Individualized Patient Education in the Primary Care Clinic

Mary Campos, RN, CDE EKLMC Diabetes Case Manager Individualized PatientEducation in the Primary Care Clinic

Background Information • Disease specific education (traditional) • Diabetes Ed • HTN Ed • CHF Ed • Asthma Ed • CRF Ed • Nutrition Ed

Referral Criteria • Diabetes Ed: • HbA1C >/= 8 9%, new type 1, new to insulin • HTN Ed: • Stage II or new onset Stage I • CKD Ed: • Stage III or greater • CHF Ed: • EF of 40 or lower • Lifestyle Balance Weight Loss program: • BMI >/= 30kg/m2

When and Where • Traditional Education • Pre-set schedule • Minimal flexibility • One location Money Kids Gas Work Ride

Stepping up to the Challenge Improve Patient Education Model

“Improve Patient Ed Model” • What do patients want? • What do patients need? • How can we effectively provide this?

Patient Centered • Convenience • Cost savings • Quality Care • Support • Education

Objectives • Develop an educational process within the medical home. • Improve disease management indicators through staff and patient education. • Increase patient awareness of preventative health maintenance and resources. • Engage patients to become leaders of their health care through education and support of their efforts.

Target Audience • Patients followed at NBR CL • 1 PCP - 3 days a week • Specific chronic diseases (DM, HTN, CKD, CHF, Asthma, Obesity) • Others requiring preventative health maintenance updates

Program Design • Patient driven • No set format • No appointments • Same day education • Located within the medical home • Basic education only

Key Components • IdentifyBarriers…problem solving • Education • Encourage adherence • Offer support to patient and provider • Assist with resources

Pre-clinic Activities • Obtained clinic roster • Copied Cliq summary page • Identified our patients • Communicated with staff CLIQ Summary

Clinic Activities: Pt. Encounter • Assessed current health habits… • Helped identify barriers…problem solving • Provided chronic disease or wellness education

Clinic Activities: Pt. Encounter • Reviewed Health Maintenance requirements • Distributed contact information • Reviewed clinic call back process • Indigent Pharmacy hours • Discussed Resources • Referrals (if interested)

Clinic Activities: Pt. Encounter • Encouraged Accountability • Engaged patient in becoming pro-active • Encouraged to request updates of disease specific indicators • Gave approval and prompted to ask questions

Other Case Management Activities • Completed documentation form • Placed form on chart for PCP review • Discussed specific issues with PCP (if indicated) • Recorded encounter on billing sheet • STAT- Pt wellness-ind. education

Results: June-November 2011

Traditional vs. CM in Clinic

2011 Diabetes Indicators

Barriers or Opportunities for Improvement • Sufficient staffing- Case Managers (CM) • 5 Staff MD’s -25 slots each per clinic • 9 NP’s - 20-22 slots each per clinic • Interns and Residents - ≈15-30 attend per half day Clinic • CM within the Medical Home • Phone call follow up • Data base

Advantages of CM within the Medical Home • Educate all stages of disease process • More time to focus on barriers • Partner with the practitioner • Support and advocate for the patient • More patient centered • Improve outcomes

The End!

Individualized Patient Education in the Primary Care Clinic

Individualized Patient Education in the Primary Care Clinic

Presentation Transcript

Patient Centric Primary Care Roundtable

Patient-Centered Primary Care

Patient Safety in Primary care: an overview

Patient Experiences of Primary Care in Malta

A Primary Care Wellness Clinic

Patient-Centered Primary Care Collaborative

Individualized Care

Patient Experience in Primary Care

Patient Centered Primary Care Collaborative

The Individualized Education Program

Patient Safety in Primary Care The Linneaus Collaboration

Patient-Centered Primary Care in Prison

Electronic patient record in primary care

Pharmaceutical Compounding Individualized Patient Care

Patient Centered Primary Care Collaborative

Nigeria Primary Care Clinic Project

Primary Care for the Transgender Patient

The electronic patient record in primary care

Clinic Navigation 2011 – Primary Care

The Primary Care Physician and the Patient

Individualized Education

Primary Care Clinic