The 131st Annual Meeting (November 15-19, 2003) of APHA

Abstract #54382

Cheryl F. MacDonald, MSN, MPH, Falls Family Practice and Counseling, 4333 Kelly Drive, Philadelphia, PA 19129, 215-843-2580, cmacd@voicenet.com

Clinical team members in a Family Practice were asked to develop a class for diabetic patients. Overall diabetic control in this urban, mostly African-American population was very poor with many patients running high blood sugars levels daily. There was a need for improved overall diabetic management. This nurse-run primary care setting is part of a Health Disparities Collaborative project through the Institute for Health Improvement. A study focused on identifying and treating depression had been underway for one year. The health center was asked to “spread” its work on depression into chronic care management, specifically diabetes by applying a similar model. This model focuses on identifying a Problem, Developing a plan, Studying that plan, taking Action through implementation (PDSA cycle). Periodically, each cycle is reviewed, modified and repeated as needed to ensure that the initial goals and objectives are being met.

Using the PDSA model, a clinical team including Nurse Practitioners, Nursing staff, Medical Assistants and Americorps workers were brought together to implement a course for diabetic patients. Data was collected using pre- and post testing for diabetic beliefs and self-care measures, monitoring Hemoglobin A1c levels, and identifying the incidence of depression. A customized self-management goal tool was used to improve overall diabetic care. Using this model, a curriculum can be developed for any group of patients with a chronic illness and is customizable for an outpatient health care class. This presentation will present how one clinical team approached improved diabetic care and depression screening in an outpatient setting.

Learning Objectives:

• Identify essential components of a successfull community-based course in chronic illness using the plan, study, do, act (PDSA) model. 2.Describe the links between depression and diabetes in primary care. 3.Plan and implement customized self-management and screening tools for a community-based chronic care class.

Keywords: Diabetes, Depression

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.