Team/Organization Name Background and structure Location Brief system information (type, size) Pilot population

Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Resources and Policies Community Organization of Health Care Registry Care remind- ers Patient Subgroups Care-planning Team roles and tasks Planned visits Continuity Follow-up Guidelines Specialty interaction Provider education Guidelines for patients Emphasize patient role Assessment Interventions Care planning and problem solving On this slide briefly describe what your team did in each area.

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Goals Benefits Provider incentives Improvement strategy Senior leaders Health System Resources and Policies Community Organization of Health Care Effective programs Partnerships Coordination On this slide briefly describe what your team did in each area.

Describe Key Changes made. For example: Assessment of selected clinical priorities Evidence-based interventions targeted based on assessment Protocols used Collaborative plan formulated with each participant, based on PCP input and participants readiness Self-management support was emphasized Proactive follow-up for one year Informed, Activated Patient Productive Interactions Prepared Practice Team On this slide briefly describe key changes made, example below

Instructions for next 6 slides. You will only need to use one of the next six slides. Keep only the model component slide for your breakout session. The second-level bullets, designated with a hyphen, are examples of interventions that may have been implemented. Modify these examples to explain what your team has accomplished. Call or Melissa, Donna or La Don if you have any questions. ( )

Use this slide to highlight the model component for your breakout session Clinical Information Systems Registry –DEMS –Process flow from encounter to entry established Care Reminders –Outlier reporting to identify patients in need of test –Letters and labels produced from demographic info Patient Subgroups –MDs receive lists of patients with HgbA1c > 8.0% Care-Planning –Lists generated for those with missing labs

Use this slide to highlight the model component for your breakout session Decision Support Guidelines –Provider agreement to adopt ADA guidelines –Printed on encounter forms Specialty Interaction –Faxback forms developed for opthalmology and podiatry specialists Provider Education –Pocket cards –Educational seminars Guidelines for patients –Wallet cards

Use this slide to highlight the model component for your breakout session Delivery System Design Team Roles & Tasks –Nurses/MA perform foot exams –MD briefly mentions the importance of self- management and refers to educator Planned Visits –Scheduling for labs before appointment Continuity –prompts for specialty MD contact Follow-up –CDE calls patients regularly

Use this slide to highlight the model component for your breakout session Self-Management Support Emphasize Patient Role –Multiple providers send this message to patient Assessment –Downloaded assessment from Web site –CDE assesses patient at planned visit Interventions –CDE received training through Chronic Disease Self-Management Program Care-Planning & Problem Solving –Use of motivational interviewing techniques

Use this slide to highlight the model component for your breakout session Community Resources Effective Programs –Identifies community resources at YMCA –Modifies resource booklet and placed in Toolbox Partnerships –Diabetes fair sponsored by Safeway and local hospital Coordination –CDE discusses resources with patient

Use this slide to highlight the model component for your breakout session Organization of Health Care Goals –Switching from a reactive to proactive approach Benefits –Working closely with health plan to cover group visits Provider Incentives –Set BP goals for team to achieve Improvement Strategy –Working closely with pilot team to spread to another clinic Senior Leaders –Approved position for assisting pilot and spread teams on tracking and reporting on Collaborative measures

Functional and Clinical Outcomes List results achieved toward targeted measures Baseline Actual Target Oct 99 Nov 2000 –HbA1c < % 65% 60% –Self-mgt. goals set 5% 25% 50%

Barriers Describe challenges here

Keys to Success This is a place to summarize the lessons you learned