Kevin Alfaro-Martinez Eva Galvez, MD Primary Care Community Family - PowerPoint PPT Presentation

Kevin Alfaro-Martinez Eva Galvez, MD Primary Care Community Family Physician Outreach Worker

Development of the Care Team Clinical pharmacists and Care Teams behavioral health More recently… providers Initiated 2007 Community Outreach Additions A referral Workers and more coordinator, patient structured patient self- care coordinator, management nurse, 2 FTE programs providers

• Information and tools • Work with patients for managing diabetes who struggle to balance health concerns CHWs and Behavioral Diabetes Health Educators Providers Non-Provider Care Team Roles Clinical Nurses Pharmacists • Collaborate with • Reinforce education, providers to maximize work to help patients medication therapy in set goals, medication balance with lifestyle titration

Referrals • Referrals to clinical pharmacy and behavioral health are ordered in the patents chart and involve warm-handoffs. • Others through chart routing and staff messaging • CHW involved in warm hand-off referrals

Role of the Community Outreach Worker

CHW Supervision and Support Share cases Standardized with social documentation Report directly Work workers and New CHWs and work with to the Clinic independently the Behavioral shadow more the Operations Manager and for day-to-day Health experienced Manager to meet once a manager for ensure work is activities. CHWs. month. guidance and within scope of advice practice.

Other CHW Considerations Standardization of work and documentation is critical. CHWs should network with other agencies that provide services Consider panel size for CHWs (at Virginia Garcia two CHWs see approximately 100 patients/month) Avoid promising too much, remember that CHWs cannot solve all patient problems.

Diabetes Care Team Challenges

Pitfalls Knowing when patients are ready to Early involvement of behavioral engage with support and remembering health (especially for patients with and who and how to refer A1c >9). Solutions Clinical pharmacy struggled with large Changed to referral protocol to number of referrals for low-risk, low- patients with complex medication complexity patients regimens including insulin. Low attendance and no-shows to Continuing to explore how to diabetes education classes. address this issue Patient life circumstances make it Better accommodating same-day difficult to maintain them in care patients and bundling services (homelessness, lack of communication (provider, referrals, labs, pharmacy, and/or transportation) and social services)

Has Virginia Garcia seen improvements since implementing team based care?

https://virginiagarcia.org/

Questions and Discussion

Kevin Alfaro-Martinez Eva Galvez, MD Primary Care Community Family - PowerPoint PPT Presentation

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