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Health Access Network Works to Improve Diabetic Care

Tammy Chabot, RN, Operations Director

04/19/2007

In July 2006, HAN was accepted into a federal collaborative designed specifically to help patients who are diagnosed with diabetes. HAN currently serves over 1,700 patients diagnosed with diabetes in the Lincoln and Millinocket service areas. The collaborative is a group of Federally Qualified Health Centers (FQHC’s) throughout New England, New York and Puerto Rico working together to help patients with specific chronic illness. The collaborative has given HAN providers and staff extensive training on how to implement this system which monitors diabetes patients more closely. At this point, the new system is in place with Joye Jewell, FNP-C, at our West Enfield clinic with plans to expand to all HAN clinics in the near future.  One positive outcome we’ve experienced from participating in this collaborative has been the ability to network with other FQHC’s and health care providers to develop best practices and solutions in the care of our diabetic patients.  

The new system of diabetic care includes a computerized registry to track the patients’ last visit, testing (lab or other), referrals and education.  We create reports from this system to identify each patient’s individual needs, which assures continuous high quality care.   Prior to the patient visit with the provider, the Medical Assistant or Nurse refers to a checklist using guidelines from the American Diabetes Association (ADA) and American Medical Association (AMA) to review the patient’s chart and determine what testing, support, and training the patient has not received.  This information is all entered into a computerized tracking system.  At the time of the visit the Nurse or Medical Assistant will also review necessary testing and referrals with the patient to determine if these are something the patient would like to follow through with.  The patient is assisted to set realistic personal goals.  Once goals are set, staff will work with the patient to help reach them. 

HAN has started having “Diabetes Day” each month at the Enfield clinic.  On this day we schedule one provider to see diabetic patients.  The focus of the visit on diabetes day not only includes assuring the patient has all needed referrals and tests as noted above, but also includes time for education based on the patient’s chosen self management goals.  Since joining the collaborative, the number of follow up appointments and testing/referrals completed with Joye’s patients has increased by up to 75%.  

HAN’s annual budget includes staff and resources necessary to continue our work with the collaborative and promote better care of our diabetic patients. Our healthcare plan focuses on care of chronic illness with particular emphasis on diabetes. Our strategic plan, which was created by HAN’s board and staff at all levels, includes an organizational-wide commitment to improve diabetes management.  Although it’s too early to see the long-term results of our work so far, we are optimistic this project will have a significant and positive impact on the health and lives of our diabetic patients well into the future.