Diabetes And Community Medicine Patrick Chen, M.D. Share Our Selves January 30, 2010.

DiabetesAnd

Community Medicine

Patrick Chen, M.D.Share Our SelvesJanuary 30, 2010

Objectives

1.Highlight services at a community clinic

2.Characterize a diabetic patient population

3.Describe a multi-disciplinary approach

Share Our Selves (SOS)

1550 Superior Avenue

Costa Mesa, CA 92627

(949) 650-0640

www.shareourselves.org

What is SOS?

• 501(c)(3) non-profit organization• Health services for OC’s poor and uninsured• All services are free of charge• 2009 operational budget $6.6 million• More than 100,000 patients/clients annually• 45 employees• 400 volunteers

Our Mission Statement

We are servants who

provide free care and assistance

to those in need and

act as advocates for systemic change

SOS – A Brief History

• Founded in 1970 to provide for OC’s poor• Food• Clothing• Financial aid

• Evolution• 1984 Medical Clinic• 1987 Dental Clinic• 2005 Comprehensive CARE Center• 2009 SOS Family Center

5 Core Services

• Social Services

• Comprehensive CARE Center

• Family Center

• Dental Clinic

• Medical Clinic

Social Services• Food

• Financial Aid

• Clothing

• Legal aid

• Education Classes

• Fundraising Drives

Comprehensive CARE Center

• Counseling - individual, group therapy

• Advocacy - case management

• Resources - linkage to benefits/programs

• Emergency Services - crisis intervention

Family Center

• Pregnant women, families with kids 0-5 y.o.

• Education and in-home support:– Prenatal – Breastfeeding– Parenting– Diabetes prevention

Dental Clinic• Hygiene, x-rays, extractions, restorations• 2 dentists• 8124 visits annually

Medical Clinic

• 15,000 visits annually

• Chronic program– 2200 patients

• Walk-in clinic– ER diversion rate: 29%

• Specialty clinics

SOS – Hoag Partnership• Symbiotic collaboration between two

independent non-profit healthcare institutions

• Hoag provides $1.5 million in-kind support: two physicians, meds, diagnostics, services

• SOS provides primary care, ER diversion, and follow-up for discharged patients

Socioeconomic Profile

• Federal Poverty Level

– Single: $10,800

– Family of 4: $22,000

Socioeconomic Profile

• Medical Services Initiative (MSI)– OC’s safety net

program– < 200% FPL

Employed Providers

• 1.5 FTE Internists

• Family Physician

• Physician Assistant

• Nurse Practitioner

• 1.5 FTE Pharmacists

Volunteer On-site Providers

• Internist

• Cardiologist

• Nephrologist

• Optometrist

• Diabetic Educator

• Gynecologist

• Uro-Gynecologist

• Physician Assistant

• Nurse Practitioner

• Physical Therapist

SOS Diabetes Program

• 393 patients

• 4.4 average visits/yr

• MSI and Uninsured

• Geographic focus

• Demand is increasing

SOS Diabetes Program

• Labs

• Specialty Care

• Medications

• Education

• Mental Health

• Case Management

A Multi-disciplinary Team

• Primary care

• Specialty care

• Pharmacists

• Diabetes educators

• LCSW/MFT

• Case Managers

ADA Guidelines• Targets:– Hb A1C – BP – HDL, LDL

• Medications:– Statins– Antiplatelet– Immunizations

• Screening:– Neuropathy– Retinopathy– Nephropathy

• Lifestyle Changes:– Physical Activity– Smoking Cessation

First Encounter

• How do patients get into the program?

–Walk-in patient

– Referral from a hospital

– Our patient develops diabetes

First Encounter

• Patient Contract

• Financial Screening

• Depression screening

• Medications

• Referral to a diabetes educator

Medications

1. SOS purchases

2. $4 Pharmacy programs

3. Patients Assistance Program (PAP)

4. Hoag Pharmacy

Medications

• Oral diabetic agents

• Insulin

• Statins

• Fibrates

• Antiplatelets

• ACE Inhibitor / ARB

• BP therapy

• Antidepressants

• Vaccines

• ED meds

Medications

Value Dispensed 2009

1. SOS - Metformin $167,984

2. PAP – Atorvastatin $372,740

3. Hoag – Insulin $74,852

Diabetic Education

1. Latino Health Access

2. SOS Medication Therapy Management

3. Hoag Diabetes Center

Diabetic Education

• Pathophysiology

• Glucometer Training

• Nutrition

• Exercise

• Medications

• Insulin Instruction

Integrative Behavioral Health

• Counselors are Providers

• Collaboration (“Our patient”)

• High-risk for depression

• Behavioral change is critical

Integrative Behavioral Health

• Depression Screening– PHQ-9 each visit

• Depression Management– Counseling– Antidepressants

Integrative Behavioral Health

Over the past 2 weeks, how often have you been bothered

by any of these problems?

Not at all

Several days

More than half the days

Nearly Every Day

Little interest or pleasure in doing things

0 1 2 3

Feeling down, depressed, or hopeless

0 1 2 3

PHQ-2 Depression Screen

•Score of 3: 83% Sensitivity, 90% specificity

- Administer PHQ-9

Integrative Behavioral Health• Case Management– Care coordination– Special needs

• Family Conference– Patient / Family members– Provider– LCSW / Case Manager

Family Center

• Target families of diabetic patients

• Diabetes Prevention Classes

• Exercise Classes

Specialty Care

• Nephrology

• Optometry

• Cardiology

Eye Care

• Bimonthly eye clinic

• Prescription lenses

• Retinopathy screening

• Referral to Ophthalmology

Foot Care

• “Feet and Finger sticks” each chronic visit

• Providers perform microfilament exam

• Referral to podiatry

• Hoag Wound Care Clinic

Nephropathy

• BUN/Cr, Ur. Microalbumin Qyr

• ACE Inhibitor / ARB

• Referral to Nephrology

Dental Care

• Referral to Cypress College Dental Hygiene Program

• Referral to SOS Dental Clinic

Challenges to Care

• Patient resources

• Transportation

• Clinical Space

• Volunteer staff

• Access to specialists

• Increasing demand

The Future

• Electronic Health Records

• Standardized management algorithms

• Group Visits

• Self-analysis (targets, outcomes)

• Open another site