1. Diabetes Management a Patient Centered Collaborative Care Model
Betty Colletta

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

3. Community Volunteers in Medicine

4. 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.

5. Who we serve

6. 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

7. How we do it Students Volunteers
390 Volunteers donate over 53,000 hours of time and talent
Community Partners
A total of $2,431, 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

8. 100% supported by philanthropy
Community support
100% supported by philanthropy
Corporations &
Organizations
Board Members &
Individuals
Foundations

9. Fund raising 101

10. Our Patients with diabetes

11. NEWSFLASH…

12. > 29 million people in the US have Diabetes
242 of them are our patients at CVIM
117 female 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

13. Collaborative care

16. Patient centered medical home
Sabina Louise Pierce

18. 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

19. 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

20. 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

21. 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

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

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

24. There are No magic beans

25. Questions?

26. Share a pearl?

27. Kid President
A pep talk