Presentation on theme: "Mary Campos, RN, CDE EKLMC Diabetes Case Manager."— Presentation transcript:
Mary Campos, RN, CDE EKLMC Diabetes Case Manager
Disease specific education (traditional) Diabetes Ed HTN Ed CHF Ed Asthma Ed CRF Ed Nutrition Ed
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
Traditional Education Pre-set schedule Minimal flexibility One location Work Ride Kids Money Gas
What do patients want ? What do patients need ? How can we effectively provide this?
Convenience Cost savings Quality Care Support Education
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.
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
Patient driven No set format No appointments Same day education Located within the medical home Basic education only
Identify Barriers…problem solving Education Encourage adherence Offer support to patient and provider Assist with resources
Sufficient staffing- Case Managers (CM) 5 Staff MDs -25 slots each per clinic 9 NPs - 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
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