Diabetes Management a Patient Centered Collaborative Care Model Betty Colletta

objectives That each participant would leave with a practice pearl That each participant leaves with knowing that myself and CVIM are a resource

Community Volunteers in Medicine

Community Volunteers in Medicine provides compassionate primary medical and dental care and health education to people who live or work in the Chester County region who lack access to insurance, in order to support their goals to lead productive, healthy, and hopeful lives.

Who we serve

Health Care Home Access to Care: Medical Patients: Dental Patients: Coordinated Care: 35,178 patient visits in fiscal year 2016 Access to Care: 1,575 new patients came to CVIM for care Medical Patients: 3,392 people served through CVIM medical programs Dental Patients: 3,353 people served through CVIM dental programs Financial Impact: Provided a total estimated value of care to the community of $5.9 milllion

How we do it Students Volunteers 390 Volunteers donate over 53,000 hours of time and talent Community Partners A total of $2,431,621.21 of medications were procured for our patients Students Over 200 students do clinical rotations each year, receiving more than 11,000 hours of hands-on experience

100% supported by philanthropy Community support 100% supported by philanthropy Corporations & Organizations Board Members & Individuals Foundations

Fund raising 101

Our Patients with diabetes

NEWSFLASH…

> 29 million people in the US have Diabetes 242 of them are our patients at CVIM 117 female 41 male Mean age 46 95% DMT2 All are high risk CD + comorbidities + socioeconomic issues We are also working with 233 patients with pre-diabetes Promoting Prevention - stopping diabetes before it starts

Collaborative care

Patient centered medical home Sabina Louise Pierce

Why practice Patient centered collaborative care for persons with diabetes? Diabetes is chronic - lifelong engagement in self-management   Diabetes management requires many resources Diabetes is progressive –needs will change / evolve over time, these changes may be permanent or temporary Diabetes does not stand alone – poly-morbidities (it takes a village…medical home) Good diabetes outcomes require a personal investment from our patients + a relationship with their health care team

Why practice Patient centered collaborative care for persons with diabetes? Diabetes is chronic – requires lifelong engagement in self-management Many of our patients have limited literacy levels + differing cultural + health care beliefs [crisis vs health care] Personalized approach – relationships, motivational interviewing Patient education navigator Practice wide support – we all sing the same song

Why practice Patient centered collaborative care for persons with diabetes? Diabetes is progressive –needs will change / evolve over time, these changes may be permanent or temporary Diabetes management requires many resources Diabetes does not stand alone – poly-morbidities (it takes a village…medical home) Additional medical needs Personal resources; psychosocial, life style change, financial bien estar

Why practice Patient centered collaborative care for persons with diabetes? Good diabetes outcomes require a personal investment from our patients + a relationship with their health care team Time [transportation, inflexible or variable work schedules, food insecurity] Self-care behavior is a foreign concept Self-efficacy – personalized achievable goal setting teach back method Treat the family Diabetes Knowledge – health literacy, patient education Ongoing support and health assessment

“I want to ring the bell” This is what it is all about

Why is a patient-centered focus key to improved outcomes? Each patient is a unique individual

There are No magic beans

Questions?

Share a pearl?

Kid President A pep talk