1. NCI Care Coordination Collaborative
Carly Draper RD, CDN, CDE Carthage Area Hospital
Teresa Intorcia RD, CDN, CDE Samaritan Medical Center
Susie Kim MS, RD, CDN, CNSC Carthage Area Hospital

2. Certified Diabetes Educators
Certified Diabetes Educators (CDE) responsibilities:
Consultation on diabetes management which can include diet education, medication recommendations, patient skill development, etc
Offer Diabetes Self Management Education and Training (DSME/T)
Provide support and in-service educations to Community Health Workers who work directly with patients
Provide telemedicine as the clinics, providers, and patients are willing

3. Service Areas Service Area 1
North Country Family Health Center (Lowville)
Carthage Area Hospital
Howard T. Meny, MD, PC
Family Medicine of Carthage, PC
Lowville Medical Associates, LLP
Clifton Fine Healthcare Corporation
CDE’s for this area: Carly Draper Susie Kim (obtaining CDE)

4. Service Areas Service Area 2 CDE for this area: Teresa Intorcia
North Country Family Health Center (Watertown)
Samaritan Medical Center
Watertown Internists
North Country Family Medicine, PLLC
Complete Family Care
Family Medicine of NNY
CDE for this area: Teresa Intorcia

5. Services Offered
Variety of nutritional services are offered through CAH and SMC including but not limited to:
Diabetes
Cardiovascular Disease
GI Disorders
Bariatric Nutrition
Weight Management & Obesity
Cardiac Rehab
Food Allergies
Pediatric Nutrition
Diabetes Self Management Program at CAH (accredited by AADE)

6. Referral Process
Primary Care Providers faxes referral forms, including:
Past medical history
Current medications
Pertinent medical visit summaries
Most recent labs
Once received, we call the patient and set up next available appointment or group class

7. Diabetes Self Management Program
Initial appointment 1:1 to assess patient
Followed by 3 group classes
1-3 hours per class
Group interactive discussion
Activities
Goal Setting
Curriculum: AADE 7 core concepts
Healthy eating
Physical activity
Monitoring
Medication
Problem solving
Coping Strategies
Prevention

8. NCI and DSRIP Collaboration
Through this collaboration, we offer:
Weekly phone consultation to care managers, nurses, and providers as needed or requested to help with engaging high risk diabetes clients in improving their care and self-management of the disease
A resource for referrals for additional education and/or support in managing diabetes either in the group setting with our DSME program or in the one-on-one setting
Telehealth services
On-site clinic visits for your clients who may need additional support, but are unable to travel or utilize the telehealth services
Diabetes resources and materials

9. Questions?