August 2004 Issue

Section 1-Results

Teams in Central Indiana participated in collaborative learning sessions of the Indiana Chronic Disease Management Program beginning in June 2003.  Concepts of the Chronic Care Model and Model for Improvement were shared with the teams as well as the program components of the Indiana Chronic Disease Management Program (ICDMP).  List serve communication and periodic meetings occurred over the next 12 months that reinforced these concepts and allowed teams to share successes and barriers to implementation.  Teams were expected to report data results as well as PDSA cycles on a monthly basis to the ICDMP faculty.  The following is an example of the success achieved for two teams that implemented the program for their diabetic population.

Section 2- PDSA Cycles

These are the tests of change (PDSA cycles) that the two teams utilized to achieve the above success.  These changes were tested at different times over the course of the year. 

HbA1c < 8-

Flagging chart for MD to order A1c as needed, performing A1c at time of visit, utilizing flow sheet to record A1c results, patients with A1c of 9 or higher are case managed by PharmD and dietician, nurse call patient if A1c was elevated and referred to dietician as needed, patient education on necessity of A1c testing for diabetics in waiting rooms.

Self Management Goals-

Modeled planned visits after chronic care model, established schedule of visits, diet, exercise, foot care, blood sugar routine are gone over at each visit and patient is asked to set at least on self management goal at each visit, follow up on self management goals from prior visit and then set new ones – set more than one goal each time, patient satisfaction survey completed with positive results.

Section 3-Contacts

ICDMP-  contains program materials and information on chronic disease.

1-866-311-3101  Help Desk- for CDMS or general program questions.

1-317-234-2760 – Mary Jo Golubski – Collaborative and program support.

1-317-233-7346 – Kathy Moses – Medicaid Chronic Disease Director