University Medicine Governor St. Primary Care Diabetes and A 1 c Control Dr. Michael Johnson Maureen Claflin
Governor St. A 1 c Metric Over Time
Team Based Care Team • • Physician Nurse Care Manager Medical Assistant Nutritionist Behavioral Health Patient Caregivers Pharmacist
Protocols • Pre-visit planning – determine need for A 1 c • At visit – MA will do an in-house A 1 c if not done in last 3 months when patient is being roomed • A 1 c results > 8. 5 referral to NCM or nutritionist • All newly diagnosed patients and patients new to Insulin are referred to NCM for teaching
CSI Quality Improvement Team • Meets bi-weekly • All providers, NCM, practice manager, QI assistant and MA’s from each pod • Review provider level data monthly • Process/systems improvements discussed • PDSAs • Rollout to practice
Patient Self-Management • Patients are integral to their care • Education happens at each visits o Ophthalmology f/u o Podiatry f/u o Neurology f/u if necessary • Short and long term SMG established • Internal resources/External resources • Reinforcement of patient teaching and goals
Community Partners • • • Team Works educational sessions Community CDOEs VNA and Home Care Diabetic Educators YMCA program for diabetics Nutritionists Behavioral health
Challenges • Patient activation – especially for poor control • Obesity epidemic • Coordinating patient care with Endocrinology groups • Elderly population with multiple co-morbid conditions
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