Individualized Patient

Education in the

Primary Care Clinic

Mary Campos, RN, CDEEKLMC Diabetes Case Manager

Background Information

Disease specific education (traditional) ▪ Diabetes Ed▪ HTN Ed▪ CHF Ed▪ Asthma Ed▪ CRF Ed▪ Nutrition Ed

Referral Criteria

Diabetes Ed: HbA1C >/= 8 9%, new type 1, new to insulin

HTN Ed: Stage II or new onset Stage I

CKD Ed: Stage III or greater

CHF Ed: EF of 40 or lower

Lifestyle Balance Weight Loss program: BMI >/= 30kg/m2

When and Where

Traditional Education Pre-set schedule Minimal flexibility One location

Work Ride

KidsMoneyGas

Stepping up to the Challenge

Improve Patient Education Model

“Improve Patient Ed Model”

What do patients want?

What do patients need?

How can we effectively provide this?

Patient Centered

Convenience Cost savings Quality Care Support Education

Objectives

Develop an educational process within the medical home.

Improve disease management indicators through staff and patient education.

Increase patient awareness of preventative health maintenance and resources.

Engage patients to become leaders of their health care through education and support of their efforts.

Target Audience

Patients followed at NBR CL▪ 1 PCP - 3 days a week

▪Specific chronic diseases (DM, HTN, CKD, CHF, Asthma, Obesity)

▪Others requiring preventative health maintenance updates

Program Design

Patient driven

No set format

No appointments

Same day education

Located within the medical home

Basic education only

Key Components

Identify Barriers…problem solving Education Encourage adherence Offer support to patient and provider Assist with resources

Pre-clinic Activities

Obtained clinic roster Copied Cliq summary page Identified our patients Communicated with staff

CLIQ

Summary

Clinic Activities: Pt. Encounter

Assessed current health habits…

Helped identify barriers…problem solving

Provided chronic disease or wellness education

Clinic Activities: Pt. Encounter

Reviewed Health Maintenance requirements

Distributed contact information▪ Reviewed clinic call back process▪ Indigent Pharmacy hours

Discussed Resources

Referrals (if interested)

Clinic Activities: Pt. Encounter

Encouraged Accountability

▪ Engaged patient in becoming pro-active

▪ Encouraged to request updates of disease specific indicators ▪ Gave approval and prompted to ask questions

Other Case Management Activities

Completed documentation form▪ Placed form on chart for PCP review▪ Discussed specific issues with PCP (if indicated)

Recorded encounter on billing sheet▪ STAT- Pt wellness-ind. education

Results: June-November 2011

Initial Chronic Dz Education Follow Up Wellness and Preventative Health Education0

20406080

100120140160180

157

16 12

-----------------Types of CM Encounters-----------------

Traditional vs. CM in Clinic

Diabetes Ed

HTN Ed CHF Ed CKD Ed0

20

40

60

80

100

120

140

38

7 1 09 4 1 0

75

130

2010

---------Education Outcomes---------

Traditional Ed Referrals

Attended Traditional EDCM Ed in Medical Home

2011 Diabetes Indicators

0%10%20%30%40%50%60%70%80%

March September

December

Barriers or Opportunities for Improvement

Sufficient staffing- Case Managers (CM)▪ 5 Staff MD’s -25 slots each per clinic▪ 9 NP’s - 20-22 slots each per clinic▪ Interns and Residents - ≈15-30 attend per half

day Clinic

CM within the Medical Home Phone call follow up Data base

Advantages of CM within the Medical Home Educate all stages of disease process More time to focus on barriers Partner with the practitioner Support and advocate for the patient More patient centered Improve outcomes

The End!