University Medicine
Governor St. Primary Care
Diabetes and A1c Control
Dr. Michael Johnson
Maureen Claflin
Governor St. A1c Metric Over Time
Team Based Care Team
•
•
•
•
•
•
•
•
Physician
Nurse Care Manager
Medical Assistant
Nutritionist
Behavioral Health
Patient
Caregivers
Pharmacist
Protocols
• Pre-visit planning – determine need for A1c
• At visit – MA will do an in-house A1c if not
done in last 3 months when patient is being
roomed
• A1c results > 8.5 referral to NCM or
nutritionist
• All newly diagnosed patients and patients new
to Insulin are referred to NCM for teaching
CSI Quality Improvement Team
• Meets bi-weekly
• All providers, NCM, practice manager, QI
assistant and MA’s from each pod
• Review provider level data monthly
• Process/systems improvements discussed
• PDSAs
• Rollout to practice
Patient Self-Management
• Patients are integral to their care
• Education happens at each visits
o Ophthalmology f/u
o Podiatry f/u
o Neurology f/u if necessary
• Short and long term SMG established
• Internal resources/External resources
• Reinforcement of patient teaching and goals
Community Partners
•
•
•
•
•
•
Team Works educational sessions
Community CDOEs
VNA and Home Care Diabetic Educators
YMCA program for diabetics
Nutritionists
Behavioral health
Challenges
• Patient activation – especially for poor control
• Obesity epidemic
• Coordinating patient care with Endocrinology
groups
• Elderly population with multiple co-morbid
conditions