Sutter Medical Foundation Diabetes Management Program Kimberly Buss, MD, MPH Medical Director of...
17
Sutter Medical Foundation Diabetes Management Program Kimberly Buss, MD, MPH Medical Director of Diabetes Education, SMF Medical Advisor of Diabetes Disease Management Program, SHSSR Jan Van der Mei,RN, MS, ACM Director, Ambulatory Care Management Sutter Health Sac Sierra Region
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Transcript of Sutter Medical Foundation Diabetes Management Program Kimberly Buss, MD, MPH Medical Director of...
Sutter Medical FoundationDiabetes Management Program
Kimberly Buss, MD, MPHMedical Director of Diabetes Education, SMF
Medical Advisor of Diabetes Disease Management Program, SHSSR
Jan Van der Mei,RN, MS, ACMDirector, Ambulatory Care Management
Sutter Health Sac Sierra Region
Sutter Health Sacramento Sierra RegionDiabetes Patients
Sacramento County 2010Prevalence of Diabetes by Zip Code
2000
2010
Sacramento County 2000 and 2010Prevalence of Diabetes by Ethnicity
Overall Male Female White Black Hispanic Other
10%
10%
Sutter Health Sacramento Sierra RegionEndocrinologists 2011
Diabetes EducatorPt Educ One-on-one
Appt
Primary Care Physician
EPIC
EPIC
EPIC
Disease Management Program
Patient Resources
Epic Tools
Outpatient Guidelines
Care Center StaffEducators
Care Coordinators
Lipids
Blood Pressure
Glycemic Control
Jan Van der Mei, RN, MS, ACMDirector, Ambulatory Care Management
Sutter Health Sac Sierra Region
Ambulatory Care Management Programs
Case Management• Sutter Care
Coordination Program(SCCP)
• Transitions of Care• AIM Telemanagement
Disease Management•Diabetes•Asthma•CHF•Anti-Coagulation Program
Sutter Select• Heart Health
Diabetes Program Enrollment
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov
Diabetes 8519 8502 8524 8486 8916 8876 9132 9058 9018 8957 8936
8,100
8,300
8,500
8,700
8,900
9,100
Diabetes Telemanagmenet ProgramMonthly Enrollment 2012
Members
Diabetes Management
• Nurses and DMS work with patients, families and physicians to optimize management of individuals with diabetes
• Key interventions at key times– Lab reminders– Overdue for testing– Abnormal lab - repeat testing
• Reinforce education• Self-Management Tools• Individualized care planning
– Insulin Management• Care coordination
– Providers– Education– Equipment
RN Assessment and Interventions
• Review medical record, medications, and history• Target treatment goals according to standard of care• Contact with patients includes:
• Identification of treatment barriers• Determine education needs; schedule class or
reinforce as needed• Develop treatment plan with patient and PCP• Identification of patients personal goals for
managing disease process• Physician contact and update as needed via EPIC• Provide culturally relevant educational material• Follow-up phone appointments are scheduled as
appropriate
Diabetes Program: Controlling Blood Sugars
A drop of 1.0 on the A1C scale is significant and impacts positively the long-term prevention of diabetes complications.
An elevated A1C level indicates poor blood sugar control over time and is a primary predictor of cardiovascular disease in patients with diabetes. An A1C >9 is considered "high risk" for this analysis.
Q3-2011 Q4-2011 Q1-2012 Q2-2012 Q3-2012
A1C High Risk Pre-intervention 10.8 10.5 10.6 10.7 10.6
A1C High Risk Post-intervention 9.3 9.3 9.4 9.3 9.3
8.75
9.25
9.75
10.25
10.75
Average A1C (Blood Sugar Control) Improvement in High Risk Diabetes Patients
Avg A1C
Diabetes Program Helps to Improve Control of Cholesterol
Patients enrolled in the diabetes program experienced an improvement between 16% and 21% during the period of
Q3 2011 to Q3 2012.
An elevated LDL (bad cholesterol) level is a primary predictor of cardiovascular disease in patients with diabetes. An LDL >100 is considered "high risk" for this analysis.
Q3-2011 Q4-2011 Q1-2012 Q2-2012 Q3-2012
Diab LDL High Risk Pre-intervention
123 123 124 124 126
Diabetes High Risk Post-intervention
98 101 105 96 104
10
30
50
70
90
110
130
Average LDL (bad cholesterol) Improvement in High Risk Diabetes Patients
LDL Level
Sustained Improvement in Diabetic Control
Q3-2011 Q4-2011 Q1-2012 Q2-2012 Q3-2012
High Risk # Improved 384 362 376 432 471
Low-Mod Risk # improved 1228 1206 1390 1451 1466
100
300
500
700
900
1100
1300
1500
Number of Members With A1C Reductions
MemberCount
LDL and BP Control
Q3-2011 Q4-2011 Q1-2012 Q2-2012 Q3-2012
Diabetes % Below LDL+A1C
0.630000000000002
0.630000000000002
0.670000000000003
0.640000000000003
0.68
Diabetes % Below BP
0.58 0.59 0.600000000000001
0.640000000000003
0.660000000000003
53%
55%
57%
59%
61%
63%
65%
67%
69%
Members Below Goal
% Below Goal
