202003 A network of nurse practitioner primary care practices serving underserved populations and the PA Governor's Chronic Care Initiative

Tuesday, November 10, 2009: 5:00 PM

Grace Lee, MS , National Nursing Centers Consortium, Philadelphia, PA
Nancy L. Rothman, EdD, RN , Department of Nursing, College of Health Professions, Temple University, Philadelphia, PA
The aim was to implement the six components of the Wagner chronic care model (Community, Health System, Self Management Support, Delivery System Design, Decision Support and Clinical Information Systems) for the redesign of practice for adult diabetic patients in a network of four nurse-managed primary care practices serving the homeless, public housing and immigrant farm workers. The baseline for performance of the Improving Performance In Practice (IPIP) goals for diabetes was June, 2008. These goal indicate very good care based upon national standards and include: Blood Pressure (<130/80 at >70%); Cholesterol (LDL <100mg/dl at >70%); A1C ( >9% at <5%); dilated eye exam (>80%); tested or under treatment for nephropathy (>90%); asked about smoking and if smoking counseled to stop (>90%); on statin ( >60%); over 40 on an aspirin (>85%); 55-75 yrs. of age on ACE/ARB (>75%); BP<140/90 (>90%); A1C<7% (>75%); at least one LDL (>90%); LDL <130 mg.dl (>90 %); foot exam (>90%); influenza vaccination (>75%); pneumonia vaccine (>90%) and documented self-management goals (>90%). Baseline measures and 3 month, 6 month, 9 month and 12 month measures will be shared along with the re-design of the practice network toward meeting the goals. The IPIP goals for this initiative are to be met within three years.

Learning Objectives:
1) Evaluate the IPIP outcomes for adults with diabetes in a re-designed nurse-managed primary care pratice based on the Wagner Chronic Care Model.

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the Consultant/Director for the PHMC Nursing Network and over see quality and policy, including our involvement in the Governor's Chronic Care Initiative.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.