Making the Montefiore Medical Group
Health Disparities Collaborative Work
at Montefiore Medical Center
The MMG HDC Team
Bronx CREED
September 30, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
This is NOT “Zach’s Diabetes Thing”


Coordinated effort on the part of a lot of folks.
This afternoon:
•
•
•
•
•
•
•
•
Eleanor Larrier Introduction
Me Introduction
Nandini Deb: Clinical Information Systems
Jennifer Klein: Diabetes Education
CFCC: Judy Leuchter, Peer Educators
FHC: April Evangelista, Health Ed PDSA
WB:
Sean Misciagna, M.D., FM Resident
Nutrition: Helen Persovsky
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
“We don’t just talk about reducing health
disparities . .
we reduce ‘em!”
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
So . . .
how do we reduce health disparities?
‘THE COLLABORATIVE MODEL”
What’s so great about that model?
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
OLD QI METHODOLOGY

“Swoop and Poop”
Do everything to everyone all at once.
 Punish whoever doesn’t have good scores.
 Create simplistic and token responses to
real problems.

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
REAL PROBLEM

Health care worker lack of comprehensive
understanding of the dimensions of pain,
pain control, addiction, emotional response
to pain and end of life issues, etc.

Patients feel too much pain in the hospital,
report being ignored, addicts turned away
from pain treatments, etc.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
THE “SOLUTION” TO THESE COMPLEX
AND MULTIDIMENSIONAL, REAL
PROBLEMS:
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Collaborative Philosophy and Method
Fix what is wrong, help clean the mess
yourself.
 Tests of change on small populations, then
“SPREAD” to everyone - GRADUALLY
 Realize that making mistakes is part of the
process. Without mistakes no one learns.
 Share senselessly, steal shamelessly

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Chronic Care Model

Can be applied to all chronic conditions:
•
•
•
•
•
•
•
•
Asthma
Depression
Hypertension
Coronary Artery Disease
HIV
Diabetes
Domestic Violence
Emergency Preparedness
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Six Elements of the Chronic Care Model

Medical Information Systems
• the registry
• populated progress note





Self-Management (e.g., classes, health educators)
Community (e.g., salsa classes)
Delivery Systems Design (e.g., planned visit)
Decision support (listserv guidelines)
Organization of Health Care (spread to MMC)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
PDSA
Plan, Do, Study, Act
 Disciplined, results oriented method of
group discussion.
 Topic tracking and adherence.
 Track progress.
 Learn from failures.
 Over and over and over and over again.

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Collaborative Sponsorships
of Montefiore Medical Group
• Bureau of Primary Healthcare/National
Collaborative
• New York City Department of Health:
Spread Collaborative
• Academic Chronic Care Collaborative
(ACCC by American Association of
Medical Colleges)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
What is the National
Diabetes Collaborative?
Made up of
hundreds of health
centers from all
over the country
Northeast
Cluster
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
That’s all very special, so tell me, how
do you get collaborative stuff going?

Get blessed.
• Great leaders, great support, wonderful energy, motivated people.
• Where do they come from?
• We pick them out.




Do something good with no money. Then write about it
and present it to everyone every chance you have.
Get money. “Salvador Dali: With Gold You Get Gold.”
Get going. Getting going is easy, thinking about getting
going is hard.
Keep going (THE VERY HARDEST PART!)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
What were goals in first year
for MMG HDC?
1.
2.
3.
4.
5.
6.
Identify successes of FHC.
Spread to CHCC, CFCC and WB in
Diabetes
Establish working teams.
Determine key measures for all sites.
Establish uniform/compatible data
collection system for registry.
Identify key measures needing
improvement and begin interventions.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #1
Spread to CHCC, CFCC and WB in Diabetes
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
Montefiore Medical Group Health
Disparities Collaborative
Montefiore Medical Group
Health Disparities Collaborative
FHC
(DM)
CHCC
(DM)
WB
(non 330)
DM
CFCC
(DM)
Bronx Community Health Network Sites
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal 2.0

Create centralized working group/leadership
team:
•
•
•
•
Facilitate, supervise, train, develop the sites.
Coordinate allocation of resources.
Plan for future
Communicate with larger Collaborative
organizations.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Medical Group:
Health Disparities Collaborative
Senior Leadership











Jon Swartz, M.D., Senior Leader
Arnel Tirado, Senior Leader
Victoria Gorski, Senior (Academic Leader)
Jennifer Klein, Director, Health Education
Nandini Deb, Information Specialist
Arthur Blank, PhD
Eleanor Larrier and Celia Alfalla, M.D., Bronx
Community Health Network
Rita Louard, M.D., Joel Zonszein, M.D., Endocrine
Clyde Schecter, M.D., Research
Helen Persovsky, Nutritionist
Zach Rosen, M.D., Project Director
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Bronx Defeat Diabetes Project
(BDDP)

Bronx Community Health Network
(Eleanor Larrier and Celia Alfalla)
• Obtained $3 M grant/3 years for community
based initiatives – Diabetes Educators, Peer
Educators, Diabetes Training, Specialty Care,
etc.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #2.1
Establish working teams.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
MMG HDC
Multidisciplinary
Work Teams
•Administrative Director
•Medical Director
•Physician Champion
•Nurse or Nurse Manager
•Diabetes Educator
•Peer Educator
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Family Health Center
The Bronx Diabeaters:





Ibis Castro, Health
Educator, MFHC
Jose Delgado, Associate
Director, MFHC
Wayne Joseph, MD,
Attending, MFHC
Zach Rosen, MD, Medical
Director, MFHC
April Evangelista,
Diabetes Educator
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Williamsbridge Family Health Center
“The Sugarbusters”
•
•
•
•
•
•
Sandra Barnaby, R.N.
Noel Brown, M.D.
Joanne Dempster, M.D.
Blanche Doati
Victoria Gorski, M.D.
Danette Ortiz
Staff Nurse
Medical Director
Team Leader
Associate Director
Academic Leader
Front desk supervisor
(day-to-day leader)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Comprehensive Family Care Center
(CFCC)




Medical Director
Physician Champion
Team Leader
Team Members
Marta Rico, MD
Chris Meserve, MD
Carol Lau, FNP, Associate
Director
Carmen CintronLopez, Assistant Administrator
Joanna White, Administrative Nurse Manager
Judy Leuchter, Health Education Manager
Bobbie Jamison, Health Educator
Jennifer Sanchez, PECS data entry
Estelle Vargas, LCSW
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CHCC Team
Joe Deluca, M.D., Team Leader and
Physician Champion
 Jennifer Santiago-Rivera Health Educator
 Donna Wade, Nurse Manager
 Erwin Duran, Data Entry
 Carmen Guerra , Nurse

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #3:
Determine key measures for all sites.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
Goal
Shared Core Measures
<8%
Average HgbA1c
70%
% of patients with BP< or = 130/80
70%
% of patients with an LDL <100
90%
% of patients who have had pneumococcal vaccine
90%
(90%
% of patients with documented LEAP foot exam in
the past 12 months
% of patients receiving annual flu shots)
90%
% patients on aspirin (or other anti-coagulant)
70%
Signed self management contract in chart
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Other measures
Smoking
 Passive smoking (asthmatics)
 Nutrition
 Exercise
...

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Goal #4
Establish uniform/compatible
data collection system - Registry
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
Goal #5
Identify key measures
needing improvement
and begin PDSA’s
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
FHC: Percent of DM Patients with Pneumococcal Vaccine
(10 years)
PDSA
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FOOT EXAM PDSA (s)
1.
2.
3.
4.
5.
From registry get print out of all charts
without pneumovax.
Pull charts and have provider review
(some charts didn’t have it recorded but
had pneumovax given).
Put yellow stickies in charts without
pneumovax.
Combine fluvax and pneumovax forms.
Etc. etc. etc.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
So where’s the data?
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
DM Collaborative: Key Measures By Site
May 2004 – May 2005
Clinic
FHC
Number
of
Patients
with 1+
visits
% Patients
% Patients
% Patients % Patients
% Patients
Average % Patients % Patients
with
% Patients with LEAP
with Flu
with Retinal
with HbA1c HbA1c for with BP <=
with
Pneumoccoc
on Aspirin exam (12
Vaccine (12 Exam (12
< 8.0
DM Patients 130/80
LDL<100
al vaccine
months)
months)
months)
(ever)*
ACTIVE
PT.
ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.
ACTIVE
PT.
ACTIVE PT.
% DM
Patients
with SM
Goal (12
months)
ACTIVE PT. ACTIVE PT. ACTIVE PT.
760
191
60%
64%
7.9
7.8
56%
47%
54%
66%
53%
59%
60%
35%
78%
54%
40%
18%
28%
31%
33%
47%
273
606
64%
61%
7.7
8.0
65%
46%
57%
50%
59%
38%
38%
32%
54%
69%
35%
19%
22%
22%
15%
8%
TOTAL 1830
61%
7.9
53%
54%
50%
45%
69%
30%
25%
23%
Goal
70%
6.5
70%
70%
70%
90%
90%
70%
70%
70%
CFCC
CHCC
WB
Note: Data from FHC and WB are for patients with Pneumococcal
Vaccine in the past 10 years
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Number of Patients in Registry
Latest
Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
FHC: Average HbA1c for DM Patients
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with One HbA1c (12
months)
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Last HbA1c >=9.5
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with BP <=130/80
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with LDL <100 (of DM
patients with Lipid Screen)
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM patients with SM Goal (12 months)
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Daily Aspirin Use
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Foot Exam (12
months)
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Retinal Exam (12
months)
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
FHC: Percent of DM Patients with Microalbumin Screen
(12 months)
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Moving Forward:
Goals for MMG HDC Diabetes






ABC’s improvement.
Selected Targeted Population Parameters
for MMG HDC (e.g. self-management
scores)
Selected Targeted Population Parameters
by site (e.g. LEAP at FHC)
Incorporation of MIS into MMC CIS
Monte Home Care Collaboration
Build on Peer and Health Educator gains.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Clinical Information Systems
DM Collaborative Core Team:
Dr. Jon Swartz, Dr. Zach Rosen,
Arthur Blank, Jennifer Klein
In response to the Montefiore Quality Council, this information isand
provided
under Section
2805-m of the New York
Nandini
Deb
Public Health Law.
CIS currently used:

CVDEMS
- Cardiovascular and Diabetic Electronic
Management System
- Microsoft Access Based Program

PECS
- Patient Electronic Care System
- Microsoft Access Based Program
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Medical Group
Health Disparities Collaborative
Montefiore Medical Group
Health Disparities Collaborative
FHC
CHCC
CFCC
WB
CVDEMS
PECS
PECS
CVDEMS
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CVDEMS Data Capturing
Process: FHC AS MODEL
Data Collection:

At each visit, Nurses print out CVDEMS form with last
encounter data and demographic information of the
patient

Providers update form at current visit—CVDEMS
form gets into chart

EHIT generates weekly encounter list at FHC
(~100/week)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CVDEMS Form
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
CVDEMS Data Capturing Contd.
Data Monitoring

Semi-annual generation of list of all patients with no visits
in the last 6 months, given to Health Educators for
outreach

Annual pruning of patients with no visits in the past year
(after outreach attempted)

Bi-yearly reassignment of Providers/matching Providers
with patients

Data quality checks—random sample of 5% charts
reviewed to assess validity, reliability and completeness of
data
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Data
Capturing
Contd.
Bi-weekly CVDEMS
automatic lab data
transfer
to CVDEMS
and
PECS for FHC, WB, CFCC and CHCC:

Tuesday: Program identifies all patients who had labs
done in the last two weeks

Wednesday: Program dumps all labs for the identified
patients

Wednesday: Lab results are sent back to the sites
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Monthly Reports

Monthly report generation:
- Registry Summary Report
- Provider Report
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Registry Summary Report
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Provider Report
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Key Measures by Site
Clinic
FHC
Number
of
Patients
with 1+
visits
% Patients
% Patients
% Patients % Patients
% Patients
Average
% Patients % Patients
with
% Patients with LEAP
with Flu
with Retinal
with HbA1c HbA1c for with BP <=
with
Pneumoccoc
on Aspirin exam (12
Vaccine (12 Exam (12
< 8.0
DM Patients
130/80
LDL<100
al vaccine
months)
months)
months)
(ever)*
ACTIVE
PT.
ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.
ACTIVE
PT.
ACTIVE PT.
% DM
Patients
with SM
Goal (12
months)
ACTIVE PT. ACTIVE PT. ACTIVE PT.
760
191
60%
64%
7.9
7.8
56%
47%
54%
66%
53%
59%
60%
35%
78%
54%
40%
18%
28%
31%
33%
47%
273
606
64%
61%
7.7
8.0
65%
46%
57%
50%
59%
38%
38%
32%
54%
69%
35%
19%
22%
22%
15%
8%
TOTAL 1830
61%
7.9
53%
54%
50%
45%
69%
30%
25%
23%
Goal
70%
6.5
70%
70%
70%
90%
90%
70%
70%
70%
CFCC
CHCC
WB
Reporting Period: May 2004-May 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Our Persistent Challenges

CVDEMS and PECS rigidities

CVDEMS forms not completely filled out

Problems due to manual data entry

Resource constraints at the sites

System crashes—very painful!
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Our Successes

Structured monitoring of data

Automatic lab data transfer for all the
sites

Monthly Reports for FHC, WB, CFCC
and CHCC
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Our Plans for the Future

Montefiore CIS system with Provider entry of
data

Chronic Disease Management Screen—with
capabilities to present the entire history of the
patient.

How to use this data repository to ask research
questions?
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Acknowledgements

Each and everybody who has worked and currently
working with the DM Collaborative

Special thanks to Jasmine Smith, Erwin Duran and
Jennifer Sanchez — our data support personnel

Nadav Tanners (Having fun at Yale!)

Yan Chai — DFSM Data Manager
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
SELF-MANAGEMENT
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Patient Self-Management

Patients already self manage
• All patients make decisions and engage in
behaviors that affect their health.
• They are in control.
• They decide on what health behaviors they will
or will not engage in.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Traditional vs Collaborative Care

Shared expertise
Shared responsibility

Provider as expert


Provider is principle
caregiver and problem solver
Provider gives instructions to
 Patient sets goals
be complied with




Behavior is externally
motivated
Provider identifies
problem
Provider solves
problems

Internal Motivation

Patient identifies the
problem
Patient is taught
problem solving skills

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management Education
Based on Self Efficacy Theory (Self
Confidence)
 Emphasizes

• Problem Solving
• Decision making
• Confidence building

Goal Setting
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
What would you like to do to improve
your health?
Monitoring
Physical Activity
You
choos
e
Medications
Coping
Unhealthy Behaviors
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management Goal Setting

My Action Plan
•
•
•
•




What
Where
When
How often
Barriers
Problem Solving to overcome barriers
Support needed to reach goal
Confidence level
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management Goals
Teaching Techniques
 Facilitative
 Participatory
 Collaborative
• Use of Motivational Interviewing techniques to
elicit Self- Management Goals
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self-Management Support at MMG






Educational Classes
Group Medical visits
Support groups
Walking club
Individual Sessions
Cooking Classes





Waiting Room Talks
Phone Contacts
Salsa Classes
Peers Support
Community
involvement
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Comprehensive Family Care
Center – Bronx Community Health Network
(MMG-CFCC/ BCHN)
1621 Eastchester Road
Bronx, New York 10461
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
Montefiore Medical Group
Comprehensive Family Care Center
About Us








75,000 visits / year
Internal Medicine, Pediatrics, &
ObGyn Residency Programs
60 atttending MDs
102 (48 IM, 31 Peds, 28
ObG)Residents
Nurse practitioners, midwives
Numerous other providers
Total users 2004 – 18,682
Of those 1042 (5.6%) are patients
w/Diabetes mellitus
Demographics






Black/African-American 30%
Hispanic/Latino 46%
White (not H/L) 12%
Unknown/unreported 11%
Asian/Pacific Islander 1%
Native Am/Alaskan Native .02%
Languages
 English
 Spanish
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
AIM
AIM:
Montefiore Medical Group – CFCC will
redesign our care delivery system to maximize
the health and quality of life for our patients
with Diabetes mellitus, by assuring that they
receive effective, evidence-based services, using
a coordinated care plan.
We will achieve this by implementing a
comprehensive approach, using the
components of the Chronic Care Model
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self Management, highlights
GROUP LEARNING




Group Educational Series: English and Spanish
Team presentation of learning sessions (Health Educator, Residents,
Physician, Social worker and Nutritionist).
Collaborative, interactive format
Alumni lunches held once a month to re-visit self-management , education
and problem solving issues
GROUP ACTIVITES



Walking club twice a week, open to all CFCC patients
Birthday Lunch
Breakfast Club: pilot
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self Management, cont.
INDIVIDUALIZED GOALS



Individualized sessions at the end group to define self-management goals.
Individual mini-sessions prior to provider visits consisting of diabetes
education, nutritional counseling, and self-management goal setting.
Individualized sessions with nutritionist.
PEER SUPPORT





CFCC patients with diabetes trained as Peer Educators for Bronx Defeat
Diabetes Project. We have 4 peer educators.
Participation in all group activities.
Waiting room contacts with ADA risk assessments completed.
Development of peer patient panels to encourage compliance and supply
support. Ongoing training in 1-1 diabetes management education.
Outreach activities within the health center and into the community.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Family Health Center
360 East 193rd Street
Bronx, New York 10458
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York
Public Health Law.
Montefiore Medical Group Family
Health Center
About Us





45,000 visits / year
Family Medicine Residency
Program
18 Providers
16 Residents
# Diabetic patients: 755
Primary Insurance
 Medicaid
39%
 Self Pay
29%
 Medicare BC/BS Empire 13%
 Bronx Health Plan
 GHI
Demographics






Black/African-American 30%
Hispanic/Latino 41%
White (not H/L) 13%
Unknown/unreported 8%
Asian/Pacific Islander 7%
Native Am/Alaskan Native .02%
Languages
 English
 Spanish
 Cambodian
 Vietnamese
 Other
56.70%
36.20%
5.30%
1.30%
0.40%
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Self Management Highlight
Diabetic referrals via Walkie Talkie




GOAL: Coordinate efforts with 2nd and 3rd floor
PCTs, Health Educators and Nutritionist to increase
percentage of self-management goals set at FHC.
ACTION: Individual health educator or nutritionist
counseling sessions with diabetic patients pre/post
provider visit.
PROCEDURE: Use walkie-talkie between central
locations: PCTs call health educator or nutritionist
through walkie talkie once a diabetic is prepped.
While waiting for the provider patient is then seen by
the health educator or nutritionist in the exam room.
RESULT: SUCCESS 8% increase in the percentage
of self-management goals set from July until August
at FHC.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Resident Collaborative Involvement
Thinking outside the box to improve
community oriented primary care of chronic
disease
 Identifying community resources

• Care doesn’t just happen inside the clinic
• Better understanding of pt’s social context
• Contributing to the community and the bouquet
of services that already exist

Looking to the future
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Nutrition
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Ways I Work With Patients
One to One sessions
 Group sessions
 Setting self-management goals
 Community Outreach

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Teaching Methods
Food models
 Visuals
 Power points
 Food demonstrations

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Challenges
Scheduling follow-ups
 Show up rates
 Reminder calls
 Follow up on self-management goals

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Successes
Cooking classes
 Changes on patients HgA1C
 Outreach lectures

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.