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This is NOT “Zach’s Diabetes Thing”

Making the Montefiore Medical Group Health Disparities Collaborative Work at Montefiore Medical Center The MMG HDC Team Bronx CREED September 30, 2005. This is NOT “Zach’s Diabetes Thing”. Coordinated effort on the part of a lot of folks. This afternoon: Eleanor Larrier Introduction

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This is NOT “Zach’s Diabetes Thing”

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  1. Making the Montefiore Medical GroupHealth Disparities Collaborative Workat Montefiore Medical CenterThe MMG HDC TeamBronx CREEDSeptember 30, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  2. This is NOT “Zach’s Diabetes Thing” • Coordinated effort on the part of a lot of folks. • This afternoon: • Eleanor Larrier Introduction • Me Introduction • Nandini Deb: Clinical Information Systems • Jennifer Klein: Diabetes Education • CFCC: Judy Leuchter, Peer Educators • FHC: April Evangelista, Health Ed PDSA • WB: Sean Misciagna, M.D., FM Resident • Nutrition: Helen Persovsky In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  3. “We don’t just talk about reducing health disparities . . we reduce ‘em!” In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  4. So . . . how do we reduce health disparities? ‘THE COLLABORATIVE MODEL” What’s so great about that model? In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  5. OLD QI METHODOLOGY • “Swoop and Poop” • Do everything to everyone all at once. • Punish whoever doesn’t have good scores. • Create simplistic and token responses to real problems. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  6. REAL PROBLEM • Health care worker lack of comprehensive understanding of the dimensions of pain, pain control, addiction, emotional response to pain and end of life issues, etc. • Patients feel too much pain in the hospital, report being ignored, addicts turned away from pain treatments, etc. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  7. THE “SOLUTION” TO THESE COMPLEX AND MULTIDIMENSIONAL, REAL PROBLEMS: In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  8. Collaborative Philosophy and Method • Fix what is wrong, help clean the mess yourself. • Tests of change on small populations, then “SPREAD” to everyone - GRADUALLY • Realize that making mistakes is part of the process. Without mistakes no one learns. • Share senselessly, steal shamelessly In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  9. Chronic Care Model • Can be applied to all chronic conditions: • Asthma • Depression • Hypertension • Coronary Artery Disease • HIV • Diabetes • Domestic Violence • Emergency Preparedness In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  10. Six Elements of the Chronic Care Model • Medical Information Systems • the registry • populated progress note • Self-Management (e.g., classes, health educators) • Community (e.g., salsa classes) • Delivery Systems Design (e.g., planned visit) • Decision support (listserv guidelines) • Organization of Health Care (spread to MMC) In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  11. PDSA • Plan, Do, Study, Act • Disciplined, results oriented method of group discussion. • Topic tracking and adherence. • Track progress. • Learn from failures. • Over and over and over and over again. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  12. Collaborative Sponsorships of Montefiore Medical Group • Bureau of Primary Healthcare/National Collaborative • New York City Department of Health: Spread Collaborative • Academic Chronic Care Collaborative (ACCC by American Association of Medical Colleges) In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  13. What is the NationalDiabetes Collaborative? Made up of hundreds of health centers from all over the country Northeast Cluster In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  14. That’s all very special, so tell me, how do you get collaborative stuff going? • Get blessed. • Great leaders, great support, wonderful energy, motivated people. • Where do they come from? • We pick them out. • Do something good with no money. Then write about it and present it to everyone every chance you have. • Get money. “Salvador Dali: With Gold You Get Gold.” • Get going. Getting going is easy, thinking about getting going is hard. • Keep going (THE VERY HARDEST PART!) In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  15. What were goals in first year for MMG HDC? • Identify successes of FHC. • Spread to CHCC, CFCC and WB in Diabetes • Establish working teams. • Determine key measures for all sites. • Establish uniform/compatible data collection system for registry. • Identify key measures needing improvement and begin interventions. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  16. Goal #1Spread to CHCC, CFCC and WB in Diabetes In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  17. Montefiore Medical Group Health Disparities Collaborative WB (non 330) DM Bronx Community Health Network Sites In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  18. Goal 2.0 • Create centralized working group/leadership team: • Facilitate, supervise, train, develop the sites. • Coordinate allocation of resources. • Plan for future • Communicate with larger Collaborative organizations. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  19. Montefiore Medical Group:Health Disparities CollaborativeSenior Leadership • Jon Swartz, M.D., Senior Leader • Arnel Tirado, Senior Leader • Victoria Gorski, Senior (Academic Leader) • Jennifer Klein, Director, Health Education • Nandini Deb, Information Specialist • Arthur Blank, PhD • Eleanor Larrier and Celia Alfalla, M.D., Bronx Community Health Network • Rita Louard, M.D., Joel Zonszein, M.D., Endocrine • Clyde Schecter, M.D., Research • Helen Persovsky, Nutritionist • Zach Rosen, M.D., Project Director In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  20. Bronx Defeat Diabetes Project(BDDP) • Bronx Community Health Network (Eleanor Larrier and Celia Alfalla) • Obtained $3 M grant/3 years for community based initiatives – Diabetes Educators, Peer Educators, Diabetes Training, Specialty Care, etc. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  21. Goal #2.1Establish working teams. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  22. MMG HDC Multidisciplinary Work Teams • Administrative Director • Medical Director • Physician Champion • Nurse or Nurse Manager • Diabetes Educator • Peer Educator In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  23. Ibis Castro, Health Educator, MFHC Jose Delgado, Associate Director, MFHC Wayne Joseph, MD, Attending, MFHC Zach Rosen, MD, Medical Director, MFHC April Evangelista, Diabetes Educator Montefiore Family Health CenterThe Bronx Diabeaters: In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  24. Williamsbridge Family Health Center“The Sugarbusters” • Sandra Barnaby, R.N. Staff Nurse • Noel Brown, M.D. Medical Director • Joanne Dempster, M.D. Team Leader • Blanche Doati Associate Director • Victoria Gorski, M.D. Academic Leader • Danette Ortiz Front desk supervisor (day-to-day leader) In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  25. Medical Director Marta Rico, MD Physician Champion Chris Meserve, MD Team Leader Carol Lau, FNP, Associate Director Team MembersCarmen CintronLopez, Assistant Administrator Joanna White, Administrative Nurse Manager Judy Leuchter, Health Education Manager Bobbie Jamison, Health Educator Jennifer Sanchez, PECS data entry Estelle Vargas, LCSW Comprehensive Family Care Center (CFCC) In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  26. CHCC Team • Joe Deluca, M.D., Team Leader and Physician Champion • Jennifer Santiago-Rivera Health Educator • Donna Wade, Nurse Manager • Erwin Duran, Data Entry • Carmen Guerra , Nurse In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  27. Goal #3: Determine key measures for all sites. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  28. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  29. Other measures • Smoking • Passive smoking (asthmatics) • Nutrition • Exercise • . . . In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  30. Goal #4 Establish uniform/compatibledata collection system - Registry In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  31. Goal #5Identify key measures needing improvement and begin PDSA’s In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  32. FHC: Percent of DM Patients with Pneumococcal Vaccine (10 years) PDSA Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  33. FOOT EXAM PDSA (s) • From registry get print out of all charts without pneumovax. • Pull charts and have provider review (some charts didn’t have it recorded but had pneumovax given). • Put yellow stickies in charts without pneumovax. • Combine fluvax and pneumovax forms. • Etc. etc. etc. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  34. So where’s the data? In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  35. DM Collaborative: Key Measures By SiteMay 2004 – May 2005 Note: Data from FHC and WB are for patients with Pneumococcal Vaccine in the past 10 years In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  36. FHC: Number of Patients in Registry Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  37. FHC: Average HbA1c for DM Patients Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  38. FHC: Percent of DM Patients with One HbA1c (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  39. FHC: Percent of DM Patients with Last HbA1c >=9.5 Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  40. FHC: Percent of DM Patients with BP <=130/80 Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  41. FHC: Percent of DM Patients with LDL <100 (of DM patients with Lipid Screen) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  42. FHC: Percent of DM patients with SM Goal (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  43. FHC: Percent of DM Patients with Daily Aspirin Use Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  44. FHC: Percent of DM Patients with Foot Exam (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  45. FHC: Percent of DM Patients with Retinal Exam (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  46. FHC: Percent of DM Patients with Microalbumin Screen (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  47. Moving Forward:Goals for MMG HDC Diabetes • ABC’s improvement. • Selected Targeted Population Parameters for MMG HDC (e.g. self-management scores) • Selected Targeted Population Parameters by site (e.g. LEAP at FHC) • Incorporation of MIS into MMC CIS • Monte Home Care Collaboration • Build on Peer and Health Educator gains. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  48. Clinical Information Systems DM Collaborative Core Team: Dr. Jon Swartz, Dr. Zach Rosen, Arthur Blank, Jennifer Klein and Nandini Deb In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  49. CIS currently used: • CVDEMS - Cardiovascular and Diabetic Electronic Management System - Microsoft Access Based Program • PECS - Patient Electronic Care System - Microsoft Access Based Program In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

  50. Montefiore Medical Group Health Disparities Collaborative In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

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