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DiabetesAnd
Community Medicine
Patrick Chen, M.D.Share Our SelvesJanuary 30, 2010
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Objectives
1.Highlight services at a community clinic
2.Characterize a diabetic patient population
3.Describe a multi-disciplinary approach
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Share Our Selves (SOS)
1550 Superior Avenue
Costa Mesa, CA 92627
(949) 650-0640
www.shareourselves.org
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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
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Our Mission Statement
We are servants who
provide free care and assistance
to those in need and
act as advocates for systemic change
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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
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5 Core Services
• Social Services
• Comprehensive CARE Center
• Family Center
• Dental Clinic
• Medical Clinic
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Social Services• Food
• Financial Aid
• Clothing
• Legal aid
• Education Classes
• Fundraising Drives
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Comprehensive CARE Center
• Counseling - individual, group therapy
• Advocacy - case management
• Resources - linkage to benefits/programs
• Emergency Services - crisis intervention
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Family Center
• Pregnant women, families with kids 0-5 y.o.
• Education and in-home support:– Prenatal – Breastfeeding– Parenting– Diabetes prevention
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Dental Clinic• Hygiene, x-rays, extractions, restorations• 2 dentists• 8124 visits annually
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Medical Clinic
• 15,000 visits annually
• Chronic program– 2200 patients
• Walk-in clinic– ER diversion rate: 29%
• Specialty clinics
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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
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Socioeconomic Profile
• Federal Poverty Level
– Single: $10,800
– Family of 4: $22,000
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Socioeconomic Profile
• Medical Services Initiative (MSI)– OC’s safety net
program– < 200% FPL
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Employed Providers
• 1.5 FTE Internists
• Family Physician
• Physician Assistant
• Nurse Practitioner
• 1.5 FTE Pharmacists
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Volunteer On-site Providers
• Internist
• Cardiologist
• Nephrologist
• Optometrist
• Diabetic Educator
• Gynecologist
• Uro-Gynecologist
• Physician Assistant
• Nurse Practitioner
• Physical Therapist
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SOS Diabetes Program
• 393 patients
• 4.4 average visits/yr
• MSI and Uninsured
• Geographic focus
• Demand is increasing
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SOS Diabetes Program
• Labs
• Specialty Care
• Medications
• Education
• Mental Health
• Case Management
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A Multi-disciplinary Team
• Primary care
• Specialty care
• Pharmacists
• Diabetes educators
• LCSW/MFT
• Case Managers
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ADA Guidelines• Targets:– Hb A1C – BP – HDL, LDL
• Medications:– Statins– Antiplatelet– Immunizations
• Screening:– Neuropathy– Retinopathy– Nephropathy
• Lifestyle Changes:– Physical Activity– Smoking Cessation
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First Encounter
• How do patients get into the program?
–Walk-in patient
– Referral from a hospital
– Our patient develops diabetes
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First Encounter
• Patient Contract
• Financial Screening
• Depression screening
• Medications
• Referral to a diabetes educator
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Medications
1. SOS purchases
2. $4 Pharmacy programs
3. Patients Assistance Program (PAP)
4. Hoag Pharmacy
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Medications
• Oral diabetic agents
• Insulin
• Statins
• Fibrates
• Antiplatelets
• ACE Inhibitor / ARB
• BP therapy
• Antidepressants
• Vaccines
• ED meds
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Medications
Value Dispensed 2009
1. SOS - Metformin $167,984
2. PAP – Atorvastatin $372,740
3. Hoag – Insulin $74,852
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Diabetic Education
1. Latino Health Access
2. SOS Medication Therapy Management
3. Hoag Diabetes Center
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Diabetic Education
• Pathophysiology
• Glucometer Training
• Nutrition
• Exercise
• Medications
• Insulin Instruction
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Integrative Behavioral Health
• Counselors are Providers
• Collaboration (“Our patient”)
• High-risk for depression
• Behavioral change is critical
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Integrative Behavioral Health
• Depression Screening– PHQ-9 each visit
• Depression Management– Counseling– Antidepressants
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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
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Integrative Behavioral Health• Case Management– Care coordination– Special needs
• Family Conference– Patient / Family members– Provider– LCSW / Case Manager
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Family Center
• Target families of diabetic patients
• Diabetes Prevention Classes
• Exercise Classes
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Specialty Care
• Nephrology
• Optometry
• Cardiology
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Eye Care
• Bimonthly eye clinic
• Prescription lenses
• Retinopathy screening
• Referral to Ophthalmology
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Foot Care
• “Feet and Finger sticks” each chronic visit
• Providers perform microfilament exam
• Referral to podiatry
• Hoag Wound Care Clinic
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Nephropathy
• BUN/Cr, Ur. Microalbumin Qyr
• ACE Inhibitor / ARB
• Referral to Nephrology
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Dental Care
• Referral to Cypress College Dental Hygiene Program
• Referral to SOS Dental Clinic
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Challenges to Care
• Patient resources
• Transportation
• Clinical Space
• Volunteer staff
• Access to specialists
• Increasing demand
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The Future
• Electronic Health Records
• Standardized management algorithms
• Group Visits
• Self-analysis (targets, outcomes)
• Open another site