Ending Type 2 Diabetes One Exercise, Nutrition, and Gardening Class at a Time

Posts Tagged ‘Chronic Care Model’

OGTT’s Evolution from Pilot to Paramount

In OGTT Screening on October 25, 2010 at 4:14 PM

There was a marked increase in the number of patients screened for diabetes and prediabetes when the Donoghue grant became operational. From 2006-2008 under the Connecticut Health Foundation’s initial grant, research was limited to hispanic women between the ages of 18-55 years old. Limited is not the best word, however. The number of Oral Glucose Tolerance Test (OGTT) patients perfectly matched the structures and resources available to the Fair Haven Community Health Center at the time.

During this initial 2-year period, OGTT screening referrals amounted to approximately 2-4 per week. Clinicians generated them conservatively, being new to the group-screening paradigm. One Diabetes Prevention Program staff member handled the entire referral to recruitment process. She stocked exam rooms with referral forms, collected filled-out forms each Friday. She called each patient within 3 weeks to schedule them for a screening, and filed the referral forms in patients’ charts herself. Mari also kept impeccable excel spreadsheets on all relevant numbers and names.

In 2004, when the clinic won a substancial Donoghue Foundation grant, however, this system needed to be expanded. Now, any patient that displayed a risk factor was offered a free diabetes screening. Having observed the previous two years’ success, clinicians were poised and ready to ramp up their referrals. And they did! Referrals went from the aforementioned 2-4 per week to 20-25 per week. The Diabetes Prevention Program had to hire another staff member who shared the referral and recruitment responsibilities. Once in a while there were so many referrals that Eva had to set aside entire series of workdays just to make referral calls. To meet the demand, the Diabetes Prevention Program also increased their screenings from one per month to three.  The success, therefore, of the initial two years of ‘limited’ access screenings established the program’s credibility and systematic foundation.

The Donoghue grant, however, made it possible for any patient at the Fair Haven Community Health Center, whether male female, child or adult, Balinese or African American, to get screened. Today, the DPP receives between 20-25 OGTT screening referrals per week, a major increase from the 2-4 one year ago.


Chronic Care Model: Tracking Chronic Disease with PECS

In About the Program on October 13, 2010 at 1:45 PM

The patient registry represented the clinical information component of the chronic care model, established at the Fair Haven Community Health Center when the clinic participated in the Health Disparities Collaboratives in the early 2000’s. The Collaboratives used the Institute for Healthcare Improvement’s Breakthrough Series to improve diabetes treatment and prevention nation-wide by utilizing three development stages: 1) learning model, where education and sharing best practices took place, 2) Chronic Care model, which included six components from self-management to clinical information systems, and 3) Model for Improvement, or implementing and testing new strategies. The clinical information systems as part of the second development stage, made tracking and targeting at-risk patients feasible. Taken from the Robert Wood Johnson Foundation, the intention of the clinical information component of the Chronic Care Model is to:

Organize patient and population data to facilitate efficient and effective care
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 (2003 update)
Monitor performance of practice team and care system

Effective chronic illness care is virtually impossible without information systems that assure ready access to key data on individual patients as well as populations of patients. 11, 12 A comprehensive clinical information system can enhance the care of individual patients by providing timely reminders for needed services, with the summarized data helping to track and plan care. At the practice population level, an information system can identify groups of patients needing additional care as well as facilitate performance monitoring and quality improvement efforts.

Today, clinicians fill out an encounter form for every patient who has a chronic condition, or is at risk for chronic disease. Three FHCHC staff members regularly enter patient information into our central Patient Electronic Care System (PECS) that emerges from patient appointments and chronic-care related programs. PECS is designed to simplify tracking and managing chronic disease. When a patient has hypertention, for instance, the systolic and diastolic blood pressure data is highlighted in red on the form to bring the clinician’s attention to that data.

This is a sample of the front page of an encounter form.

10.2337/diaspect.17.2.102Diabetes Spectrum April 2004vol. 17 no. 2 102-106

Clinicians also add components to the basic PECS encounter form, which gives them specific information about the program or patient they are managing. Below are examples of these addendums.

The following two forms are for adults that attend OGTT screenings. The box on the first page is added to the basic encounter form. The second page is printed on the back of the basic encounter form. It is mostly used for billing but the data is useful when providers miss certain questions in the basic encounter form.

Page 1 Encounter Form Addendum  for Adult OGTT Screening:

Page 2 Encounter Form Addendum for Adult OGTT Screening:

Page 1 Encounter Form Addendum for Pediatric OGTT Screening:

Page 2 Encounter Form Addendum for Pediatric OGTT Screening:

Page 1 Encounter Form Addendum for Adult School-Based Health Center Care:

Page 2 Encounter Form Addendum for Adult School-Based Health Center Care:

Page 1 Encounter Form Addendum for Pediatric School-Based Health Center Care:

Page 2 Encounter Form Addendum for Pediatric School-Based Health Center Care:

Chronic Care Model: Encounter Form Sample

In About the Program on October 13, 2010 at 10:30 AM

10.2337/diaspect.17.2.102Diabetes Spectrum April 2004vol. 17 no. 2 102-106

Where Diabetes Prevention Began at FHCHC: from Individual to Systematic Care Models PART I

In About the Program on August 11, 2010 at 6:12 PM

“25 years ago, the occasional adult had diabetes. Then something interesting happened. Ask any family provider in this country today, and they will report that around 15 years ago, numbers of prediabetic and diabetic patients increased dramatically.” Elizabeth, one of the family nurse practitioners responsible for starting the Fair Haven Community Health Center’s Diabetes Prevention Program, describes the diabetes screenings’ evolution. “There was just no denying the onslaught of diabetic and prediabetic symptoms.”

The other providers at the Fair Haven Community Health Center also began to notice the sharp incline of patients with diabetic and prediabetic symptoms. Together they launched a proverbial offensive. Using American Diabetes Association guidelines, they regularly initiated one on one conversations with their at-risk patients, organized a diabetes education group, and created management tools like diabetes flow sheets and occasions to jointly review charts.

Soon, however, providers began to notice that the breadth of their offensive was disproportionate to the growth of the disease. One initiative, the Breakfast Club, is a perfect example of this inequity. Elizabeth met with diabetic patients 2-3 mornings per week. Over a diabetes-appropriate breakfast, they would talk about nutrition, lifestyle, exercise, and all the other circumstances that impacted their health. The program was extremely successful while in session. As soon as there was a break or lapse in meetings, however, Elizabeth’s patients’ numbers would shoot right back up again. Self management was one of the systemic gaps in diabetes prevention and care that the providers felt the need to fill once their preliminary offensive was launched.

The provider’s collective insight into the next required level of diabetes care came the same year that the Institute for Healthcare Improvement teamed up with the Bureau of Primary Health Care to enlist all community health centers nationwide in Health Disparities Collaboratives (HDCs). (Click here for a comprehensive report on the evolution of HDCs). The Fair Haven Community Health Center received a number of benefits for participating in this healthcare improvement project, the most revolutionary being an online patient registry. In 1995 within a short period of time, providers had the ability to create lists from the entire patient population based on predetermined criteria. They could cull all patients with a family history of diabetes, or see all patients diagnosed with acanthuses. Providers were also able to see, on one sheet of paper, an overview of patients’ chronic conditions. (Click here to view a sample chronic care encounter form). The possibilities for data collection and group action were endless, and what was at first an individualized offensive on diabetes became a collaborative and systematic campaign.

%d bloggers like this: