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Defining the local context prior to introducing shared medical appointments (SMAs) |
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| Care System Components |
Defined via Local Diabetes Care Context |
Existing Diabetes Care-Based Practices Pre-SMA (January 2005) |
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| Supramacro |
VHA Central Office |
Initiatives on outpatient quality with necessity to figure out how to operationalize locally |
| Advanced Clinic Access mandate to reduce waiting times; increase efficiency |
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| Chronic Disease Index (a series of performance measures) emerging as a priority |
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| Electronic medical record tracking performance measures & providing feedback |
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| Macro |
Cleveland Dept. of Veterans Affairs Medical Center |
Pursue current mandate: Advanced Clinic Access to reduce waiting times for appointments |
| Meetings about intermediate diabetes care goals |
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| Wanted updates about how goals were going to be met |
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| Primary care clinics focus on medical training not quality care |
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| Longer-term major construction creating space constraints |
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| Mesosystems |
Primary care clinics |
Monthly reports about meeting diabetes care goals |
| Monthly clinic meetings review & allocate resources |
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| No formal process to identify and refer high-risk patients |
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| Individual meetings with silo representatives |
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| Go to macro level for change if needed |
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| Other services |
Primary care provider is additional signer on notes for patients |
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| Clinical pharmacy |
Individual referral to education (meds and adherence) |
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| Medication algorithms (augment/adjust; problems) |
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| Health Psychologist |
Referral to education: Medication adherence; barriers |
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| Nursing |
Nurse manager meeting & viewed separately |
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| Clerks |
Make appointments for follow-up/referrals |
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| Microsystems |
Individual Units |
One-on-one meetings with patient |
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| Intra-micro |
~1,500 with A1c > 9% |
Come for individual visits (every 3 months recommended) |
| Patient |
High-risk |
Follow-up with referrals to other services including: |
| Pick-up new medications now and then see: |
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| Clinical pharmacist to change medications (1 month) |
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| Lab work prior to next visit |
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| Nurse |
2 Licensed practical nurses |
Take vital signs, updates from patient, etc. |
| 4 Registered nurses |
Provide case management/education as referred |
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| Provider |
Primary care provider with diabetes patient: |
Expected to meet performance measures but limited support |
| Worked individually with patient |
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| 8 Part-time attendings |
Goals A1c < 9%; LDL-cholesterol < 100 mg/dL; systolic blood pressure < 140 mmHg |
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| 5 Nurse practitioners |
Receive scores regarding % of patients meeting goals |
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| 1 Physician assistant |
If patient not meeting measures, then educate patient via: |
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| Preceptors (5 new) |
Referrals for Consults to one or more (variable) specialists → |
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| Residents (60/year) |
Nurse; Clinical Pharmacist; Nutritionist; Endocrinologist/Diabetologist |
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| Clinic; Health Psychologist ; Diabetes Self-management classes |
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| *Primary focus: medications to get to goal |
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Kirsh et al. Implementation Science 2008 3:34 doi:10.1186/1748-5908-3-34 |
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