California Chronic Care Learning Communities Initiative Collaborative

1. California Chronic Care Learning Communities Initiative Collaborative Final Outcomes CongressDecember 9, 2005

2. San Mateo Medical Center • Location: Primary Care Clinic in the Main Campus of San Mateo Medical Center • Size: 122 Patients From Dr Rebecca Ashe’s panel with diagnosis of Diabetes, Hypertension, and Hyperlipidemia • Population Served: All residents of San Mateo County for health care needs with an emphasis on education and prevention, without regard for ability to pay. ICIC Website: http://www.improvingchroniccare.org/

3. San Mateo Medical Center Community Health System Resources and Policies Organization of Health Care DeliverySystem Design Decision Support ClinicalInformationSystems Self-Management Support • Use of Diabetes • care flow sheet • Utilizing CDEMS to reach out to patients with poor control • Patients are • encouraged to • attend self-help group • Patients are reminded to bring all • medications to each visit • Each patient is given • a Diabetes Care card • to track current labs • and meds • Group visits • with Dr Ashe’s • patients • CDEMS for • better tracking • Developed • Foot stamp • Expanded role • for MA’s • (Foot exam prep • and Action Plans) • Diabetes Basic • classes • Increased • communication • with clinics: • endocrinology • ophthalmology • and podiatry

4. San Mateo Medical Center Community Health System • Presentations to hospital committee’s for • spread of registry • Collaboration with Kaiser on PHASE project Organization of Health Care Resources and Policies • Referrals to “Active for Life” Program • Smoking cessation program • Education Materials from California • Diabetes Society and • Nutrition Education classes sponsored by • American Diabetes Association Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

5. San Mateo Medical Center Informed, Activated Patient Prepared Practice Team Productive Interactions • Improved patient tracking with use of CDEMS registry • Planned Diabetes Group Visits • Diabetes Basic Facts classes • Improved teamwork of clinic staff and expanded roles for MA’s • Establishment of Action Plans for better self-management • Development of foot stamp and process for providers to perform • foot exams

6. Delivery System Design • Team Roles & Tasks • MA prepares patient for a foot exam • MA initiates Action Plan with patient, MD and RN follow up with them • Planned Visits • Group visits with Dr Ashe’s patients • Continuity • CDE, RN and MA conducting Diabetes Basic Facts classes monthly in English and Spanish - Increased communication with specialty clinics • Follow-up • CDEMS registry to track visits and labs

7. Functional and Clinical Outcomes Baseline Actual Target Dec 04 Oct 05 • HbA1c < 7.0 36.9% 44.6% 60% • Self mgt goals set 32.3% 85.3% 70% • LDL < 100 45.9% 59.8% 70% • Foot exam 28.5% 77.1% 60% • BP < 130/80 23.4% 35.0% 40% • On Ace/ARB 76.6% 83.3% 75%

8. Barriers • Resistance to change – improving teamwork by adjusting roles of clinic staff • Labs not interfaced with CDEMS – currently working with administration and IT for solution • Time – we continue to meet weekly as a team at lunch and enter data manually

9. Keys to Sustaining and Spreading Our Chronic Care Improvements • Success achieved through continued support from senior leadership • To spread and sustain change we recently obtained grant funds to interface labs with CDEMS and for ongoing clinical data entry and IT support

10. Group Visit Session at San Mateo Medical Center “This visit was very helpful. I have learned what to eat and how to exercise.” “I could start checking my sugar at home.”

11. “I have learned the Basic Facts of Diabetes and I will exercise more and have better eating habits.” “I know what happens when you don’t take your medicine. I will follow all lessons learned.” Patient’s Comments after a Group Visit Session

12. THANK YOU