Moving Pickens County Primary Care towards Patient-Centered Medical Home Qualifications through a Diabetes Self-Management Education Program
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1 Moving Pickens County Primary Care towards Patient-Centered Medical Home Qualifications through a Diabetes Self-Management Education Program Elizabeth Junkin, MS3
2 Outline Background Objectives Methods Results/ Impact
3 Outline Background Objectives Methods Results/ Impact
4 Pickens County, AL Population: 19,349 7 primary care physicians
5 Pickens County, AL Pickens County Primary Care Dr. Julia Boothe
6 Pickens County, AL 15.1% of the population >20 years old has been told by a physician they have diabetes 12.12% in the state of Alabama 9.11% in the United States
7 Why a Diabetes Self-Management Education (DSME) Program? Patients are more likely to engage in preventative care services and are less likely to participate in risky health behavior. Goal for Healthy People 2020: Increase the amount of diabetic patients that receive diabetes education training to 62.5% In 2008, only 56.8% of diabetic patients reported they participated in a diabetes education program
8 Which Patient-Centered Medical Home (PCMH) qualification will this fulfill? The Quality and Safety standard set by the Joint Principles of the Patient-Centered Medical Home Involves assuring the patient participates in the decision-making process
9 Why must the DSME be recognized by the American Diabetes Association (ADA)? Recognition is mandatory in order to receive reimbursement from Medicaid and Medicare. Standards based on National Standards for Diabetes Self-Management Education and Support
10 National Standards for Diabetes Self-Management Education and Support Internal Structure External Input Access Program coordination Instructional staff Curriculum Individualization Ongoing support Patient progress Quality improvement
11 DSME Curriculum 1. Diabetes disease process 2. Nutritional management 3. Physical activity 4. Medications 5. Monitoring blood sugar 6. Acute complications 7. Chronic complications 8. Psychosocial issues 9. Health and behavior change
12 Outline Background Objectives Methods Results/ Impact
13 Outline Background Objectives Methods Results/ Impact
14 Objectives 1. What are the characteristics, health status, and educational needs of the diabetic patients at Pickens County Primary Care, and are they interested and/or willing to participate in a DSME Program? 2. Is the staff of Pickens County Primary Care interested and/or willing to be involved in the creation and implementation of a DSME Program? 3. Does Pickens County Primary Care have the resources and staff to meet the requirements for their DSME Program to receive recognition from the American Diabetes Association Education Recognition Program? 4. What curriculum and structure should the DSME Program for Pickens County Primary Care follow to best meet their patients educational and support needs?
15 Outline Background Objectives Methods Results/ Impact
16 Outline Background Objectives Methods Results/ Impact
17 Methods EHR Review Patient Survey DSME Implementation Plan Clinic Staff Survey
18 EHR Review Assess the total number of diabetic patients Assess complications, controlled vs. uncontrolled, and number of diabetes-related visits through ICD-9 codes
19 All codes for Type II Diabetes Controlled/ ICD-9 Code Complication Uncontrolled C None UC C Ketoacidosis UC C Hyperosmolarity UC C Other Coma UC C Renal UC C Ophthalmic UC C Neuro UC C Peripheral Circulatory Disorder UC C Other UC C Unspecified UC
20 Patient Survey Based on Diabetic Care Profile by the Michigan Diabetes Research and Training Center Demographics Health status Education/advice received Topics Include: Understanding of diabetes care Social support Logistics of classes Transportation availability Technology access General interest
21 Clinic Staff Survey Assess the resources and willingness of the staff to help with the development and implementation of a DSME program
22 Methods EHR Review Patient Survey DSME Implementation Plan Clinic Staff Survey
23 Outline Background Objectives Methods Results/ Impact
24 Outline Background Objectives Methods Results/ Impact
25 Results of EHR Review (Data from July 2014 to Dec 2014) Estimated # of patients: 5200 Total number of diabetic patients seen: 342 Gender Age 59% females Average: 62 41% males Min: 15 Max: 96
26 Results of EHR Review Age and Gender Distributions Number of patients F M Age Ranges
27 Results of EHR Review Total number of visits: 858 Average of 2.5 visits per patient Max # of visits: 10 # Patients with (C) and (UC) Only (59%) Both 102 (30%) Only (11%)
28 Results of EHR Review Controlled vs. Uncontrolled Visits Visits with Complications , 29% 592, 71% (controlled) (uncontrolled) (coma, C) (eye, C) (eye, UC) (neuro, C) (neuro, UC) (unspecified, UC)
29 Results To be continued
30 Impact Needs assessment of the diabetic patient population at Pickens County Primary Care Selection of the best curriculum for the clinic Preliminary plan of implementation for a DSME Program
31 Acknowledgements Dr. Lea G. Yerby Partially supported by the Alabama Family Practice Rural Health Board
32 References 1. Map of Alabama highlighting Pickens County, Courtesy of Wikimedia Commons, accessed on 4/13/15 2. US Department of Health & Human Services, Health Resources and Services Administration, Area Health Resource File. Courtesy: Community Commons, January 24, 2015, date retrieved. 3. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Courtesy: Community Commons, April 3, 2015, date retrieved. 4. Strine TW, Okoro CA, Chapman DP, Beckles GL, Balluz L, Mokdad AH. The impact of formal diabetes education on the preventive health practices and behaviors of persons with type 2 diabetes. Prev Med Jul;41(1): Epub 2004 Nov 19. PubMed PMID: Healthy People (2015). Retrieved from 6. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). Joint principles of the patient-centered medical home. practice_management/pcmh/initiatives/pcmhjoint.pdf. Accessed January 24, Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, Fisher EB, Hanson L, Kent D, Kolb L, et al. National standards for diabetes self-management education and support. Diabetes Care Jan;37 Suppl 1:S doi: /dc14-S144. PubMed PMID: ; PubMed Central PMCID: PMC Fitzgerald JT, Davis WK, Connell CM, Hess GE, Funnell MM, and Hiss RG, "Development and Validation of the Diabetes Care Profile," Evaluation and the Health Professions, 1996; 19(2):
33 Questions? Contact Information: Elizabeth Junkin, MS3
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