![Page 1: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/1.jpg)
Individualized Patient
Education in the
Primary Care Clinic
Mary Campos, RN, CDEEKLMC Diabetes Case Manager
![Page 2: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/2.jpg)
Background Information
Disease specific education (traditional) ▪ Diabetes Ed▪ HTN Ed▪ CHF Ed▪ Asthma Ed▪ CRF Ed▪ Nutrition Ed
![Page 3: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/3.jpg)
Referral Criteria
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
![Page 4: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/4.jpg)
When and Where
Traditional Education Pre-set schedule Minimal flexibility One location
Work Ride
KidsMoneyGas
![Page 5: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/5.jpg)
Stepping up to the Challenge
Improve Patient Education Model
![Page 6: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/6.jpg)
“Improve Patient Ed Model”
What do patients want?
What do patients need?
How can we effectively provide this?
![Page 7: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/7.jpg)
Patient Centered
Convenience Cost savings Quality Care Support Education
![Page 8: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/8.jpg)
Objectives
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.
![Page 9: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/9.jpg)
Target Audience
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
![Page 10: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/10.jpg)
Program Design
Patient driven
No set format
No appointments
Same day education
Located within the medical home
Basic education only
![Page 11: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/11.jpg)
Key Components
Identify Barriers…problem solving Education Encourage adherence Offer support to patient and provider Assist with resources
![Page 12: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/12.jpg)
Pre-clinic Activities
Obtained clinic roster Copied Cliq summary page Identified our patients Communicated with staff
CLIQ
Summary
![Page 13: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/13.jpg)
Clinic Activities: Pt. Encounter
Assessed current health habits…
Helped identify barriers…problem solving
Provided chronic disease or wellness education
![Page 14: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/14.jpg)
Clinic Activities: Pt. Encounter
Reviewed Health Maintenance requirements
Distributed contact information▪ Reviewed clinic call back process▪ Indigent Pharmacy hours
Discussed Resources
Referrals (if interested)
![Page 15: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/15.jpg)
Clinic Activities: Pt. Encounter
Encouraged Accountability
▪ Engaged patient in becoming pro-active
▪ Encouraged to request updates of disease specific indicators ▪ Gave approval and prompted to ask questions
![Page 16: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/16.jpg)
Other Case Management Activities
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
![Page 17: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/17.jpg)
Results: June-November 2011
Initial Chronic Dz Education Follow Up Wellness and Preventative Health Education0
20406080
100120140160180
157
16 12
-----------------Types of CM Encounters-----------------
![Page 18: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/18.jpg)
Traditional vs. CM in Clinic
Diabetes Ed
HTN Ed CHF Ed CKD Ed0
20
40
60
80
100
120
140
38
7 1 09 4 1 0
75
130
2010
---------Education Outcomes---------
Traditional Ed Referrals
Attended Traditional EDCM Ed in Medical Home
![Page 19: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/19.jpg)
2011 Diabetes Indicators
0%10%20%30%40%50%60%70%80%
March September
December
![Page 20: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/20.jpg)
Barriers or Opportunities for Improvement
Sufficient staffing- Case Managers (CM)▪ 5 Staff MD’s -25 slots each per clinic▪ 9 NP’s - 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
![Page 21: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/21.jpg)
Advantages of CM within the Medical Home 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
![Page 22: Mary Campos, RN, CDE EKLMC Diabetes Case Manager](https://reader036.vdocuments.site/reader036/viewer/2022062404/551a0a33550346a4248b47ff/html5/thumbnails/22.jpg)
The End!