1. Sutter Medical Foundation Diabetes Management Program Kimberly Buss, MD, MPH Medical Director of Diabetes Education, SMF Medical Advisor of Diabetes Disease Management Program, SHSSR Jan Van der Mei,RN, MS, ACM Director, Ambulatory Care Management Sutter Health Sac Sierra Region

2. Introduction to Sutter Health, Sacramento Sierra Region

3. Sutter Health Sacramento Sierra Region
Diabetes Patients
Summary of Diabetes Population of Sutter Health Sac Sierra Region.
About 325,000 adult patients
About 30,000 diabetes patient (9.3% of adults)
About 8,000 diabetes patients on insulin

4. Prevalence of Diabetes by Zip Code
Sacramento County 2010
Prevalence of Diabetes by Zip Code
Note that our population has with high prevalence, substantial geographic variation, remarkably increasing prevalence over time (estimate increasing about 800 diabetes patients per year)

5. Prevalence of Diabetes by Ethnicity
Sacramento County 2000 and 2010
Prevalence of Diabetes by Ethnicity
10%
2000
Our population has substantial ethnic diversity, with significant variation in diabetes prevalence by ethnicity. Rates of diabetes are increasing in all populations. Required a approach to manage diabetes and other CV risk factors with high quality, culturally appropriate, consistent care.
10%
2010
Overall
Male
Female
White
Black
Hispanic
Other

6. Sutter Health Sacramento Sierra Region
Endocrinologists 2011
Also working in a region with a limited supply of diabetes specialists to help manage the population

7. Disease Management Program
Epic Tools
Outpatient Guidelines
Patient Resources
Care Center Staff
Educators
Care Coordinators
Patient
EPIC
Given these factors, 10 years ago John Thompson, myself and a team of others decide to start a pilot diabetes management program, which systematically looked at helping patients manage diabetes including glycemic control, Blood Pressure and Cholesterol – in order to prevent the complications of the disease and improve the cardiovascular health of the population. This program has grown and matured over time.
Disease Management Program
EPIC
EPIC
Glycemic Control
Lipids
Blood Pressure

8. Jan Van der Mei, RN, MS, ACM Director, Ambulatory Care Management Sutter Health Sac Sierra Region

9. Ambulatory Care Management Programs
Case Management
Sutter Care Coordination Program (SCCP)
Transitions of Care
AIM Telemanagement
Disease Management
Diabetes
Asthma
CHF
Anti-Coagulation Program
Sutter Select
Heart Health

10. Diabetes Program Enrollment

11. Diabetes Management
Nurses and DMS work with patients, families and physicians to optimize management of individuals with diabetes
Key interventions at key times
Lab reminders
Overdue for testing
Abnormal lab - repeat testing
Reinforce education
Self-Management Tools
Individualized care planning
Insulin Management
Care coordination
Providers
Education
Equipment

12. RN Assessment and Interventions
Review medical record, medications, and history
Target treatment goals according to standard of care
Contact with patients includes:
Identification of treatment barriers
Determine education needs; schedule class or reinforce as needed
Develop treatment plan with patient and PCP
Identification of patients personal goals for managing disease process
Physician contact and update as needed via EPIC
Provide culturally relevant educational material
Follow-up phone appointments are scheduled as appropriate

13. Diabetes Program: Controlling Blood Sugars
An elevated A1C level indicates poor blood sugar control over time and is a primary predictor of cardiovascular disease in patients with diabetes. An A1C >9 is considered "high risk" for this analysis.
A drop of 1.0 on the A1C scale is significant and impacts positively the long-term prevention of diabetes complications.

14. Diabetes Program Helps to Improve Control of Cholesterol
An elevated LDL (bad cholesterol) level is a primary predictor of cardiovascular disease in patients with diabetes. An LDL >100 is considered "high risk" for this analysis.
Patients enrolled in the diabetes program experienced an improvement between 16% and 21% during the period of
Q to Q

15. Sustained Improvement in Diabetic Control

16. LDL and BP Control

17. questions