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Individualized Patient
Education in the
Primary Care Clinic
Mary Campos, RN, CDEEKLMC Diabetes Case Manager
Background Information
Disease specific education (traditional) ▪ Diabetes Ed▪ HTN Ed▪ CHF Ed▪ Asthma Ed▪ CRF Ed▪ Nutrition Ed
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
When and Where
Traditional Education Pre-set schedule Minimal flexibility One location
Work Ride
KidsMoneyGas
Stepping up to the Challenge
Improve Patient Education Model
“Improve Patient Ed Model”
What do patients want?
What do patients need?
How can we effectively provide this?
Patient Centered
Convenience Cost savings Quality Care Support Education
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.
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
Program Design
Patient driven
No set format
No appointments
Same day education
Located within the medical home
Basic education only
Key Components
Identify Barriers…problem solving Education Encourage adherence Offer support to patient and provider Assist with resources
Pre-clinic Activities
Obtained clinic roster Copied Cliq summary page Identified our patients Communicated with staff
CLIQ
Summary
Clinic Activities: Pt. Encounter
Assessed current health habits…
Helped identify barriers…problem solving
Provided chronic disease or wellness education
Clinic Activities: Pt. Encounter
Reviewed Health Maintenance requirements
Distributed contact information▪ Reviewed clinic call back process▪ Indigent Pharmacy hours
Discussed Resources
Referrals (if interested)
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
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
Results: June-November 2011
Initial Chronic Dz Education Follow Up Wellness and Preventative Health Education0
20406080
100120140160180
157
16 12
-----------------Types of CM Encounters-----------------
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
2011 Diabetes Indicators
0%10%20%30%40%50%60%70%80%
March September
December
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
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
The End!
