HEART FAILURE PROJECT &DIABETES REGIONAL PROJECT

Heart Failure: NEED IDENTIFIED

• Address Readmission Rate• Robust inpatient management but need for

streamlined community navigation•HF patients have been using the ED as primary care• Intensify Heart Failure patient discharge education to start on admission

Heart Failure: NURSE NAVIGATOR

•Heart Failure Self Management Book•One-on-one patient education•HF follow-up: phone, Cardiac Rehab referral, PCP• Intensify Heart Failure patient discharge education to start on admission hospital wide involvement• Streamline community resources•Heart Failure Support Group

Heart Failure: NAVIGATOR STATISTICS

DATES ENCOUNTERS

EDUCATION TELEPHONE/FOLLOW UP

May ‘12 – Dec ‘12

1758 529 298

Jan ‘13 – Dec ‘13

3665 1452 775

Jan ‘14 – Feb ‘14

730 274 59

TOTAL 6153 2255 1132

Heart Failure: READMISSION PROJECTS

• Rapid Diuresis protocol• Utilization of CPC•Mid-level managed clinics

Heart Failure: FUTURE

•Grow Support Group• Regional Education and Outreach• Streamline involvement with population health, community navigation and faith based network• Integrate care between inpatient-outpatient-PCP• Full utilization of cardiac rehab

Diabetes: REGIONAL LEADER

• TJC Disease Specific Certified• 4 in the State of Texas

•ADA Recognized Diabetes Self Management Program• 102 in the State of Texas• 1758 in the United States

Diabetes: NEED IDENTIFIED

•High undiagnosed rate of diabetes in Ector County• Community unawareness of resources•Meaningful education and screening process• Restructure the process to be:Risk

StratificationScreen

CBG/A1C Education PCP/Follow Up

Diabetes: COMMUNITY COORDINATOR

•Diabetes community health education•Meaningful Screening Tool• Education Piece• Risk Stratification and Self Assessment• CBG testing / A1C

• Taking the tool to the community/ health Fairs• Scheduling free Survival Skills 2-3 hour class in English and Spanish

Diabetes: TRAIN-THE-TRAINER MODEL

• 4 Hours Core Class and 3 Hours of Nutrition• 3 Hours shadow with clinical educator• Designed for organizations without any Nursing

Education Department or Diabetes Educators• End goal: Staff will develop beginning skills and

working knowledge on helping patients with diabetes

• Permian Regional Medical Center – Andrews• Pecos County Memorial Hospital – Ft. Stockton

Diabetes: FUTURE

• Regional Outreach/ Education in collaboration with PRMC and PCMHFS•Grow the current APN based providers for those

without PCPs and referred to ProCare• Streamline involvement with population health,

community navigation and faith based network• Integrate care between inpatient-outpatient-PCP