Anne Camp, MD, Physician Champion
Elizabeth Magenheimer, FNP, CDE, Team Champion
Lynn Price, FNP, Team Leader
Karen Klein, PNP, Health Promotion Coordinator

• 90 percent of patients with two HbA1c's, at least three months apart, in 12 months
• 70 percent of patients with documented self-management goals
• 95 percent of patients obtained lipid profile annually
• 70 percent of patients have LDL less than 130
• 95 percent of patients assessed for smoking
• 100 percent of smokers counseled to stop smoking

Utilizing the Chronic Care Model, we identified high impact changes within each of the six components that would ultimately aid us in achieving our aim.

Self-Management Support:

• Ran weekly Group Educational Series
• Convened weekly Behavioral Modification Group "Breakfast Club"
• Developed Medical Assistant Training Program and Continuing Education
• Provided One-on-One Patient Education
• Implemented a Walking Club
• Offered Weight Management Programs

Community:

• Building relationship with State Diabetes Control Program
• Partnered with local optometrists to give regular free exams
• Partnered with pharmaceutical companies to provide regular support for group work and screenings, and commitment to ongoing medication support for selected patients
• Partnered with hospital for donation of diagnostic studies

Health Care Organization:

• Gradually integrated data entry into legitimate overhead
• Integrated quality improvement and monitoring systems
• Involved Board

Decision Support:

• Utilized electronic registry (DEMS) for monitoring patient progress
• Developed multi-tiered decision support system providing information by patient, provider, and population
• Implemented regular chart reviews to obtain provider feedback, target specific issues, obtain peer review

Clinical Information Systems:

• Created working registry
• Provided real-time data support for management of patients and clinic resources
• Utilized DEMS electronic registry sheet as progress note AND data tool
• Inputed patient data within 24-hours
• Used registry reports as advocacy tool for individuals, population health, and policy-making

Delivery System Design:

• Entered patient visit data real time
• Utilized electronic registry as progress note
• Linked labs to electronic data entry process
• Integrated population-based case management and follow-up

• 82 percent have a documented a self-management goal (70 percent goal)
• 77 percent have two HbA1c's, 3 months apart (90 percent goal)
• 88 percent have had complete lipid profile (95 percent goal)
• 70 percent have LDL less than 130 (70 percent goal)
• 97 percent of patients assessed for smoking (95 percent goal)
• 91 percent of smokers counseled to stop (100 percent goal)

Anne Camp, MD
Endocrinologist
jflande@ziplink.net

Elizabeth Magenheimer, MSN, APRN, CNM, FNP, CDE
elimag@fhchc.org