250406 Implementation of an integrated team approach to improve diabetes care by meeting medical and psycho-social needs of an immigrant population

Monday, October 31, 2011

Gina M. Pistulka, PhD, MPH, APHN-BC , Mary's Center for Maternal and Child Care, Washington, DC
Bethany Sanders, MPH , Mary's Center for Maternal and Child Care, Inc, Washington, DC
Alis Marachelian, MPH , Health Promotion, Mary's Center for Maternal and Child Care, Inc. / Washington AIDS Partnership, Washington, DC
Elsa Romero, CHW , Health Promotion, Mary's Center for Maternal and Child Care, Inc, Washington, DC
Vivian Cativo, RN , Clinical Department, Mary's Center for Maternal and Child Care, Inc, Washington, DC
Mabel Hernandez, Certified Nutritionist , Mary's Center for Maternal and Child Health, Inc, Washington, DC
Gita Agarwal, MD , Clinical Department, Mary's Center for Maternal and Child Care, Inc., Washington, DC
Meg Backas, LICSW , Mental Health Department, Mary's Center for Maternal and Child Care, Inc., Washington, DC
The prevalence of type 2 diabetes mellitus is rapidly growing in populations seen in this Federally Qualified Health Center in Washington DC, which serves an uninsured/underinsured immigrant population, made up of 80% Latino patients with additional distinct populations from Ethiopia and Vietnam. A quality improvement and process design was used to improve the clinical team approach in supporting patients with diabetes self management, as well as the overall health outcomes. Monthly integrated team rotational clinics were held, whereby diabetic patients would meet with all members of the Care Team, including clinician, RN, nutritionist, health promotion educator and case manager. Pre-clinic team meetings were held to coordinate care. Post-clinic meetings were held to debrief and agree on follow-up. Monthly meetings of the care team, supervisors and quality improvement staff discussed progress, addressed barriers and tested changes. Health outcomes included a diabetes bundle an all or nothing measure made up of an annual Hemoglobin A1c test, LDL test, Microalbumin test, depression screen and blood pressure screening. Additional measures included annual foot and eye exams, and contact with all members of the team. Results were tracked quarterly and compared to both baseline and patients not attending the rotational clinic. Results: Baseline and quarterly measures will be presented, in addition to qualitative and process data. Conclusion: The rotational clinic design showed itself to be a best practice model for meeting the needs of our diabetic population. Meeting with multiple members of the team reinforced simple educational messages and helped develop self management goals, whilst addressing psycho-social barriers that impede attainment of such goals. The dedicated clinic also allowed for better planning and coordination of patient care through the system of pre and post meetings, without placing undue burdens on already stretched staff capacities.

Learning Areas:
Chronic disease management and prevention

Learning Objectives:
1. Identify strategies to achieve an integrated approach of care in a community health clinic setting, including clinical and behavioral health supports. 2. Examine the process improvement and overall effectiveness of a culturally -appropriate intervention to improve diabetes care in an immigrant population.

Keywords: Diabetes, Immigrants

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am qualified to present because I oversee clinical and health promotion programming within a community health center.
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.