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A few of the slides you created for your previous storyboard might remain consistent, (i.e. Aim Statement, list of key measures, list of team members.) The exception would be if the directors provided comments/edits to any of these areas on your monthly report. You need to remain consistent and have the AIM statement, list of key measures, etc as they appear on your monthly report.

You will have submitted two monthly reports by learning session two. You are either TESTING ideas under each component of the Chronic Care Model and/or have already IMPLEMENTED changes under the components of the Care Model. (remember, that means that the change would not go away in your organization if you ended participation in the Collaborative process today…!!) The tests of change and changes implemented is the new information you will be sharing at learning session two. Most of the information you’ll need is already in your monthly report. Keep the description short and to the point but with enough description that the reader can get the major points from your storyboard.

Update your data and insert the graphs from your excel file on slides as demonstrated on slide #13 and 14. Make the graphs large enough so that they are easy to read…no more than 2 to a page, if possible. Therefore, you will need more than 2 slides to display your progress for all measures that you are tracking. DO NOT SUFFER IN SILENCE !Please post a ticket to the Help Desk on SharePoint as soon as possible if you need help accomplishing this step.

project samaritan health services

Location:Damian Family Care Center, Jamaica, NY

Size:17,550 visits per year. Total medical/dental providers = 5.6 FTE's (2.0 FTE's are PCP)

Scope of Services:Primary medical care,(Adult & Peds) GYN, Dental, Psychiatry, Optometry, GI/Hepatology and Podiatry.

Special Programs: HIV, Hepatitis C & Homeless

Population Served -75 currently registered Diabetics who meet the selection criteria for POF.

Ethnic mix: 36.2% African-American, 29% Hispanic, 13% Asian, 10.1% Caucasian, Other/unspecified: 11.5%

team members
Team Members

NameTitle Role on Team

M. Gebhardt CEO Senior Leader

P.Wylie-Kennedy COO Senior Leader

K.Begum MD Provider Champion

S. Pierre, RN Nurse Manager Day-to-Day Leader

J. Roscoe RN QI Facilitator Clinical/Tech Support

C. Pocasangre Adm. Asst. PECS Data Maintenance

Asif Ahmed MIS Specialist MIS Contact

Team Leader Contact: Email: Prohlt53@aol.comTel: (718) 298-5100

aim statement
AIM Statement

AIM: The Diabetic health care team at Project Samaritan Health Services will apply the six components of the Chronic Care Model to:

  • Ensure the application of evidence-based practices for all Adult Diabetic patients.
  • Promote optimum clinical outcomes in the POF for all clinical measures over the next year through planned visits and timely follow-up procedures.
  • Provide strong support and guidance for patient self-management and establishment of self-management goals.
  • Redesign existing documentation tools to facilitate and guide the plan of care at each encounter.
selected dm measures
Selected DM Measures
  • Average HbA1c < 7.0%
  • > 90% DM Patients with Two (or More) HbA1c in Last 12 Months (>90 days apart)
  • > 70% DM Patients with SM Goal Setting in Last 12 Months
  • > 40% DM Patients with BP <130/80
  • > 70% DM Patients with LDL <100
  • > 70% DM Patients who had a Dental exam in past 12 months
  • Cardiac Risk Reduction Option 3: > 80% DM Patients, age 40 or older, on Aspirin or antithrombotic agent
  • Optional Measures:
  • > 70% DM Patients who had a dilated eye exam done in last 12 months
self management

Currently Testing:

  • Effectiveness of Self-management form in helping patients establish realistic SM goals.
  • Dental Self-Management form with goals specific to dental care.
  • Implemented into our Delivery System:
  • Form titled, “Diabetes Self-Management”
  • Processes for: (1) Use of 5 A's for SM to assist patients in establishing& hopefully achieving written goal(s), (2) Keeping a SM form in chart as part of permanent record to be used by providers as flow sheet for tracking SM outcomes at follow-up visits.
  • A system to communicate patient’s specific self-management goal(s) to PECS staff for entry into registry & on to PECS Encounter form.

Currently Testing:

  • Partnering with local hospital to refer PSHS patients to their Diabetes support group programs.
  • Partnering with Faith based organization for additional community outreach services.

Implemented into our Delivery System

  • Relationship established with NYSDOH for various support systems, i.e. patient educational materials, patient support services, testing equipment, community outreach programs.
  • Relationship with CHCANYS well-established & excellent source for networking.
healthcare organization
Healthcare Organization

Currently Testing:

  • Development of Orientation package for all employees on the collaborative models.

Implemented into our Delivery System:

  • Care Model and Model for Improvement is fully integrated into our organization-wide performance improvement program.
  • Collaborative report presented at each BOD and Quality of Care Council meeting. Includes summary of monthly narrative report and Excel charts.
decision support
Decision Support

Currently testing:

  • A system to obtain verification & reports from external providers on dental & optical exams. (This pertains to services that are not a result of PSHS referrals. System already in place if referral made by PSHS staff.)

Implemented into Delivery System:

  • RN staff, at end of each visit, use PECS encounter form to record & communicate data to PECS staff for entry into registry.
  • Continued use of Diabetes Flow sheet( developed 2003) as the primary documentation tool for providers. This form has all best practice gudelines for DM embedded in its design and has been tested as successful in guiding the plan of care.
  • A system for communicating lab/diagnostic results to PECS staff that are received post visit.
  • Didactic & interactive educational programs for medical/dental providers & support staff on care model, key measures, practice guidelines, SM, PDSA tests, process redesign & implementation.
  • A questionnaire to determine if DM patients, who have not had a dental and/or optical visit at PSHS, are receiving these services from external providers.
clinical information system
Clinical Information System

Currently Testing:

  • Computer installation in clinical work areas to provide team with immediate access to data in PECS registry and to HDC network. Training is in progress.

Implemented into Delivery System:

  • Use of the PECS registry to track, report and communicate results for the POF. Reports printed by PECS staff & distributed to HDC team.
  • Excel Reporting working very effectively. Reports used effectively to evaluate performance .
  • Use of the registry to identify patients that require follow-up for appointments, testing.
delivery system design
Delivery System Design

Currently Testing:

  • No Activity at present

Implemented into Delivery System:

  • Green colored binders used to identify charts of DM patients.
  • A System for flagging “newly diagnosed patients” which includes:
    • An RN reviews all patient records post visit. (P/P since 2001)
    • If patient is diagnosed with Diabetes, the RN reviewer communicates this to clerical staff. Clerical staff will place chart in color-coded binder.
    • Day-Day Leader or designee prepares chart abstract & forwards to PECS staff for entry of new patient into registry.
  • A process & system for ensuring that lab/diagnostic results received post visit are sent to PECS staff. This includes:
    • PECS Encounter form is held in the “pending” lab folder.
    • When test results are received/reviewed the RN will enter the test values onto the PECS form, which is then forwarded to PECS staff.
functional and clinical outcomes

Measures Goal as of 4/28/05

2 HbA1cs in last yr >90% 72%

Average HbA1c <7.0 8.6

Documented self >70% 16% management goal setting

BP < 130/80 > 40 34.7%

LDL <100 >75% 69%

Dental exam in past year >70% 26.7%

40 or Older on ASA/Thromb >80% 66.7%

Retinal exam in past year >70% 45.3%


Functional and Clinical Outcomes
senior leadership making the case for change
Senior LeadershipMaking the Case for Change
  • What information did you share with your ED/CEO and/or Board of Directors to encourage them to make improvements in the management of Diabetes?
  • Slide presentations on the collaborative model at special meetings of the BOD.
  • BOD resolution was obtained by CEO in support of submitting HDC application and BOD participated in the HDC interview process.
  • BOD was already introduced to the concepts of this process pursuant to PSHS participation in (2) NYCDOH collaboratives in 2002 -2004.
  • How did you promote the work?
  • Monthly Narrative Reports: These are very effective for reporting teams progress to ED/CEO & BOD..
  • Excel Reports/Graphs: Distributed and discussed for each key measure. PSHS actual compared to national & target goals.
Communication Plan (How are you communicating your progress at the center level and within your community)
  • At the center level:
  • BOD meetings ( Community members are on BOD)
  • Quality of Care Council meetings
  • Staff meetings( Includes medical/dental providers)
  • Management meetings
  • Special Educational programs.
  • Storyboard posted in clinic for staff & community.

At the Community level:

Through partnerships that we are establishing with community

outreach programs. (includes NYSDOH & CHCANYS)


Those that the team can resolve:

Those that leadership needs to address:

  • Clinical decision making
  • Staff responsibilities
  • Staff educational programs
  • Selection of patient education materials
  • Day-day operational policies/procedures
  • Changes to documentation processes
  • Changes to scheduling & follow-up processes for POF
  • Information systems
  • Scheduling systems
  • Resources for time and equipment
  • Allocation of additional staff resources
  • Linkages/contracts with external agencies for community outreach

Anticipating Barriers and Issues

a story to share the patient

42 year old male with new onset Diabetes diagnosed in October 2004. He was consistently a “no show”for scheduled visits with PSHS dental & optometry. At a recent visit with the PCP, our Day-Day team leader identified this via review of the PECS encounter form. Educational session held with patient to discuss importance of dental & eye care in preventing complications of Diabetes. SM plan established with patient. He has since kept appointments with dental & optometry and continues to work on setting new goals. Our team’s heightened awareness to the key DM measures and these components of the care model have now spread to all DM patients.

A story to share….the patient
a story to share our staff

We do not have one story to share but rather an overall observation of the impact we have seen to date with our PSHS staff. Our medical providers for POF, nursing staff and even our clerical support staff are working closely as a team and demonstrating a more seamless approach in the care of our POF. Better still; we are beginning to see the concepts of the collaborative care model “infiltrating” their care approach for other populations. The clinical staff, in particular, has a heightened awareness of total patient needs and is demonstrating the ability to look at the “bigger picture”. We are seeing a focus on caring for the “whole person” rather than just treating a disease.

A story to share….our staff
a story to share the organization


Timeline for EMR and Practice Management system moved from 2/3 years to within one year. System selected and approved by BOD.

Installation of computers with Internet connection in clinical areas.

Applying the concepts of the collaborative care model and PDSA testing into our performance review process system-wide. This has been fully integrated into our organizational quality improvement program.

Incorporating the self-management model into other populations & services, Ex. Asthma, Depression & Dental care.

Use of Diabetes Encounter form system-wide.

A story to share….the organization