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Sutter Health Sacramento Sierra Region Diabetes Patients

Sutter Medical Foundation Diabetes Management Program Kimberly Buss, MD, MPH Medical Director of Diabetes Education, SMF Medical Advisor of Diabetes Disease Management Program, SHSSR Jan Van der Mei,RN , MS, ACM Director, Ambulatory Care Management Sutter Health Sac Sierra Region.

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Sutter Health Sacramento Sierra Region Diabetes Patients

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  1. Sutter Medical FoundationDiabetes Management ProgramKimberly Buss, MD, MPHMedical Director of Diabetes Education, SMF Medical Advisor of Diabetes Disease Management Program, SHSSRJan Van der Mei,RN, MS, ACMDirector, Ambulatory Care ManagementSutter Health Sac Sierra Region

  2. Sutter Health Sacramento Sierra Region Diabetes Patients

  3. Sacramento County 2010 • Prevalence of Diabetes by Zip Code

  4. Sacramento County 2000 and 2010 • Prevalence of Diabetes by Ethnicity 10% 2000 10% 2010 Overall Female Male White Hispanic Black Other

  5. Sutter Health Sacramento Sierra Region Endocrinologists 2011

  6. Epic Tools Outpatient Guidelines Patient Resources Care Center Staff Educators Care Coordinators Patient EPIC Disease Management Program EPIC EPIC Glycemic Control Lipids Blood Pressure

  7. Jan Van der Mei, RN, MS, ACMDirector, Ambulatory Care ManagementSutter Health Sac Sierra Region

  8. Case Management Sutter Care Coordination Program(SCCP) Transitions of Care AIM Telemanagement Disease Management Diabetes Asthma CHF Anti-Coagulation Program Sutter Select Heart Health Ambulatory Care Management Programs

  9. Diabetes Program Enrollment

  10. Nurses and DMS work with patients, families and physicians to optimize management of individuals with diabetes Key interventions at key times Lab reminders Overdue for testing Abnormal lab - repeat testing Reinforce education Self-Management Tools Individualized care planning Insulin Management Care coordination Providers Education Equipment Diabetes Management

  11. RN Assessment and Interventions • Review medical record, medications, and history • Target treatment goals according to standard of care • Contact with patients includes: • Identification of treatment barriers • Determine education needs; schedule class or reinforce as needed • Develop treatment plan with patient and PCP • Identification of patients personal goals for managing disease process • Physician contact and update as needed via EPIC • Provide culturally relevant educational material • Follow-up phone appointments are scheduled as appropriate

  12. Diabetes Program: Controlling Blood Sugars An elevated A1C level indicates poor blood sugar control over time and is a primary predictor of cardiovascular disease in patients with diabetes. An A1C >9 is considered "high risk" for this analysis. A drop of 1.0 on the A1C scale is significant and impacts positively the long-term prevention of diabetes complications.

  13. Diabetes Program Helps to Improve Control of Cholesterol An elevated LDL (bad cholesterol) level is a primary predictor of cardiovascular disease in patients with diabetes. An LDL >100 is considered "high risk" for this analysis. Patients enrolled in the diabetes program experienced an improvement between 16% and 21% during the period of Q3 2011 to Q3 2012.

  14. Sustained Improvement in Diabetic Control

  15. LDL and BP Control

  16. questions

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