NCI Care Coordination Collaborative Carly Draper RD, CDN, CDE Carthage Area Hospital Teresa Intorcia RD, CDN, CDE Samaritan Medical Center Susie Kim MS, RD, CDN, CNSC Carthage Area Hospital

Certified Diabetes Educators Certified Diabetes Educators (CDE) responsibilities: Consultation on diabetes management which can include diet education, medication recommendations, patient skill development, etc Offer Diabetes Self Management Education and Training (DSME/T) Provide support and in-service educations to Community Health Workers who work directly with patients Provide telemedicine as the clinics, providers, and patients are willing

Service Areas Service Area 1 North Country Family Health Center (Lowville) Carthage Area Hospital Howard T. Meny, MD, PC Family Medicine of Carthage, PC Lowville Medical Associates, LLP Clifton Fine Healthcare Corporation CDE’s for this area: Carly Draper Susie Kim (obtaining CDE)

Service Areas Service Area 2 CDE for this area: Teresa Intorcia North Country Family Health Center (Watertown) Samaritan Medical Center Watertown Internists North Country Family Medicine, PLLC Complete Family Care Family Medicine of NNY CDE for this area: Teresa Intorcia

Services Offered Variety of nutritional services are offered through CAH and SMC including but not limited to: Diabetes Cardiovascular Disease GI Disorders Bariatric Nutrition Weight Management & Obesity Cardiac Rehab Food Allergies Pediatric Nutrition Diabetes Self Management Program at CAH (accredited by AADE)

Referral Process Primary Care Providers faxes referral forms, including: Past medical history Current medications Pertinent medical visit summaries Most recent labs Once received, we call the patient and set up next available appointment or group class

Diabetes Self Management Program Initial appointment 1:1 to assess patient Followed by 3 group classes 1-3 hours per class Group interactive discussion Activities Goal Setting Curriculum: AADE 7 core concepts Healthy eating Physical activity Monitoring Medication Problem solving Coping Strategies Prevention

NCI and DSRIP Collaboration Through this collaboration, we offer: Weekly phone consultation to care managers, nurses, and providers as needed or requested to help with engaging high risk diabetes clients in improving their care and self-management of the disease A resource for referrals for additional education and/or support in managing diabetes either in the group setting with our DSME program or in the one-on-one setting Telehealth services On-site clinic visits for your clients who may need additional support, but are unable to travel or utilize the telehealth services Diabetes resources and materials

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