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Objectives

Diabetes Continuum of Care and the Arizona Diabetes Alliance Donna Zazworsky, RN, MS, CCM, FAAN Vice President Community Health and Continuum Care. Objectives. Discuss the new advances and reach of Carondelet’s Diabetes Continuum of Care Provide an overview of the Arizona Diabetes Alliance.

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Objectives

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  1. Diabetes Continuum of Careand the Arizona Diabetes AllianceDonna Zazworsky, RN, MS, CCM, FAANVice PresidentCommunity Health and Continuum Care

  2. Objectives Discuss the new advances and reach of Carondelet’s Diabetes Continuum of Care Provide an overview of the Arizona Diabetes Alliance

  3. Guiding Strategic Initiatives Establish Carondelet Diabetes Care and Outreach as the premier source of diabetes education and self-management Build and strengthen partnerships with Carondelet, Carondelet Medical Group and the community to maximize and leverage resources Establish the Carondelet Diabetes Education Institute to increase the number of qualified health professionals to teach diabetes in our communities Continue to influence diabetes care through research in evidence-based practices and policy initiatives.

  4. Carondelet Diabetes Care Continuum Carondelet Diabetes Education Institute Community Partners Diabetes Educators In Primary Care Patient Faith Community Nursing In Patient Diabetes Care Center Telehealth Services

  5. In Patient • In Patient Advanced Practice Nurse Educators • Referrals to Out Patient DSMT & Diabetes Educators in CMG offices

  6. Out-Patient ADA-recognized Diabetes Self Management Training Program • St. Joe’s and St. Mary’s Hospitals • Satellites at Carondelet Heart & Vascular Institute, Green Valley Medical Mall, PrimerosPasos & El Rio CHC (OB Gestational), St. Elizabeth Health Center (uninsured), Mt. Graham Regional Medical Center (Safford), University Physicians Hospital, Holy Cross Hospital (Nogales) • Physician Office Referral Pads: Type 1, Type 2 & Gestational • Barrier-free access: Medicare, Third-Party, Self Pay, Charity • Certified Diabetes Educators (RN, RD) & Promotoras • Provide over 5000 visits annually

  7. DSMT A1C Results CSJ Pre 7.6 % Post 6.4% CSM Pre 8.8% Post 7.0% GV Pre 9.75% Post 7.0% MTG Pre 8.8% Post 7.1%

  8. Carondelet Medical Group Diabetes Educators leased to Carondelet Medical Group (CMG) Primary Care Offices (n=11 offices) • Diabetes Nurse Educators • Dietitians • Diabetes Navigators

  9. Diabetes Clinics with Health Plans Annual Eye and Foot Exams Medical Nutrition Therapy Vital Signs and Labs

  10. Community Health Outreach Workers Lay Workers in Carondelet Diabetes Continuum Promotores: Hispanic Navigators: Primary Care Offices ePromotoras: Facilitate telehealth activities General Certificate & Specialty training Service Coordination, Self-management support, data collection & management

  11. e Promotora/Navigator

  12. Carondelet Telemedicine Services • TeleDiabetes Services • TeleOphthalomogly • Medical Nutrition Therapy • TeleDiabetes Day Clinics Telederm Telecardiology • TeleProfessional Classes • Diabetes • Cardiology • Neuro

  13. Improve number of Annual Retinopathy Exams TeleOphthalmology

  14. 16

  15. Dark Eye

  16. Light Eye

  17. Abnormal Eye

  18. TeleDiabetes Classes

  19. CHN continues to provide Medical Nutrition Therapy Consults, Diabetes Day Clinics & Classes Page Amado

  20. Patient & PromotoraMariposa CHC, Nogales, AZ Diabetes Nutrition Teleconsultation

  21. Phoenix Indian Medical Center Diabetes Education Core ClassesCarondelet Diabetes Education Institute Graduated over 1000 health professionals 150 in Rural Communities

  22. CDEI Advance Classes Gestational Diabetes, Type 1, Insulin Pump, Wound Care, Renal Care, Promotora/MA Series

  23. Diabetes Tele-Turnkey Models • Mount Graham Regional Health Center, Safford, AZ (ADHS Grant): established diabetes continuum of care • Southeast Texas Health System: 8 Critical Access Hospitals • St. Alphonsus, Boise, Idaho

  24. Virtual Diabetes Day: UA Mobile Health Unit, MGRMC & Carondelet for Diabetes Day at Canyonland CHC in Safford

  25. Telementoring from Tucson

  26. Carondelet Person-Centered Care in Primary Care

  27. CMG Diabetes Disease Management Program Diabetes Scorecard

  28. Carondelet Medical Group: Scorecard Elements HbA1c Blood Pressure LDL Neuropathy score Retinopathy score GFR

  29. CMG Diabetes Intervention Grid PCP Visits (EHR Diabetes Template) Diabetes Nurse Educator Visits Telehealth monitoring for high-risk patients Dietitian Visits Behavioral Health Visits for Chronic Disease Diabetes Day Clinics for annual exams Diabetes Navigator (Promotora) Patient Incentives (Food Cards) Pilot in CMG Offices

  30. Telehome monitoring

  31. Mercy Care Partnership beginning July 2011Payment Reform LOI submitted: High Value Care

  32. Community Benefit Teleschool Diabetes Prevention

  33. Nogales High School Hispanic TeleDiabetes Prevention to high-risk schools Ha’san Prep School Tohono O’odham

  34. How to Check Your Blood Sugar & Universal Precaution

  35. Thank You

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