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Diabetes Collaborative at Sea Mar Vancouver. Tatiana Shelepova, MD & Jamie Zentner, MPH. Washington State Collaborative Learning Session 3 September 11-12, 2006. Sea Mar Community Health Centers. Vancouver, WA Pilot Population: 158 patients Ethnicity

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slide1

Diabetes Collaborative at Sea Mar Vancouver

Tatiana Shelepova, MD & Jamie Zentner, MPH

Washington State Collaborative Learning Session 3

September 11-12, 2006

sea mar community health centers
Sea Mar Community Health Centers
  • Vancouver, WA
  • Pilot Population: 158 patients
  • Ethnicity
    • 43.2% Caucasian, 40.6% Russian, 16.1% Mix
  • Insurance
    • 57.4% DSHS, 18.1% None, 17.4% Medicare
aim statement
Aim Statement

Sea Mar Community Health Centers Vancouver will redesign the provision of care to achieve the following goals:

slide5

Key Changes in Self Management Support and Delivery System Design

Health System

Community

Organization of Health Care

Resources and Policies

Clinical Information Systems

DecisionSupport

Self-Management Support

Delivery System Design

  • Clinic Manager
  • Clinic Champion, MD
  • Day to Day Leader
  • Medical Assistants
  • CSR
  • Medical Records
  • Front Desk
  • One-on-one counseling
  • DM classes
slide6

Key Changes in Decision Support and Clinical Information Systems

Health System

Community

Organization of Health Care

Resources and Policies

Self Management Support

Delivery System Design

Decision Support

Clinical InformationSystems

  • Team attendance to wsc5 learning sessions
  • Participates in teleconferences
  • DM classes - benchmarks
  • CDEMS Registry
  • Interface CDEMS & Labcorp
  • Alert Notes in Mysis
pdsa cycles hba1c
PDSA Cycles: HbA1c
  • How was this accomplished?
    • More frequent follow-up visits
    • Physician spends more time discussing importance of management
    • Knowledgeable & motivated medical assistant
  • Next Steps:
    • Recruit patients with A1c > 7.0 to DM class
pdsa cycles cholesterol
PDSA Cycles: Cholesterol
  • How was this accomplished?
    • More follow-up visits
    • More time spent discussing importance of management
    • More aggressive treatment with lipid agent
  • Next Steps:
    • Recruit patients with LDL > 100 to participate in class
    • More time spent discussing importance of management
barriers
Barriers
  • Patients with few resources
  • Conflicting primary needs
  • No insurance
  • No show to appointments
  • Co-morbidities (mental health)
  • Creating opportunities in community for patients (healthy food & exercise)
keys to success
Keys to Success
  • Communication & Team Effort
  • Russian speaking staff
  • Personal contact & follow-up from MA
  • CDEMS & progress notes
  • Alert notes in Mysis
  • Russian diabetes education materials

http://www.swmedicalcenter.com/body.cfm?id=1926