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Patient Self-Management: in Primary Care Team SPANK: St Peter Aims for New Knowledge. March 9, 2004 Devin Sawyer, MD Joseph Wall, MHA Shari Gioimo, MA Janet Wolfram, CDE. We are…. A Residency Program- Full Scope FM 37,000 patient visits a year Residents & UW med students- 6 per year

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Patient Self-Management: in Primary Care Team SPANK: St Peter Aims for New Knowledge

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Patient self management in primary care team spank st peter aims for new knowledge l.jpg

Patient Self-Management:in Primary CareTeam SPANK: St Peter Aims for New Knowledge

March 9, 2004

Devin Sawyer, MD

Joseph Wall, MHA

Shari Gioimo, MA

Janet Wolfram, CDE


We are l.jpg

We are…

  • A Residency Program- Full Scope FM

  • 37,000 patient visits a year

  • Residents & UW med students- 6 per year

  • Aprox. 300 diabetics

  • Participated in WSDC II and RWJ grant

  • Getting better at a TEAM APPROACH to chronic care and patient Self-Management


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What we have done lately…

  • WA Diabetes Collaborative, 2000-2001

  • Focused on Patient Self-Management

  • The role of each player: providers, medical assistants, administrative support, patients, and mentors

  • RWJ funding for Advancing Diabetes Self-Management ($300,000)


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What is Self-Management?…

  • Checking blood sugars

  • Taking meds (pills and shots)

  • Eating right (CDE, doctor, other diabetics)

  • Exercising (30 mins/day, 150 mins/week)

  • Checking feet

  • Making appointments (PCP, eye doc, CDE)

    What is missing?


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24/7/365

  • “The patients right and responsibility to make decisions that make sense within the contextof their lives”

  • “Education and support refocused on helping patients make & achieve goals and outcomes that they themselves have selected”

  • “Must acknowledge and support the patients role as the key decision maker in self-management”

  • Patient role? Provider role? Staff role? Others?


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The NPR news report on ‘effective diabetes care’ in 2003N Engl J Med, 2003; 348,5:383-459 (Steno-2 study in Copenhagen)

  • An Experienced TEAM

  • Motivated

  • Enthusiastic

  • With a Gung Ho attitude


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Our program…

  • MA Planned Visits with goal setting

  • Provider Visits with emphasis on patient goal setting

  • Medical Group Visits

  • Registry to support patient care (CDEMS)

  • Exercise opportunities

  • Patient Mentoring (buddy system)

  • Newsletter


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CDEMS: Our Run Charts


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CDEMS: Our Run Charts


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What it has taken to get us here…

  • MA training (Boldt Center)

  • Provider training (faculty development, and resident workshops and precepting - BBSWAR)

  • Patient education

  • Practical description of self-management: an SMG cycles (new way of thinking for our clinic)


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How do we teach this to the MA’s?

  • A new curriculum for the MA’s (A new service for diabetes educators?)

  • Skills in-service; foot checks, CDEMS, planned visits, phone skills, group visits (Camp SPANK)

  • Shadowing

  • On the job training


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MA planned visits:(see standing orders)

  • They follow the standing orders

  • Introduce SMG

  • Occur 1 week before provider visit

  • 90% of our MA’s perform planned visits

  • This frees up some of the provider time


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How do we do and teach this to the providers?

Big Bad

Sugar WAR


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The 15 minute encounter: A toolBig Bad Sugar W.A.R.

  • Background

  • Barriers

  • Successes

  • Willingness to change

  • Action plan

  • Reinforcement


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An Action Plan:

  • Something the patient comes up with and WANTS to do

  • Should be REASONABLE

  • Behavior specific

  • Should answer the questions:

    • What?

    • How much?

    • When?

    • How often?

  • Confidence level (likelihood-of-success) 1-10


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Patient Goal Quality

  • Evaluate, record, and track patient SMG quality

    • 1 point for activity (what- i.e.: briskly walk, or stop skipping breakfast)

    • 1 point for location (where- i.e: around Capital Lake, or at home and at the office)

    • 1 point for frequency (how often- i.e: M,W,F, or 5 days a week)

    • 1 point for time/duration (how long- i.e.: for 45 minutes at 7:00 am, or 8 am before I leave for work)

    • 1 point for LOS score (from 1 to 10)


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SMG quality over time:


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The Group Visit


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The Group Visit

  • Developing patient oriented self-management curriculum

  • More providers (faculty), more staff being trained

  • More patients coming

  • Now an educational expectation for residents

  • High patient satisfaction

  • Outcomes in 2001:

    • HbA1C of our practice: 7.7

    • HbA1C of those who come to DGV: 6.3


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Patient Data Registry(CDEMS)

  • Free from the DOH, developed locally

  • MA’s do data entry and us for patient outreach

  • PCP’s use patient report with the patient visit

  • PCP/MA team can query their data to target care (outliers), for patient recall, and for patient goal reinforcement


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Exercise Opportunities

  • Walking Club

  • Pedometer Program

  • “SPFP Moves With You” Video


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Walking Club


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Pedometer Program


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“SPFP Moves With You”…

The Video


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Patient Mentoring (buddy system)

  • Patients are supporting Patients

  • One patient calls another about 2 months after the provider visit to “check-in” with their SMG

  • Sent a card with a patient’s information

  • Provides additional support and accountability

  • Bridges the gap between the planned/provider visit and the beginning of the next cycle


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What is next? Spread…

  • Graduate trained providers

  • More grant money- Phase II

  • In-service local providers- Elma

  • Provide training to local MA’s

  • A role in the STEPS grant


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Contact Info…

  • Devin Sawyer, MD- [email protected]

  • Joseph Wall, MHA- (360)493-4001 [email protected]

  • Shari Gioimo, Medical Assistant- [email protected]

  • Janet Wolfram, Diabetes Educator

    [email protected]


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