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University Medicine Governor St. Primary Care

University Medicine Governor St. Primary Care. Diabetes and A1c Control Dr. Michael Johnson Maureen Claflin. Governor St. A1c Metric Over Time. Team Based Care Team. Physician Nurse Care Manager Medical Assistant Nutritionist Behavioral Health Patient Caregivers Pharmacist. Protocols.

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University Medicine Governor St. Primary Care

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  1. University MedicineGovernor St. Primary Care Diabetes and A1c Control Dr. Michael Johnson Maureen Claflin

  2. Governor St. A1c Metric Over Time

  3. Team Based Care Team • Physician • Nurse Care Manager • Medical Assistant • Nutritionist • Behavioral Health • Patient • Caregivers • Pharmacist

  4. Protocols • Pre-visit planning – determine need for A1c • At visit – MA will do an in-house A1c if not done in last 3 months when patient is being roomed • A1c results > 8.5 referral to NCM or nutritionist • All newly diagnosed patients and patients new to Insulin are referred to NCM for teaching

  5. CSI Quality Improvement Team • Meets bi-weekly • All providers, NCM, practice manager, QI assistant and MA’s from each pod • Review provider level data monthly • Process/systems improvements discussed • PDSAs • Rollout to practice

  6. Patient Self-Management • Patients are integral to their care • Education happens at each visits • Ophthalmology f/u • Podiatry f/u • Neurology f/u if necessary • Short and long term SMG established • Internal resources/External resources • Reinforcement of patient teaching and goals

  7. Community Partners • Team Works educational sessions • Community CDOEs • VNA and Home Care Diabetic Educators • YMCA program for diabetics • Nutritionists • Behavioral health

  8. Challenges • Patient activation – especially for poor control • Obesity epidemic • Coordinating patient care with Endocrinology groups • Elderly population with multiple co-morbid conditions

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