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North East Medical Services (NEMS) San Francisco, CA. Pacific West Cluster Learning Session #2 May 12-14, 2005 Atlanta, Georgia. About NEMS.

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North East Medical Services (NEMS) San Francisco, CA

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    1. North East Medical Services(NEMS)San Francisco, CA Pacific West Cluster Learning Session #2 May 12-14, 2005 Atlanta, Georgia

    2. About NEMS • Our Mission:To provide affordable, comprehensive, compassionate and quality health care services in a linguistically competent and culturally sensitive manner to improve the health and well-being of our community. • Location: throughout San Francisco, California • Main Clinic in Chinatown/North Beach (1520 Stockton Street) • Satellite Clinic in Visitacion Valley district (82 Leland Avenue) • Newest Satellite Clinic in Sunset district (2308 Taraval Street) • Organization Size:26 Medical Providers (including part-time specialists), 8 Dentists, 130+ Staff

    3. About NEMS • Services include: • Medical (Internal Medicine, Pediatrics, OB/GYN) • Dental, Optometry, Mental Health • Lab, Pharmacy, Health Education, Nutrition, Social Services • Medical Specialties: Allergy, Cardiology, ENT, Podiatry, Radiology, Ophthalmology, and Surgery. • Population Served: • Total Patients: 30,000+ • Diabetes Patients: 1,300+ Diabetes Patients in POF: 101 • Homeless Patients: 444 ; Migrant Patients: 0 • 96% Asian (Chinese); 2% White; 2% Black/Hispanic/Other • 61% of patients are below 100% of Federal Poverty Level (FPL) • 89% of patients are below 200% of FPL • 19% of patients are age 65 and above • 88% of patients better served in a language other than English

    4. Team Members

    5. Aim Statement North East Medical Services will redesign its clinical practice to improve care for our patients with diabetes. We will accomplish this through the implementation of the Care Model. Our goals are to: • Increase the recognition rate of our diabetic patients; • Increase patient education to facilitate better self-management and compliance among patients; and • Effectively manage the continuum of care to ensure patients receive comprehensive care.

    6. Population of Focus North East Medical Services’ Population of Focus (POF) will be all patients in Dr. Edward Ko’s practice at the Stockton clinic. The initial size of our Population of Focus will be 101 patients, taking into account active diabetes patients who have had at least one annual visit with Dr. Ko and on a consistent basis. We chose Dr. Ko’s patient pool because it was a manageable number of patients, and we felt Dr. Ko would be a great “physician champion” who could share lessons learned during the Collaborative with our other providers.

    7. Key Diabetes Measures(Functional and Clinical Outcomes)

    8. Self-Management Currently Testing: • Self-management “Agreement” between patient & provider Implemented into Our Delivery System: • Nothing yet!

    9. Community Currently Testing: • Grant-writing to foundations about chronic care management Implemented into Our Delivery System: • Attending meetings at local diabetes collaborative to draw from their experiences (task, not PDSA)

    10. Healthcare Organization Currently Testing: • Integrating collaborative models into quality improvement program (in planning stage) Implemented into Our Delivery System: • Progress/input sharing sessions during Leadership meetings

    11. Decision Support Currently Testing: • Have team members liaise with diabetes specialist to coordinate information sharing • Engage Medical Records department in helping us track new POF patient visits Implemented into Our Delivery System: • Nothing yet!

    12. Clinical Information System Currently Testing: • Use PECS encounter notes as dynamic reminder system for each patient at follow-up visits • Use registry summary and information to focus our PDSAs on reaching key measures Implemented into Our Delivery System: • Nothing yet, but very soon!

    13. Delivery System Design Currently Testing: • Internal Dental Referral Forms and Referral Response Forms to share information between medical and dental departments Implemented into Our Delivery System: • Use of short dental screening questions to determine if dental referral is necessary (part of PDSA above)

    14. National Key Measures (1)

    15. National Key Measures (2)

    16. National Key Measures (3)

    17. National Key Measures (4)

    18. Senior LeadershipMaking the Case for Change Because chronic care management is such a hot topic these days, it was very easy to convince our CEO to consider it a new priority within our organization (otherwise, we wouldn’t be in the Collaborative!). Recently, we were very lucky to have two grant opportunities come by that focused on chronic care management, further proving that chronic care management is gaining notice in the community and industry. Our participation in the Health Disparities Collaborative assisted us in writing the grants, and we are waiting to see if we get funded to further develop our overall quality improvement program. Our CEO was very supportive of us focusing these grant opportunities on Collaborative-related activities.

    19. Communication Plan We have been using every opportunity we can to share the progress of our team, whether its at our monthly leadership meetings or during general staff meetings, which our entire staff sits in. This has been really useful, since it brings our work to the forefront of everyone’s mind. After hearing about our work, one of our providers helped to schedule a diabetes educational talk for our NEMS providers by a community colleague and expert! Other staff are also helping to “keep an eye out” on other related opportunities in the community, and sharing these resources with us.

    20. Those that the Team can solve… Continuous and consistent tracking of patient visits Coordination of information sharing and communication between departments Those that the Leadership must address… Hiring new staff to help with chronic care management Resistance to change Balancing staff time between Collaborative and other projects (JCAHO, etc.) Anticipating Barriers and Issues

    21. A story to share… the Patient Although initially resistant, one of our POF patients went to get a periodontal exam after Dr. Edward Ko referred him to our clinic. One of our dentist, Dr. Emil Ng, spent some time with the patient prior to the exam to explain why dental health is important to overall health, which reassured the patient. We are now one patient closer to reaching our dental key measure goal!

    22. A story to share… our Staff After hearing our Collaborative progress reports, many of our staff have become extremely interested in our work and helpful in linking us with resources in the community. Dr. Shih-Jen Chang, our OB/GYN team leader, helped us schedule an educational talk on diabetes for our providers with Dr. Melinda Scully, who directs the Diabetes & Pregnancy Program at California Pacific Medial Center in San Francisco.

    23. A story to share… NEMS Our participation in the Collaborative has really shed light on how much communication lacks between departments. Prior to our use of the dental referral and referral response forms, we had no way to share health information on a patient between departments. We now have a new system that we can adapt to other departments and specialties in the future!