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

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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

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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

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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

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Thank You