Team/Organization Name

1. Team/Organization Name • Background and structure • Location • Brief system information (type, size) • Pilot population

2. On this slide briefly describe what your team did in each area. Community Health System Resources and Policies Organization of Health Care DeliverySystem Design Decision Support ClinicalInformationSystems Self-Management Support • Registry • Care remind-ers • Patient Subgroups • Care planning • Emphasize patient role • Assessment • Interventions • Care planning andproblem solving • Team roles and tasks • Planned visits • Continuity • Follow-up • Guidelines • Specialtyinteraction • Provider education • Guidelinesfor patients

3. On this slide briefly describe what your team did in each area. Community Health System • Goals • Benefits • Provider incentives • Improvement strategy • Senior leaders Organization of Health Care Resources and Policies • Effective programs • Partnerships • Coordination Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

4. On this slide briefly describe key changes made, example below Informed, Activated Patient Prepared Practice Team Productive Interactions • Describe Key Changes made. For example: • Assessment of selected clinical priorities • Evidence-based interventions targeted based on assessment • Protocols used • Collaborative plan formulated with each participant, based on PCP  input and participant’s readiness • Self-management support was emphasized • Proactive follow-up for one year

5. Instructions for next 6 slides. • You will only need to use one of the next six slides. Keep only the model component slide for your breakout session. • The “second-level” bullets, designated with a hyphen, are examples of interventions that may have been implemented. Modify these examples to explain what your team has accomplished. • Call or e-mail Melissa, Donna or La Don if you have any questions. (206-364-9700)

6. Use this slide to highlight the model component for your breakout sessionClinical Information Systems • Registry • DEMS • Process flow from encounter to entry established • Care Reminders • Outlier reporting to identify patients in need of test • Letters and labels produced from demographic info • Patient Subgroups • MDs receive lists of patients with HgbA1c > 8.0% • Care Planning • Lists generated for those with missing labs

7. Use this slide to highlight the model component for your breakout sessionDecision Support • Guidelines • Provider agreement to adopt ADA guidelines • Printed on encounter forms • Specialty Interaction • Faxback forms developed for opthalmology and podiatry specialists • Provider Education • Pocket cards • Educational seminars • Guidelines for patients • Wallet cards

8. Use this slide to highlight the model component for your breakout sessionDelivery System Design • Team Roles & Tasks • Nurses/MA perform foot exams • MD briefly mentions the importance of self-management and refers to educator • Planned Visits • Scheduling for labs before appointment • Continuity • Prompts for specialty MD contact • Follow-up • CDE calls patients regularly

9. Use this slide to highlight the model component for your breakout sessionSelf-Management Support • Emphasize Patient Role • Multiple providers send this message to patient • Assessment • Downloaded assessment from Web site • CDE assesses patient at planned visit • Interventions • CDE received training through Chronic Disease Self-Management Program • Care Planning & Problem Solving • Use of motivational interviewing techniques

10. Use this slide to highlight the model component for your breakout sessionCommunity Resources • Effective Programs • Identifies community resources at YMCA • Modifies resource booklet and placed in Toolbox • Partnerships • Diabetes fair sponsored by Safeway and local hospital • Coordination • CDE discusses resources with patient

11. Use this slide to highlight the model component for your breakout sessionOrganization of Health Care • Goals • Switching from a reactive to proactive approach • Benefits • Working closely with health plan to cover group visits • Provider Incentives • Set BP goals for team to achieve • Improvement Strategy • Working closely with pilot team to spread to another clinic • Senior Leaders • Approved position for assisting pilot and spread teams on tracking and reporting on Collaborative measures

12. Functional and Clinical Outcomes • List results achieved toward targeted measures Baseline Actual Target Oct 99 Nov 2000 • HbA1c < 8.0 40% 65% 60% • Self-mgt. goals set 5% 25% 50%

13. Barriers • Describe challenges here

14. Keys to Success • This is a place to summarize the lessons you learned