team/organization name background and structure location brief system information (type, size) pilot...
TRANSCRIPT
Team/Organization Name
• Background and structure
• Location
• Brief system information (type, size)
• Pilot population
DeliverySystemDesign
Decision Support
ClinicalInformation
Systems
Self-Management Support
Health System
Resources and Policies
Community
Organization of Health Care
• Registry• Care remind-
ers• Patient
Subgroups• Care-planning
• Team roles and tasks
• Planned visits• Continuity• Follow-up
• Guidelines• Specialty
interaction• Provider
education• Guidelines
for patients
• Emphasize patient role
• Assessment• Interventions• Care planning and
problem solving
On this slide briefly describe what your team did in each area.
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Functional and Clinical Outcomes
•Goals•Benefits•Provider incentives•Improvement strategy•Senior leaders
Health System
Resources and Policies
Community Organization of Health Care
•Effective programs•Partnerships•Coordination
On this slide briefly describe what your team did in each area.
Describe Key Changes made. For example:•Assessment of selected clinical priorities•Evidence-based interventions targeted based on assessment•Protocols used•Collaborative plan formulated with each participant, based on PCP input and participant’s readiness•Self-management support was emphasized•Proactive follow-up for one year
Informed,ActivatedPatient
ProductiveInteractions
PreparedPractice Team
On this slide briefly describe key changes made, example below
Instructions for next 6 slides.
• You will only need to use one of the next six slides. Keep only the model component slide for your breakout session.
• The “second-level” bullets, designated with a hyphen, are examples of interventions that may have been implemented. Modify these examples to explain what your team has accomplished.
• Call or e-mail Melissa, Donna or La Don if you have any questions. (206-364-9700)
Use this slide to highlight the model component for your breakout session
Clinical Information Systems• Registry
– DEMS
– Process flow from encounter to entry established
• Care Reminders– Outlier reporting to identify patients in need of test
– Letters and labels produced from demographic info
• Patient Subgroups– MDs receive lists of patients with HgbA1c > 8.0%
• Care-Planning– Lists generated for those with missing labs
Use this slide to highlight the model component for your breakout session
Decision Support• Guidelines
– Provider agreement to adopt ADA guidelines
– Printed on encounter forms
• Specialty Interaction– Faxback forms developed for opthalmology and
podiatry specialists
• Provider Education– Pocket cards
– Educational seminars
• Guidelines for patients– Wallet cards
Use this slide to highlight the model component for your breakout session
Delivery System Design• Team Roles & Tasks
– Nurses/MA perform foot exams
– MD briefly mentions the importance of self-management and refers to educator
• Planned Visits– Scheduling for labs before appointment
• Continuity– prompts for specialty MD contact
• Follow-up – CDE calls patients regularly
Use this slide to highlight the model component for your breakout session
Self-Management Support• Emphasize Patient Role
– Multiple providers send this message to patient
• Assessment– Downloaded assessment from Web site
– CDE assesses patient at planned visit
• Interventions– CDE received training through Chronic Disease
Self-Management Program
• Care-Planning & Problem Solving– Use of motivational interviewing techniques
Use this slide to highlight the model component for your breakout session
Community Resources• Effective Programs
– Identifies community resources at YMCA
– Modifies resource booklet and placed in Toolbox
• Partnerships– Diabetes fair sponsored by Safeway and local
hospital
• Coordination– CDE discusses resources with patient
Use this slide to highlight the model component for your breakout session
Organization of Health Care • Goals
– Switching from a reactive to proactive approach
• Benefits– Working closely with health plan to cover group visits
• Provider Incentives– Set BP goals for team to achieve
• Improvement Strategy– Working closely with pilot team to spread to another
clinic
• Senior Leaders– Approved position for assisting pilot and spread teams
on tracking and reporting on Collaborative measures
Functional and Clinical Outcomes
• List results achieved toward targeted measures
Baseline Actual Target
Oct 99 Nov 2000
– HbA1c < 8.0 40% 65% 60%– Self-mgt. goals set 5% 25% 50%
Barriers
• Describe challenges here
Keys to Success
• This is a place to summarize the lessons you learned