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Patient Self-Management: in Primary Care Team SPANK: St Peter Aims for New Knowledge. March 9, 2004 Devin Sawyer, MD Joseph Wall, MHA Shari Gioimo, MA Janet Wolfram, CDE. We are…. A Residency Program- Full Scope FM 37,000 patient visits a year Residents & UW med students- 6 per year

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patient self management in primary care team spank st peter aims for new knowledge

Patient Self-Management:in Primary CareTeam SPANK: St Peter Aims for New Knowledge

March 9, 2004

Devin Sawyer, MD

Joseph Wall, MHA

Shari Gioimo, MA

Janet Wolfram, CDE

we are
We are…
  • A Residency Program- Full Scope FM
  • 37,000 patient visits a year
  • Residents & UW med students- 6 per year
  • Aprox. 300 diabetics
  • Participated in WSDC II and RWJ grant
  • Getting better at a TEAM APPROACH to chronic care and patient Self-Management
what we have done lately
What we have done lately…
  • WA Diabetes Collaborative, 2000-2001
  • Focused on Patient Self-Management
  • The role of each player: providers, medical assistants, administrative support, patients, and mentors
  • RWJ funding for Advancing Diabetes Self-Management ($300,000)
what is self management
What is Self-Management?…
  • Checking blood sugars
  • Taking meds (pills and shots)
  • Eating right (CDE, doctor, other diabetics)
  • Exercising (30 mins/day, 150 mins/week)
  • Checking feet
  • Making appointments (PCP, eye doc, CDE)

What is missing?

24 7 365
24/7/365
  • “The patients right and responsibility to make decisions that make sense within the contextof their lives”
  • “Education and support refocused on helping patients make & achieve goals and outcomes that they themselves have selected”
  • “Must acknowledge and support the patients role as the key decision maker in self-management”
  • Patient role? Provider role? Staff role? Others?
slide6
The NPR news report on ‘effective diabetes care’ in 2003N Engl J Med, 2003; 348,5:383-459 (Steno-2 study in Copenhagen)
  • An Experienced TEAM
  • Motivated
  • Enthusiastic
  • With a Gung Ho attitude
our program
Our program…
  • MA Planned Visits with goal setting
  • Provider Visits with emphasis on patient goal setting
  • Medical Group Visits
  • Registry to support patient care (CDEMS)
  • Exercise opportunities
  • Patient Mentoring (buddy system)
  • Newsletter
what it has taken to get us here
What it has taken to get us here…
  • MA training (Boldt Center)
  • Provider training (faculty development, and resident workshops and precepting - BBSWAR)
  • Patient education
  • Practical description of self-management: an SMG cycles (new way of thinking for our clinic)
how do we teach this to the ma s
How do we teach this to the MA’s?
  • A new curriculum for the MA’s (A new service for diabetes educators?)
  • Skills in-service; foot checks, CDEMS, planned visits, phone skills, group visits (Camp SPANK)
  • Shadowing
  • On the job training
ma planned visits see standing orders
MA planned visits:(see standing orders)
  • They follow the standing orders
  • Introduce SMG
  • Occur 1 week before provider visit
  • 90% of our MA’s perform planned visits
  • This frees up some of the provider time
the 15 minute encounter a tool big bad sugar w a r
The 15 minute encounter: A toolBig Bad Sugar W.A.R.
  • Background
  • Barriers
  • Successes
  • Willingness to change
  • Action plan
  • Reinforcement
an action plan
An Action Plan:
  • Something the patient comes up with and WANTS to do
  • Should be REASONABLE
  • Behavior specific
  • Should answer the questions:
    • What?
    • How much?
    • When?
    • How often?
  • Confidence level (likelihood-of-success) 1-10
patient goal quality
Patient Goal Quality
  • Evaluate, record, and track patient SMG quality
    • 1 point for activity (what- i.e.: briskly walk, or stop skipping breakfast)
    • 1 point for location (where- i.e: around Capital Lake, or at home and at the office)
    • 1 point for frequency (how often- i.e: M,W,F, or 5 days a week)
    • 1 point for time/duration (how long- i.e.: for 45 minutes at 7:00 am, or 8 am before I leave for work)
    • 1 point for LOS score (from 1 to 10)
the group visit21
The Group Visit
  • Developing patient oriented self-management curriculum
  • More providers (faculty), more staff being trained
  • More patients coming
  • Now an educational expectation for residents
  • High patient satisfaction
  • Outcomes in 2001:
    • HbA1C of our practice: 7.7
    • HbA1C of those who come to DGV: 6.3
patient data registry cdems
Patient Data Registry(CDEMS)
  • Free from the DOH, developed locally
  • MA’s do data entry and us for patient outreach
  • PCP’s use patient report with the patient visit
  • PCP/MA team can query their data to target care (outliers), for patient recall, and for patient goal reinforcement
exercise opportunities
Exercise Opportunities
  • Walking Club
  • Pedometer Program
  • “SPFP Moves With You” Video
patient mentoring buddy system
Patient Mentoring (buddy system)
  • Patients are supporting Patients
  • One patient calls another about 2 months after the provider visit to “check-in” with their SMG
  • Sent a card with a patient’s information
  • Provides additional support and accountability
  • Bridges the gap between the planned/provider visit and the beginning of the next cycle
what is next spread
What is next? Spread…
  • Graduate trained providers
  • More grant money- Phase II
  • In-service local providers- Elma
  • Provide training to local MA’s
  • A role in the STEPS grant
contact info
Contact Info…
  • Devin Sawyer, MD- devin.sawyer@providence.org
  • Joseph Wall, MHA- (360)493-4001 joseph.wall@providence.org
  • Shari Gioimo, Medical Assistant- shari.gioimo@providence.org
  • Janet Wolfram, Diabetes Educator

janet.wolfram@providence.org