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Sands of Time

Sands of Time. Diabetes Self-Management Education Jacqueline Thomas, MSN,CRNP,CDE. Identify strategies to improve Diabetes Self-Management Education using the Chronic Care Model.

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Sands of Time

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  1. Sands of Time Diabetes Self-Management Education Jacqueline Thomas, MSN,CRNP,CDE

  2. Identify strategies to improve Diabetes Self-Management Education using the Chronic Care Model. Discuss the use of the Chronic Care Model in a primary health care setting and community in Diabetes Self-Management. Describe a Health Care Organization partnership with a Medicare Quality Improvement Organization in facilitating Diabetes Self-Management. Objectives

  3. DSME is defined as the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence- based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life. National Standards for Diabetes Self-Management Education. American Diabetes Association, Diabetes Care, Vol. 30, No. 6, June, 2007. What isDiabetes Self-ManagementEducation?

  4. SRHCC is a non-profit organization that has served the underserved population since 1977. Federally Qualified Health Center serving 5 Counties of Franklin, Lawrence, Lauderdale, Morgan and Colbert in the State of Alabama. All Counties are designated in whole/part Medically Underserved Areas and Health Professional Shortage areas. 35.1% area population residents with incomes below the federal poverty level. In October, 2004 SRHCC was accepted into the Bureau of Primary Health Care Health Disparities Collaborative with diabetes as initial chronic condition. Diabetes Registry- 681 patients diagnosed with diabetes. 68.7% Caucasian, 29.4% African-American/Black,1.8% Hispanic, 0.1% American Indian. Diabetes Registry- Age 65-84(23.4%) Southern Rural Health Care Consortium, Inc.

  5. Family Nurse Practitioner (Primary Care Provider at remote site) current interim position. Process leader for 5 health center teams (Conditions: diabetes, asthma, cancer and cardiovascular) Certified Diabetes Educator (Individual and group classes) SRHCC representative with the Alabama Diabetes Network and Alabama Comprehensive Cancer Control Coalition. Program planner for community and provider/staff health education activities. Participant in community health activities Role in Diabetes Education at SRHCC

  6. Chronic Care Model SRHCCDiabetes Self-Management Education Program

  7. Center Key Measures Diabetes

  8. A story to share….our staff The Collaborative has made a great impact with our staff at Southern Rural Health Care Consortium. The pilot team and spread teams are true champions. They are willing to go the extra mile for patients in order to improve outcomes. They believe in the team approach. No matter how tough things get with staff turnover and having to do PDSA cycles, they really make an effort to make sure we sustain. As a process leader, it is great working with the teams. Jacqueline Thomas, Process Leader

  9. Provider of Educational Resources/Tools. Cultural Competency Modules. Participant and Supporter of SRHCC Health Disparities Symposium. Medicare Preventive Services to include the Initial Preventive Physical Examination ((IPPE). Updates to Medicare’s Diabetes-related Covered Services. CMS Physician Quality Reporting Initiative (PQRI). Electronic Health Records Electronic Prescriptions (E-Prescribe) Email, site-visits, phone-calls. AQAF“A Medicare QIO that works with SRHCC for quality improvement”

  10. Organization Leadership Health Care Providers Clinical, Clerical & Support Staff Patients and Families Community Medicare Quality Improvement Organizations working with Health Care Professionals in DSME Program.Success of Collaborative Self-Management involves the support of following:

  11. Sands of Time Half the cost of illnesses are wasted on conditions that could be prevented. From the book “Total Wellness”, Dr. Joseph Pizzorno

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