Diabetes And Community Medicine

1. DiabetesAnd Community Medicine Patrick Chen, M.D. Share Our Selves January 30, 2010

2. Objectives Highlight services at a community clinic Characterize a diabetic patient population Describe a multi-disciplinary approach

3. Share Our Selves (SOS) 1550 Superior Avenue Costa Mesa, CA 92627 (949) 650-0640 www.shareourselves.org

4. What is SOS? • 501(c)(3) non-profit organization • Health services for OC’s poor and uninsured • All services are free of charge • 2009 operational budget $6.6 million • More than 100,000 patients/clients annually • 45 employees • 400 volunteers

5. Our Mission Statement We are servants who provide free care and assistance to those in need and act as advocates for systemic change

6. SOS – A Brief History • Founded in 1970 to provide for OC’s poor • Food • Clothing • Financial aid • Evolution • 1984 Medical Clinic • 1987 Dental Clinic • 2005 Comprehensive CARE Center • 2009 SOS Family Center

7. 5 Core Services • Social Services • Comprehensive CARE Center • Family Center • Dental Clinic • Medical Clinic

8. Social Services • Food • Financial Aid • Clothing • Legal aid • Education Classes • Fundraising Drives

9. Comprehensive CARE Center • Counseling - individual, group therapy • Advocacy - case management • Resources - linkage to benefits/programs • Emergency Services - crisis intervention

10. Family Center • Pregnant women, families with kids 0-5 y.o. • Education and in-home support: • Prenatal • Breastfeeding • Parenting • Diabetes prevention

11. Dental Clinic • Hygiene, x-rays, extractions, restorations • 2 dentists • 8124 visits annually

12. Medical Clinic • 15,000 visits annually • Chronic program • 2200 patients • Walk-in clinic • ER diversion rate: 29% • Specialty clinics

13. SOS – Hoag Partnership • Symbiotic collaboration between two independent non-profit healthcare institutions • Hoag provides $1.5 million in-kind support: two physicians, meds, diagnostics, services • SOS provides primary care, ER diversion, and follow-up for discharged patients

14. Socioeconomic Profile • Federal Poverty Level • Single: $10,800 • Family of 4: $22,000

15. Socioeconomic Profile • Medical Services Initiative (MSI) • OC’s safety net program • < 200% FPL

16. Employed Providers • 1.5 FTE Internists • Family Physician • Physician Assistant • Nurse Practitioner • 1.5 FTE Pharmacists

17. Volunteer On-site Providers • Internist • Cardiologist • Nephrologist • Optometrist • Diabetic Educator • Gynecologist • Uro-Gynecologist • Physician Assistant • Nurse Practitioner • Physical Therapist

18. SOS Diabetes Program • 393 patients • 4.4 average visits/yr • MSI and Uninsured • Geographic focus • Demand is increasing

19. SOS Diabetes Program • Labs • Specialty Care • Medications • Education • Mental Health • Case Management

20. A Multi-disciplinary Team • Primary care • Specialty care • Pharmacists • Diabetes educators • LCSW/MFT • Case Managers

21. ADA Guidelines • Targets: • Hb A1C • BP • HDL, LDL • Medications: • Statins • Antiplatelet • Immunizations • Screening: • Neuropathy • Retinopathy • Nephropathy • Lifestyle Changes: • Physical Activity • Smoking Cessation

22. First Encounter • How do patients get into the program? • Walk-in patient • Referral from a hospital • Our patient develops diabetes

23. First Encounter • Patient Contract • Financial Screening • Depression screening • Medications • Referral to a diabetes educator

24. Medications • SOS purchases • $4 Pharmacy programs • Patients Assistance Program (PAP) • Hoag Pharmacy

25. Medications • Oral diabetic agents • Insulin • Statins • Fibrates • Antiplatelets • ACE Inhibitor / ARB • BP therapy • Antidepressants • Vaccines • ED meds

26. Medications Value Dispensed 2009 • SOS - Metformin $167,984 • PAP – Atorvastatin $372,740 • Hoag – Insulin $74,852

27. Diabetic Education • Latino Health Access • SOS Medication Therapy Management • Hoag Diabetes Center

28. Diabetic Education • Pathophysiology • Glucometer Training • Nutrition • Exercise • Medications • Insulin Instruction

29. Integrative Behavioral Health • Counselors are Providers • Collaboration (“Our patient”) • High-risk for depression • Behavioral change is critical

30. Integrative Behavioral Health • Depression Screening • PHQ-9 each visit • Depression Management • Counseling • Antidepressants

31. Integrative Behavioral Health PHQ-2 Depression Screen • Score of 3: 83% Sensitivity, 90% specificity - Administer PHQ-9

32. Integrative Behavioral Health • Case Management • Care coordination • Special needs • Family Conference • Patient / Family members • Provider • LCSW / Case Manager

33. Family Center • Target families of diabetic patients • Diabetes Prevention Classes • Exercise Classes

34. Specialty Care • Nephrology • Optometry • Cardiology

35. Eye Care • Bimonthly eye clinic • Prescription lenses • Retinopathy screening • Referral to Ophthalmology

36. Foot Care • “Feet and Finger sticks” each chronic visit • Providers perform microfilament exam • Referral to podiatry • Hoag Wound Care Clinic

37. Nephropathy • BUN/Cr, Ur. Microalbumin Qyr • ACE Inhibitor / ARB • Referral to Nephrology

38. Dental Care • Referral to Cypress College Dental Hygiene Program • Referral to SOS Dental Clinic

39. Challenges to Care • Patient resources • Transportation • Clinical Space • Volunteer staff • Access to specialists • Increasing demand

40. The Future • Electronic Health Records • Standardized management algorithms • Group Visits • Self-analysis (targets, outcomes) • Open another site