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Diabetes Continuum of Careand the Arizona Diabetes Alliance
Donna Zazworsky, RN, MS, CCM, FAANVice President
Community Health and Continuum Care
Objectives
• Discuss the new advances and reach of Carondelet’s Diabetes Continuum of Care
• Provide an overview of the Arizona Diabetes Alliance
Guiding Strategic Initiatives
• Establish Carondelet Diabetes Care and Outreach as the premier source of diabetes education and self-management
• Build and strengthen partnerships with Carondelet, Carondelet Medical Group and the community to maximize and leverage resources
• Establish the Carondelet Diabetes Education Institute to increase the number of qualified health professionals to teach diabetes in our communities
• Continue to influence diabetes care through research in evidence-based practices and policy initiatives.
Carondelet Diabetes Care Continuum
Faith CommunityNursing
Diabetes Care Center
Community Partners
PatientIn Patient
Diabetes Educators In
Primary Care
Carondelet Diabetes Education Institute
Telehealth Services
In PatientIn Patient Advanced Practice Nurse EducatorsReferrals to Out Patient DSMT & Diabetes Educators in CMG offices
Out-Patient ADA-recognized Diabetes Self Management Training Program
St. Joe’s and St. Mary’s HospitalsSatellites at Carondelet Heart & Vascular Institute, Green Valley Medical Mall, Primeros Pasos & El Rio CHC (OB Gestational), St. Elizabeth Health Center (uninsured), Mt. Graham Regional Medical Center (Safford), University Physicians Hospital, Holy Cross Hospital (Nogales)Physician Office Referral Pads: Type 1, Type 2 & GestationalBarrier-free access: Medicare, Third-Party, Self Pay, CharityCertified Diabetes Educators (RN, RD) & PromotorasProvide over 5000 visits annually
DSMT A1C Results
• CSJ Pre 7.6 % Post 6.4%• CSM Pre 8.8% Post 7.0%• GV Pre 9.75% Post 7.0%• MTG Pre 8.8% Post 7.1%
Carondelet Medical GroupDiabetes Educators leased to Carondelet Medical Group (CMG) Primary Care Offices (n=11 offices)
Diabetes Nurse EducatorsDietitiansDiabetes Navigators
Diabetes Clinics with Health Plans
Annual Eye and Foot Exams Medical Nutrition Therapy Vital Signs and Labs
Community Health Outreach Workers
•Lay Workers in Carondelet Diabetes Continuum
• Promotores: Hispanic• Navigators: Primary Care Offices• ePromotoras: Facilitate telehealth activities• General Certificate & Specialty training• Service Coordination, Self-management
support, data collection & management
11
e Promotora/Navigator
12
Telecardiology
TeleDiabetes Services-TeleOphthalomogly-Medical Nutrition Therapy-TeleDiabetes Day Clinics
Telederm
TeleProfessional Classes-Diabetes -Cardiology-Neuro
Carondelet Telemedicine Services
TeleOphthalmology
Improve number of
Annual Retinopathy Exams
16
Dark Eye
Light Eye
Abnormal Eye
TeleDiabetes Classes
CHN continues to provide Medical Nutrition Therapy Consults, Diabetes Day Clinics & Classes
Page Amado
Diabetes Nutrition
Teleconsultation
Patient & PromotoraMariposa CHC,
Nogales, AZ
Diabetes Education Core ClassesCarondelet Diabetes Education Institute
Graduated over 1000 health professionals
150 in Rural Communities
Phoenix Indian Medical Center
CDEI Advance ClassesGestational Diabetes, Type 1, Insulin Pump,
Wound Care, Renal Care, Promotora/MA Series
Diabetes Tele-Turnkey Models
• Mount Graham Regional Health Center, Safford, AZ (ADHS Grant): established diabetes continuum of care
• Southeast Texas Health System: 8 Critical Access Hospitals
• St. Alphonsus, Boise, Idaho
25
Virtual Diabetes Day: UA Mobile Health Unit, MGRMC & Carondelet for Diabetes Day at Canyonland CHC in Safford
Telementoring from Tucson
Carondelet Person-Centered Care in Primary Care
28
CMG Diabetes Disease Management ProgramDiabetes Scorecard
Patient Grade Annual Cost per Patient
A $1,621
B $3,405
C $9,720
D $21,003
Carondelet Medical Group: Scorecard Elements
HbA1cBlood PressureLDLNeuropathy scoreRetinopathy scoreGFR
30
CMG Diabetes Intervention Grid• PCP Visits (EHR Diabetes Template)• Diabetes Nurse Educator Visits•Telehealth monitoring for high-risk patients• Dietitian Visits•Behavioral Health Visits for Chronic Disease•Diabetes Day Clinics for annual exams•Diabetes Navigator (Promotora)•Patient Incentives (Food Cards)•Pilot in CMG Offices 31
Telehome monitoring
32
Mercy Care Partnership beginning July 2011Payment Reform LOI submitted: High Value Care
33
Teleschool Diabetes Prevention
Community Benefit
34
TeleDiabetes Prevention to high-risk schools
35
Ha’san Prep SchoolTohono O’odham
Nogales High SchoolHispanic
How to Check Your Blood Sugar & Universal Precaution
37
38
Thank You
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