcal Vaccine in the past 10 years
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Number of Patients in RegistryFHC: Number of Patients in Registry
Number of Patients in Registry
0
200
400
600
800
1000
Perc
ent Removed patients
with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Average HbA1c for DM PatientsFHC: Average HbA1c for DM Patients
Average HbA1c for DM Patients
6.0
7.0
8.0
9.0
10.0
11.0
12.0
Perc
ent
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with One HbA1c (12 FHC: Percent of DM Patients with One HbA1c (12 months)months)
Percent DM Patients with One HbA1c (12 months)
0%
20%
40%
60%
80%
100%
Perc
ent
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Last HbA1c >=9.5FHC: Percent of DM Patients with Last HbA1c >=9.5
Percent DM Patients with Last HbA1c >= 9.5
0%
10%
20%
30%
40%
50%
Perc
ent
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with BP <=130/80FHC: Percent of DM Patients with BP <=130/80
Percent DM Patients with BP <= 130/80
0%
20%
40%
60%
80%
100%
Perc
ent
Data before this point represent % patients with BP < 135/85
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with LDL <100 (of DM FHC: Percent of DM Patients with LDL <100 (of DM patients with Lipid Screen)patients with Lipid Screen)
Percent DM Patients with LDL < 100 (of DM patients with Lipid Screen)
0%
20%
40%
60%
80%
100%
Perc
ent
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM patients with SM Goal (12 months)FHC: Percent of DM patients with SM Goal (12 months)
Percent DM Patients with SM Goal (12 months)
0%
20%
40%
60%
80%
100%
Perc
ent
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Daily Aspirin UseFHC: Percent of DM Patients with Daily Aspirin Use
Percent DM Patients with Daily Aspirin Use
0%
20%
40%
60%
80%
100%
Perc
ent
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Foot Exam (12 FHC: Percent of DM Patients with Foot Exam (12 months)months)
Percent DM Patients with Foot Exam (12 months)
0%
20%
40%
60%
80%
100%
Perc
ent
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Retinal Exam (12 FHC: Percent of DM Patients with Retinal Exam (12 months)months)
Percent DM Patient with Retinal Exam (12 months)
0%
20%
40%
60%
80%
100%
Perc
ent
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Microalbumin Screen FHC: Percent of DM Patients with Microalbumin Screen (12 months)(12 months)
Percent DM Patient with Microalbumin Screen (12 months)
0%
20%
40%
60%
80%
100%
Perc
ent
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Moving Forward:Moving Forward:Goals for MMG HDC DiabetesGoals for MMG HDC Diabetes
ABC’s improvement. Selected Targeted Population Parameters for
MMG HDC (e.g. self-management scores) Selected Targeted Population Parameters by site
(e.g. LEAP at FHC) Incorporation of MIS into MMC CISIncorporation of MIS into MMC CIS Monte Home Care Collaboration Build on Peer and Health Educator gains.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Clinical Information SystemsClinical Information Systems
DM Collaborative Core Team:
Dr. Jon Swartz, Dr. Zach Rosen, Arthur Blank, Jennifer Klein and Nandini Deb
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CIS currently used:CIS currently used:
CVDEMS
- Cardiovascular and Diabetic Electronic Management System
- Microsoft Access Based Program
PECS
- Patient Electronic Care System
- Microsoft Access Based Program
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Medical Group Health Disparities Collaborative
FHC CHCC CFCC WB
CVDEMSPECS
PECSCVDEMS
Montefiore Medical Group Health Disparities Collaborative
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CVDEMS Data Capturing CVDEMS Data Capturing Process: FHC AS MODELProcess: FHC AS MODEL
Data Collection: At each visit, Nurses print out CVDEMS form with last
encounter data and demographic information of the patient
Providers update form at current visit—CVDEMS form gets into chart
EHIT generates weekly encounter list at FHC (~100/week)
Charts pulled and data entered from the CVDEMS form to CVDEMS CIS system
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CVDEMS FormCVDEMS Form
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CVDEMS Data Capturing Contd.CVDEMS Data Capturing Contd.
Data Monitoring Semi-annual generation of list of all patients with no visits
in the last 6 months, given to Health Educators for outreach
Annual pruning of patients with no visits in the past year (after outreach attempted)
Bi-yearly reassignment of Providers/matching Providers with patients
Data quality checks—random sample of 5% charts reviewed to assess validity, reliability and completeness of data
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CVDEMS Data Capturing Contd.CVDEMS Data Capturing Contd.Bi-weekly automatic lab data transfer to CVDEMS and PECS for FHC, WB, CFCC and CHCC:
Tuesday: Program identifies all patients who had labs done in the last two weeks
Wednesday: Program dumps all labs for the identified patients
Wednesday: Lab results are sent back to the sites
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Monthly ReportsMonthly Reports
Monthly report generation:
- Registry Summary Report
- Provider Report
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Registry Summary ReportRegistry Summary Report
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Provider ReportProvider Report
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Key Measures by SiteKey Measures by Site
Clinic
Number of
Patients with 1+ visits
% Patients with HbA1c
< 8.0
Average HbA1c for
DM Patients
% Patients with BP <=
130/80
% Patients with
LDL<100
% Patients on Aspirin
% Patients with LEAP exam (12 months)
% Patients with
Pneumoccocal vaccine
(ever)*
% Patients with Flu
Vaccine (12 months)
% Patients with Retinal Exam (12 months)
% DM Patients with SM Goal (12 months)
ACTIVE PT.
ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.ACTIVE
PT.ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.
FHC 760 60% 7.9 56% 54% 53% 60% 78% 40% 28% 33%CFCC 191 64% 7.8 47% 66% 59% 35% 54% 18% 31% 47%CHCC 273 64% 7.7 65% 57% 59% 38% 54% 35% 22% 15%WB 606 61% 8.0 46% 50% 38% 32% 69% 19% 22% 8%
TOTAL 1830 61% 7.9 53% 54% 50% 45% 69% 30% 25% 23%
70% 6.5 70% 70% 70% 90% 90% 70% 70% 70%Goal
Reporting Period: May 2004-May 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Our Persistent ChallengesOur Persistent Challenges CVDEMS and PECS rigidities
CVDEMS forms not completely filled out
Problems due to manual data entry
Resource constraints at the sites
System crashes—very painful!
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Our SuccessesOur Successes
Structured monitoring of data
Automatic lab data transfer for all the sites
Monthly Reports for FHC, WB, CFCC and CHCC
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Our Plans for the FutureOur Plans for the Future
Montefiore CIS system with Provider entry of data
Chronic Disease Management Screen—with capabilities to present the entire history of the patient.
How to use this data repository to ask research questions?
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
AcknowledgementsAcknowledgements
Each and everybody who has worked and currently working with the DM Collaborative
Special thanks to Jasmine Smith, Erwin Duran and Jennifer Sanchez — our data support personnel
Nadav Tanners (Having fun at Yale!)
Yan Chai — DFSM Data Manager
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
SELF-MANAGEMENTSELF-MANAGEMENT
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Patient Self-ManagementPatient Self-Management
Patients already self manage • All patients make decisions and engage in
behaviors that affect their health.• They are in control. • They decide on what health behaviors they will
or will not engage in.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Traditional vs Collaborative CareTraditional vs Collaborative Care
Provider as expert Provider is principle
caregiver and problem solver Provider gives instructions to
be complied with Behavior is externally
motivated Provider identifies
problem Provider solves
problems
Shared expertise Shared responsibility
Patient sets goals Internal Motivation
Patient identifies the problem
Patient is taught problem solving skills
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management EducationSelf-Management Education
Based on Self Efficacy Theory (Self Confidence)
Emphasizes• Problem Solving• Decision making• Confidence building
Goal Setting
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
What would What would youyou like to do to improve like to do to improve your health? your health?
You choos
e
Monitoring Physical Activity
MedicationsCoping Unhealthy Behaviors
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management Goal SettingSelf-Management Goal Setting
My Action Plan • What• Where• When • How often
Barriers Problem Solving to overcome barriers Support needed to reach goal Confidence level
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management Goals Self-Management Goals
Teaching Techniques Facilitative Participatory Collaborative
• Use of Motivational Interviewing techniques to elicit Self- Management Goals
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management Support at MMGSelf-Management Support at MMG
Educational Classes Group Medical visits Support groups Walking club Individual Sessions Cooking Classes
Waiting Room Talks Phone Contacts Salsa Classes Peers Support Community
involvement
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Comprehensive Family Care Montefiore Comprehensive Family Care Center – Bronx Community Health Network Center – Bronx Community Health Network
(MMG-CFCC/ BCHN)(MMG-CFCC/ BCHN)
1621 Eastchester Road
Bronx, New York 10461
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Medical Group Montefiore Medical Group Comprehensive Family Care CenterComprehensive Family Care Center
About Us 75,000 visits / year Internal Medicine, Pediatrics, &
ObGyn Residency Programs 60 atttending MDs 102 (48 IM, 31 Peds, 28
ObG)Residents Nurse practitioners, midwives Numerous other providers Total users 2004 – 18,682 Of those 1042 (5.6%) are patients
w/Diabetes mellitus
Demographics Black/African-American 30% Hispanic/Latino 46% White (not H/L) 12% Unknown/unreported 11% Asian/Pacific Islander 1% Native Am/Alaskan Native .02%
Languages English Spanish
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
AIMAIM
AIM: Montefiore Medical Group – CFCC will redesign our care delivery system to maximize the health and quality of life for our patients with Diabetes mellitus, by assuring that they receive effective, evidence-based services, using a coordinated care plan.
We will achieve this by implementing a comprehensive approach, using the components of the Chronic Care Model
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self Management, Self Management, highlightshighlights
GROUP LEARNING Group Educational Series: English and Spanish Team presentation of learning sessions (Health Educator, Residents,
Physician, Social worker and Nutritionist). Collaborative, interactive format Alumni lunches held once a month to re-visit self-management , education
and problem solving issues
GROUP ACTIVITES Walking club twice a week, open to all CFCC patients Birthday Lunch Breakfast Club: pilot
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self Management, cont.Self Management, cont.
INDIVIDUALIZED GOALS Individualized sessions at the end group to define self-management goals. Individual mini-sessions prior to provider visits consisting of diabetes education,
nutritional counseling, and self-management goal setting. Individualized sessions with nutritionist.
PEER SUPPORT CFCC patients with diabetes trained as Peer Educators for Bronx Defeat Diabetes
Project. We have 4 peer educators. Participation in all group activities. Waiting room contacts with ADA risk assessments completed. Development of peer patient panels to encourage compliance and supply support.
Ongoing training in 1-1 diabetes management education. Outreach activities within the health center and into the community.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Family Health CenterMontefiore Family Health Center
360 East 193rd Street
Bronx, New York 10458
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Medical Group Family Montefiore Medical Group Family Health CenterHealth Center
About Us 45,000 visits / year Family Medicine Residency Program 18 Providers 16 Residents # Diabetic patients: 755
Primary Insurance Medicaid 39% Self Pay 29% Medicare BC/BS Empire 13% Bronx Health Plan GHI
Demographics Black/African-American 30% Hispanic/Latino 41% White (not H/L) 13% Unknown/unreported 8% Asian/Pacific Islander 7% Native Am/Alaskan Native .02%
Languages English 56.70% Spanish 36.20% Cambodian 5.30% Vietnamese 1.30% Other 0.40%
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self Management HighlightSelf Management HighlightDiabetic referrals via Walkie TalkieDiabetic referrals via Walkie Talkie
GOAL: Coordinate efforts with 2nd and 3rd floor PCTs, Health Educators and Nutritionist to increase percentage of self-management goals set at FHC.
ACTION: Individual health educator or nutritionist counseling sessions with diabetic patients pre/post provider visit.
PROCEDURE: Use walkie-talkie between central locations: PCTs call health educator or nutritionist through walkie talkie once a diabetic is prepped. While waiting for the provider patient is then seen by the health educator or nutritionist in the exam room.
RESULT: SUCCESS 8% increase in the percentage of self-management goals set from July until August at FHC.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Resident Collaborative InvolvementResident Collaborative Involvement
Thinking outside the box to improve community oriented primary care of chronic disease
Identifying community resources• Care doesn’t just happen inside the clinic• Better understanding of pt’s social context• Contributing to the community and the bouquet
of services that already exist Looking to the future
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
NutritionNutrition
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Ways I Work With PatientsWays I Work With Patients
One to One sessions Group sessions Setting self-management goals Community Outreach
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Teaching MethodsTeaching Methods
Food models Visuals Power points Food demonstrations
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
ChallengesChallenges
Scheduling follow-ups Show up rates Reminder calls Follow up on self-management goals
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
SuccessesSuccesses
Cooking classes Changes on patients HgA1C Outreach lectures