1. California Chronic Care Learning Communities Initiative Collaborative Final Outcomes Congress December 9, 2005

2. San Mateo Medical Center Location: Primary Care Clinic in the Main Campus of San Mateo Medical Center Size: 122 Patients From Dr Rebecca Ashe’s panel with diagnosis of Diabetes, Hypertension, and Hyperlipidemia Population Served: All residents of San Mateo County for health care needs with an emphasis on education and prevention, without regard for ability to pay. ICIC Website: http://www.improvingchroniccare.org/

3. Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Resources and Policies Community Organization of Health Care Use of Diabetes care flow sheet Utilizing CDEMS to reach out to patients with poor control Group visits with Dr Ashe’s patients CDEMS for better tracking Developed Foot stamp Expanded role for MA’s (Foot exam prep and Action Plans) Diabetes Basic classes Increased communication with clinics: endocrinology ophthalmology and podiatry Patients are encouraged to attend self-help group Patients are reminded to bring all medications to each visit Each patient is given a Diabetes Care card to track current labs and meds San Mateo Medical Center

4. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Presentations to hospital committee’s for spread of registry Collaboration with Kaiser on PHASE project Health System Resources and Policies Community Organization of Health Care Referrals to “Active for Life” Program Smoking cessation program Education Materials from California Diabetes Society and Nutrition Education classes sponsored by American Diabetes Association San Mateo Medical Center

5. Improved patient tracking with use of CDEMS registry Planned Diabetes Group Visits Diabetes Basic Facts classes Improved teamwork of clinic staff and expanded roles for MA’s Establishment of Action Plans for better self-management Development of foot stamp and process for providers to perform foot exams Informed, Activated Patient Productive Interactions Prepared Practice Team San Mateo Medical Center

6. Delivery System Design Team Roles & Tasks –MA prepares patient for a foot exam –MA initiates Action Plan with patient, MD and RN follow up with them Planned Visits –Group visits with Dr Ashe’s patients Continuity –CDE, RN and MA conducting Diabetes Basic Facts classes monthly in English and Spanish - Increased communication with specialty clinics Follow-up –CDEMS registry to track visits and labs

7. Functional and Clinical Outcomes Baseline Actual Target Dec 04 Oct 05 –HbA1c < 7.0 36.9% 44.6% 60% –Self mgt goals set 32.3% 85.3% 70% –LDL < 10045.9% 59.8% 70% –Foot exam28.5% 77.1% 60% –BP < 130/80 23.4% 35.0% 40% –On Ace/ARB 76.6% 83.3% 75%

8. Barriers Resistance to change – improving teamwork by adjusting roles of clinic staff Labs not interfaced with CDEMS – currently working with administration and IT for solution Time – we continue to meet weekly as a team at lunch and enter data manually

9. Keys to Sustaining and Spreading Our Chronic Care Improvements Success achieved through continued support from senior leadership To spread and sustain change we recently obtained grant funds to interface labs with CDEMS and for ongoing clinical data entry and IT support

10. Group Visit Session at San Mateo Medical Center “This visit was very helpful. I have learned what to eat and how to exercise.” “I could start checking my sugar at home.”

11. Patient’s Comments after a Group Visit Session “I have learned the Basic Facts of Diabetes and I will exercise more and have better eating habits.” “I know what happens when you don’t take your medicine. I will follow all lessons learned.”

12. THANK YOU