diabetes and community medicine patrick chen, m.d. share our selves january 30, 2010
TRANSCRIPT
DiabetesAnd
Community Medicine
Patrick Chen, M.D.Share Our SelvesJanuary 30, 2010
Objectives
1.Highlight services at a community clinic
2.Characterize a diabetic patient population
3.Describe a multi-disciplinary approach
Share Our Selves (SOS)
1550 Superior Avenue
Costa Mesa, CA 92627
(949) 650-0640
www.shareourselves.org
What is SOS?
• 501(c)(3) non-profit organization• Health services for OC’s poor and uninsured• All services are free of charge• 2009 operational budget $6.6 million• More than 100,000 patients/clients annually• 45 employees• 400 volunteers
Our Mission Statement
We are servants who
provide free care and assistance
to those in need and
act as advocates for systemic change
SOS – A Brief History
• Founded in 1970 to provide for OC’s poor• Food• Clothing• Financial aid
• Evolution• 1984 Medical Clinic• 1987 Dental Clinic• 2005 Comprehensive CARE Center• 2009 SOS Family Center
5 Core Services
• Social Services
• Comprehensive CARE Center
• Family Center
• Dental Clinic
• Medical Clinic
Social Services• Food
• Financial Aid
• Clothing
• Legal aid
• Education Classes
• Fundraising Drives
Comprehensive CARE Center
• Counseling - individual, group therapy
• Advocacy - case management
• Resources - linkage to benefits/programs
• Emergency Services - crisis intervention
Family Center
• Pregnant women, families with kids 0-5 y.o.
• Education and in-home support:– Prenatal – Breastfeeding– Parenting– Diabetes prevention
Dental Clinic• Hygiene, x-rays, extractions, restorations• 2 dentists• 8124 visits annually
Medical Clinic
• 15,000 visits annually
• Chronic program– 2200 patients
• Walk-in clinic– ER diversion rate: 29%
• Specialty clinics
SOS – Hoag Partnership• Symbiotic collaboration between two
independent non-profit healthcare institutions
• Hoag provides $1.5 million in-kind support: two physicians, meds, diagnostics, services
• SOS provides primary care, ER diversion, and follow-up for discharged patients
Socioeconomic Profile
• Federal Poverty Level
– Single: $10,800
– Family of 4: $22,000
Socioeconomic Profile
• Medical Services Initiative (MSI)– OC’s safety net
program– < 200% FPL
Employed Providers
• 1.5 FTE Internists
• Family Physician
• Physician Assistant
• Nurse Practitioner
• 1.5 FTE Pharmacists
Volunteer On-site Providers
• Internist
• Cardiologist
• Nephrologist
• Optometrist
• Diabetic Educator
• Gynecologist
• Uro-Gynecologist
• Physician Assistant
• Nurse Practitioner
• Physical Therapist
SOS Diabetes Program
• 393 patients
• 4.4 average visits/yr
• MSI and Uninsured
• Geographic focus
• Demand is increasing
SOS Diabetes Program
• Labs
• Specialty Care
• Medications
• Education
• Mental Health
• Case Management
A Multi-disciplinary Team
• Primary care
• Specialty care
• Pharmacists
• Diabetes educators
• LCSW/MFT
• Case Managers
ADA Guidelines• Targets:– Hb A1C – BP – HDL, LDL
• Medications:– Statins– Antiplatelet– Immunizations
• Screening:– Neuropathy– Retinopathy– Nephropathy
• Lifestyle Changes:– Physical Activity– Smoking Cessation
First Encounter
• How do patients get into the program?
–Walk-in patient
– Referral from a hospital
– Our patient develops diabetes
First Encounter
• Patient Contract
• Financial Screening
• Depression screening
• Medications
• Referral to a diabetes educator
Medications
1. SOS purchases
2. $4 Pharmacy programs
3. Patients Assistance Program (PAP)
4. Hoag Pharmacy
Medications
• Oral diabetic agents
• Insulin
• Statins
• Fibrates
• Antiplatelets
• ACE Inhibitor / ARB
• BP therapy
• Antidepressants
• Vaccines
• ED meds
Medications
Value Dispensed 2009
1. SOS - Metformin $167,984
2. PAP – Atorvastatin $372,740
3. Hoag – Insulin $74,852
Diabetic Education
1. Latino Health Access
2. SOS Medication Therapy Management
3. Hoag Diabetes Center
Diabetic Education
• Pathophysiology
• Glucometer Training
• Nutrition
• Exercise
• Medications
• Insulin Instruction
Integrative Behavioral Health
• Counselors are Providers
• Collaboration (“Our patient”)
• High-risk for depression
• Behavioral change is critical
Integrative Behavioral Health
• Depression Screening– PHQ-9 each visit
• Depression Management– Counseling– Antidepressants
Integrative Behavioral Health
Over the past 2 weeks, how often have you been bothered
by any of these problems?
Not at all
Several days
More than half the days
Nearly Every Day
Little interest or pleasure in doing things
0 1 2 3
Feeling down, depressed, or hopeless
0 1 2 3
PHQ-2 Depression Screen
•Score of 3: 83% Sensitivity, 90% specificity
- Administer PHQ-9
Integrative Behavioral Health• Case Management– Care coordination– Special needs
• Family Conference– Patient / Family members– Provider– LCSW / Case Manager
Family Center
• Target families of diabetic patients
• Diabetes Prevention Classes
• Exercise Classes
Specialty Care
• Nephrology
• Optometry
• Cardiology
Eye Care
• Bimonthly eye clinic
• Prescription lenses
• Retinopathy screening
• Referral to Ophthalmology
Foot Care
• “Feet and Finger sticks” each chronic visit
• Providers perform microfilament exam
• Referral to podiatry
• Hoag Wound Care Clinic
Nephropathy
• BUN/Cr, Ur. Microalbumin Qyr
• ACE Inhibitor / ARB
• Referral to Nephrology
Dental Care
• Referral to Cypress College Dental Hygiene Program
• Referral to SOS Dental Clinic
Challenges to Care
• Patient resources
• Transportation
• Clinical Space
• Volunteer staff
• Access to specialists
• Increasing demand
The Future
• Electronic Health Records
• Standardized management algorithms
• Group Visits
• Self-analysis (targets, outcomes)
• Open another site