1. Mary Campos, RN, CDE EKLMC Diabetes Case Manager

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

3. 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

4. Traditional Education Pre-set schedule Minimal flexibility One location Work Ride Kids Money Gas

5. Improve Patient Education Model

6. What do patients want ? What do patients need ? How can we effectively provide this?

7. Convenience Cost savings Quality Care Support Education

8. 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.

9. 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

10. Patient driven No set format No appointments Same day education Located within the medical home Basic education only

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

12. Obtained clinic roster Copied Cliq summary page Identified our patients Communicated with staff CLIQ Summary

13. Assessed current health habits… Helped identify barriers…problem solving Provided chronic disease or wellness education

14. Reviewed Health Maintenance requirements Distributed contact information Reviewed clinic call back process Indigent Pharmacy hours Discussed Resources Referrals (if interested)

15. Encouraged Accountability Engaged patient in becoming pro-active Encouraged to request updates of disease specific indicators Gave approval and prompted to ask questions

16. 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

20. 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

21. 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

22. The End!