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Category: People / Lifestyle
Extent of Services: Primary restorative care,(Adult & Peds) GYN, Dental, Psychiatry, Optometry, GI/Hepatology and Podiatry. Uncommon Programs: HIV, Hepatitis C & Homeless ...
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Guidelines A couple of the slides you made for your past storyboard may stay steady, (i.e. Point Statement, rundown of key measures, rundown of colleagues.) The exemption would be if the chiefs gave remarks/alters to any of these ranges on your month to month report. You have to stay predictable and have the AIM articulation, rundown of key measures, and so forth as they show up on your month to month report. You will have submitted two month to month reports by learning session two. You are either TESTING thoughts under every segment of the Chronic Care Model and/or have effectively IMPLEMENTED changes under the parts of the Care Model. (keep in mind, that implies that the change would not leave in your association on the off chance that you finished cooperation in the Collaborative procedure today… !!) The trial of progress and changes actualized is the new data you will share at learning session two. The greater part of the data you\'ll need is as of now in your month to month report. Keep the depiction short and to the point however with enough portrayal that the peruser can get the real focuses from your storyboard. Redesign your information and addition the diagrams from your exceed expectations document on slides as showed on slide #13 and 14. Make the charts sufficiently extensive so they are anything but difficult to peruse… close to 2 to a page, if conceivable. Along these lines, you will require more than 2 slides to show your advancement for all gauges that you are following. Try not to SUFFER IN SILENCE ! If it\'s not too much trouble present a ticket on the Help Desk on SharePoint at the earliest opportunity on the off chance that you require help achieving this progression.

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Cluster: NORTHEAST CLUSTER Learning Session #2 May 12-14, 2005 Atlanta, Georgia Project Samaritan Health Services

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Location: Damian Family Care Center, Jamaica, NY Size: 17,550 visits for every year. Complete medicinal/dental providers = 5.6 FTE\'s (2.0 FTE\'s are PCP) Scope of Services: Primary restorative consideration ,( Adult & Peds) GYN, Dental, Psychiatry, Optometry, GI/Hepatology and Podiatry. Exceptional Programs : HIV, Hepatitis C & Homeless Population Served - 75 right now enlisted Diabetics who meet the determination criteria for POF. Ethnic blend: 36.2% African-American, 29% Hispanic, 13% Asian, 10.1% Caucasian, Other/unspecified: 11.5% PROJECT SAMARITAN HEALTH SERVICES

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Team Members Name Title Role on Team M. Gebhardt CEO Senior Leader P.Wylie-Kennedy COO Senior Leader K.Begum MD Provider Champion S. Pierre, RN Nurse Manager Day-to-Day Leader J. Roscoe RN QI Facilitator Clinical/Tech Support C. Pocasangre Adm. Asst. PECS Data Maintenance Asif Ahmed MIS Specialist MIS Contact Team Leader Contact: Email : Tel: (718) 298-5100

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AIM Statement AIM: The Diabetic social insurance group at Project Samaritan Health Services will apply the six parts of the Chronic Care Model to: Ensure the use of confirmation based practices for all Adult Diabetic patients. Advance ideal clinical results in the POF for every single clinical measure throughout the following year through arranged visits and auspicious follow-up strategies. Give solid backing and direction to patient self-administration and foundation of self-administration objectives. Update existing documentation instruments to encourage and direct the arrangement of consideration at every experience.

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Selected DM Measures Average HbA1c < 7.0% > 90% DM Patients with Two (or More) HbA1c in Last 12 Months (>90 days separated) > 70% DM Patients with SM Goal Setting in Last 12 Months > 40% DM Patients with BP <130/80 > 70% DM Patients with LDL <100 > 70% DM Patients who had a Dental exam in recent months Cardiac Risk Reduction Option 3 : > 80% DM Patients, age 40 or more seasoned, on Aspirin or antithrombotic operator Optional Measures: > 70% DM Patients who had a widened eye exam done in most recent 12 months

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Self-administration Currently Testing: Effectiveness of Self-administration structure in helping patients set up practical SM objectives. Dental Self-Management structure with objectives particular to dental consideration. Actualized into our Delivery System: Form titled, "Diabetes Self-Management" Processes for: (1) Use of 5 A\'s for SM to help patients in establishing& ideally accomplishing composed goal(s), (2) Keeping a SM structure in diagram as a feature of changeless record to be utilized by suppliers as stream sheet for following SM results at follow-up visits. A framework to convey patient\'s particular self-administration goal(s) to PECS staff for section into registry & on to PECS Encounter structure.

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Community Currently Testing: Partnering with nearby healing facility to allude PSHS patients to their Diabetes care group programs. Joining forces with Faith based association for extra group outreach administrations. Executed into our Delivery System Relationship built up with NYSDOH for different emotionally supportive networks, i.e. understanding instructive materials, quiet bolster administrations, testing gear, group outreach programs. Association with CHCANYS settled & fabulous hotspot for systems administration.

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Healthcare Organization Currently Testing: Development of Orientation bundle for all representatives on the synergistic models. Executed into our Delivery System: Care Model and Model for Improvement is completely coordinated into our association wide execution change program. Communitarian report exhibited at every BOD and Quality of Care Council meeting. Incorporates outline of month to month story report and Excel graphs.

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Decision Support Currently testing: A framework to get check & reports from outer suppliers on dental & optical exams. (This relates to administrations that are not an aftereffect of PSHS referrals. Framework as of now set up if referral made by PSHS staff.) Implemented into Delivery System: RN staff, at end of every visit, use PECS experience structure to record & impart information to PECS staff for section into registry. Proceeded with utilization of Diabetes Flow sheet( created 2003) as the essential documentation instrument for suppliers. This structure has all best practice gudelines for DM installed in its configuration and has been tried as fruitful in controlling the arrangement of consideration. A framework for conveying lab/demonstrative results to PECS staff that are gotten post visit. Instructional & intuitive instructive projects for therapeutic/dental suppliers & bolster staff on consideration model, key measures, hone rules, SM, PDSA tests, process overhaul & usage. A survey to figure out whether DM patients, who have not had a dental and/or optical visit at PSHS, are getting these administrations from outer suppliers.

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Clinical Information System Currently Testing: Computer establishment in clinical work ranges to give group prompt access to information in PECS registry and to HDC system. Preparing is in advancement. Executed into Delivery System: Use of the PECS registry to track, report and impart comes about for the POF. Reports printed by PECS staff & dispersed to HDC group. Exceed expectations Reporting working viably. Reports utilized adequately to assess execution . Utilization of the registry to recognize patients that require follow-up for arrangements, testing.

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Delivery System Design Currently Testing: No Activity at present Implemented into Delivery System: Green hued covers used to distinguish outlines of DM patients. A System for hailing "recently analyzed patients" which incorporates: A RN audits every single patient record post visit. (P/P since 2001) If patient is determined to have Diabetes, the RN commentator imparts this to administrative staff. Administrative staff will put outline in shading coded cover. Day-Day Leader or designee gets ready outline dynamic & advances to PECS staff for section of new patient into registry. A procedure & framework for guaranteeing that lab/analytic results got post visit are sent to PECS staff. This incorporates: PECS Encounter structure is held in the "pending" lab envelope. At the point when test outcomes are gotten/audited the RN will enter the test values onto the PECS structure, which is then sent to PECS staff.

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Measures Goal as of 4/28/05 2 HbA1cs in last yr >90% 72% Average HbA1c <7.0 8.6 Documented self >70% 16% administration objective setting BP < 130/80 > 40 34.7% LDL <100 >75% 69% Dental exam in past year >70% 26.7% 40 or Older on ASA/Thromb >80% 66.7% Retinal exam in past year >70% 45.3% REGISTRY SIZE 100 75 Functional and Clinical Outcomes

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National Key Measures

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Project Samaritan Health Services Key Measures

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Project Samaritan Health Services Key Measures

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Project Samaritan Health Services Key Measures

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Project Samaritan Health Services Key Measures

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Senior Leadership Making the Case for Change What data did you impart to your ED/CEO and/or Board of Directors to urge them to make enhancements in the administration of Diabetes? Slide presentations on the cooperative model at unique gatherings of the BOD. Body determination was acquired by CEO in backing of submitting HDC application and BOD partook in the HDC meeting process. Body was at that point acquainted with the ideas of this procedure in accordance with PSHS cooperation in (2) NYCDOH collaboratives in 2002 - 2004. How could you have been able to you advance the work? Month to month Narrative Reports: These are extremely viable for reporting groups advancement to ED/CEO & BOD.. Exceed expectations Reports/Graphs: Distributed and talked about for every key measure. PSHS genuine contrasted with national & target objectives .

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Communication Plan (How are you conveying your advancement at the middle level and inside your group) At the middle level: BOD gatherings ( Community individuals are on BOD) Quality of Care Council gatherings Staff

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