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Community Linkages in Diabetes Care: It takes a village. Doriane C. Miller, MD Director, Center for Community Health and Vitality University of Chicago Medical Center Merck Diabetes Collaborative Meeting September 29, 2009. Overview . Tasks of self-management

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community linkages in diabetes care it takes a village

Community Linkages in Diabetes Care: It takes a village

Doriane C. Miller, MD

Director, Center for Community Health and Vitality

University of Chicago Medical Center

Merck Diabetes Collaborative Meeting

September 29, 2009

overview
Overview
  • Tasks of self-management
  • Context: Chronic Care Model
  • Promising Models
  • Take-home tips
  • Evidence-based Resources
tasks of diabetes self management
Tasks of diabetes self-management
  • Taking medicine
  • Measuring blood sugar
  • Healthy diet
  • Physical activity
  • Managing stress and negative emotion
  • ENJOYING LIFE
delivery system design
Delivery System Design
  • Define roles and distribute tasks among team members
  • Use planned interactions to support evidence-based care
  • Provide clinical case management services for complex patients
  • Ensure regular follow-up by the care team
  • Give care that patients understand and that fits with their cultural background
decision support
Decision Support
  • Embed evidence-based guidelines into daily clinical practice
  • Share evidence-based guidelines and information with patients to encourage their participation
  • Use proven provider education methods
  • Integrate specialist expertise and primary care
self management support
Self-Management Support
  • Emphasize the patient's central role in managing their health
  • Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up
  • Organize internal and community resources to provide ongoing self-management support to patients
clinical information systems
Clinical Information Systems
  • Provide timely reminders for providers and patients
  • Identify relevant subpopulations for proactive care
  • Facilitate individual patient care planning
  • Share information with patients and providers to coordinate care
  • Monitor performance of practice team and care system
health care organization
Health Care Organization
  • Visibly support improvement at all levels of the organization, beginning with the senior leader
  • Promote effective improvement strategies aimed at comprehensive system change
  • Encourage open and systematic handling of errors and quality problems to improve care
  • Provide incentives based on quality of care
  • Develop agreements that facilitate care coordination within and across organizations
community resources
Community Resources
  • Encourage patients to participate in effective community programs
  • Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
  • Advocate for policies to improve patient care
evidence based resources
Evidence-based resources
  • www.diabetesinitiative.org
  • www.newhealthpartnerships.org
  • www.improvingchroniccare.org
  • AJPH Sept 2005 Racial and Ethnic Approaches to Community Health: Detroit Partnership
promising models
Promising Models
  • Center for African American Health, Denver CO: faith and health ministries collaboration with community health center
  • Open Door Health Center, Homestead FL: community health outreach workers recruited from current patients
  • Humboldt-Del Norte IPA, Arcata CA: volunteer peer support core, used existing breast cancer support network platform
promising models14
Promising Models
  • Fargo Health Center, Fargo, ND: web-based diabetes support group and blog, portal available to patients and providers
  • REACH Detroit Partnership: trained Family Health Advocates deliver tested curriculum through group meetings
community resources16
Community Resources
  • Encourage patients to participate in effective community programs
  • Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
  • Advocate for policies to improve patient care
take home tips
Take Home Tips
  • Designated Driver
  • Designated Navigator
  • Infrastructure/System
  • Know your patient population
  • Know your internal/external community
  • Use volunteers
  • Be brave and creative
slide18
Doriane C. Miller, MDDirector, Center for Community Health and Vitality

University of Chicago Medical Center

773-702-2739

doriane.miller@uchospitals.edu