1. Managing Diabetic Patients Presented by Elizabeth Eaton, RN, MPH, Care Facilitator Sparrow Medical Group North PGIP Quarterly Meeting December 6, 2013

2. Disclosure I have no conflict of interest to declare I do not have any relevant financial relationships with any commercial interests

3. Sparrow Medical Group has been committed to improvement of Diabetes for the past 6+ years  Manual Registries- started July 2008  Diabetic Lean Process in two of our Family Practice offices initiated May 2010  Rolled out to remaining

4. Beginning of Process  Hired a RN, Care Facilitator- (Me ) to work in the 8 family practice offices  focus was to start with diabetes and diabetic patients.  Used the registries to identify patients at highest risk  EMR phase-in began August 2010

5. Identification of Diabetic patients to work with Care Facilitators (hybrid care managers) Provider referral RN Care Manager may meet with patient same day as PCP visit PCP may ask patient to schedule an appointment to meet with RN Care Manager within the next month (appt made at check out)

6. Patient Identification con’t.  Support staff referrals  MA’s consult with the RN Care Manager with suggestions for patient’s in need or they may suggest directly to the patient that they should make an appointment with RN Care Manager  Front office staff schedule appointments for patients with the Care Manager  Care Managers have a separate unique schedule

7. Patient identification cont. MiPCT lists Patient Self Referral posters in exam rooms take home flyers at checkout Epic (EMR) DM registry Identify those with elevated A1C’s Identify co-morbidities and/or recent hospitalizations

8. Medical Assistant Role MA assigned to work the registries runs a DM report at least every 3 months Reviews for missing quality measures Ensures lab orders are in Epic Notes on schedule if labs are needed  Front staff reminds pt to get lab work done before appt.

9. MA notes in care coordination section of patient record if patient needs: foot exam, eye exam, mammogram, etc. Notes on schedule if labs are needed, our front staff reminds pt to get lab work done before appt.

10. Physicians Refer to RN Care Facilitator/Care Manager MiPCT is on the problem list medication assessment and reconciliation, disease education, home safety, nutritional counseling, weight reduction, injection teaching, etc. verbally to RN Care Manager noted in PCP visit note & chart cc’d to RN Care Manager written in checkout instructions for patient to make appointment with Care Facilitator

11. Coordinating Care RN Care Manager and PCP have frequent care coordination meetings during breaks between patients end of day messaging in EMR RN electronically copies PCP on all pertinent patient interactions

12. RN Care Facilitator Uses MiPCT list to determine eligible patients and notifies staff/physicians through EMR and highlighted paper schedules Provides care management services to include patient education Patient goals Referrals to community agencies Patient ongoing support with phone visits, office visits, MySparrow email visits

13. Care Management Services 1. Patient Education

14. 2. Patient Goal setting

15. 3. Provide and plan for ongoing support *RN Care Manager sets up follow up with patient at the end of visit ( both timeframe and how): *return visit *telephone call *via MySparrow/email

16. Additional Care Management Provides staff education on chronic diseases, self management, medications, PCMH, etc. Collaborates with physician regularly to review medical plans Offers group visits to DM patients Remains updated on community resources

17. QUESTIONS?