Jagruti Shukla, MD, MPHMedical Director

September 9, 2008

San Mateo Medical CenterMain Campus Primary Care Clinic

• 11 San Mateo County Clinics, FQHC

• 9 Physicians = 6 FTE, Approx. 20,000 visits/year

• Patient Population

Chronic Care Model – Past Experience

• One Provider Team in SNI Collaborative in 2004

• Introduction of CDEMS Registry

• Chronic Disease Management

• Improvements in Clinical and Process Measures

• Success working as a team

TOOLKIT INTERVENTION

• Introduced by Administration

• Random division of providers into Intervention and Control Groups

• Formation of MD-MA-Clerk teams

• Jointly set goals – 10 parameters total

•Data transfer for all Diabetic patients into CDEMS

MAJOR ACCOMPLISHMENTS

• Working together as teams

• CDEMS data sheet used as the Progress Note

• Chronic disease education at each visit

• Monthly group visits for all providers

• Some Population Management ( No labs 1 yr)

• Improvements seen in both process & outcome measures

Reflections: What worked well

• Experience of our pioneer team with CDM

• Formal structure, timelines, reporting

• Coaching Support

• Weekly meetings - time allocation for brainstorming and reporting

• Toolkit references

• Targeted Interventions: Pneumovax

Reflections: Challenges

• Time commitment for data input, reports, and meetings

• Integration of CDM into usual workflow

• Significant amount of front-end work prior to seeing benefits

• Active communication with staff not involved

• Sustaining and spreading successful ideas

• Interpretation of the variation seen in the MD’s data reports

Next Steps

• Establish patient care teams for all providers

• Identify all clinic patients with DM and populate CDEMS Registry

• Further develop role of MA, Clerk, and RN

• Monthly group visits for all providers

• Add Pharmacist and LSW into the clinic

• Continue to monitor and discuss measures

San Mateo Medical Center Main Campus Primary Care Clinic

Questions?