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HEART FAILURE PROJECT &DIABETES REGIONAL PROJECT
Heart Failure: NEED IDENTIFIED
• Address Readmission Rate• Robust inpatient management but need for
streamlined community navigation•HF patients have been using the ED as primary care• Intensify Heart Failure patient discharge education to start on admission
Heart Failure: NURSE NAVIGATOR
•Heart Failure Self Management Book•One-on-one patient education•HF follow-up: phone, Cardiac Rehab referral, PCP• Intensify Heart Failure patient discharge education to start on admission hospital wide involvement• Streamline community resources•Heart Failure Support Group
Heart Failure: NAVIGATOR STATISTICS
DATES ENCOUNTERS
EDUCATION TELEPHONE/FOLLOW UP
May ‘12 – Dec ‘12
1758 529 298
Jan ‘13 – Dec ‘13
3665 1452 775
Jan ‘14 – Feb ‘14
730 274 59
TOTAL 6153 2255 1132
Heart Failure: READMISSION PROJECTS
• Rapid Diuresis protocol• Utilization of CPC•Mid-level managed clinics
Heart Failure: FUTURE
•Grow Support Group• Regional Education and Outreach• Streamline involvement with population health, community navigation and faith based network• Integrate care between inpatient-outpatient-PCP• Full utilization of cardiac rehab
Diabetes: REGIONAL LEADER
• TJC Disease Specific Certified• 4 in the State of Texas
•ADA Recognized Diabetes Self Management Program• 102 in the State of Texas• 1758 in the United States
Diabetes: NEED IDENTIFIED
•High undiagnosed rate of diabetes in Ector County• Community unawareness of resources•Meaningful education and screening process• Restructure the process to be:Risk
StratificationScreen
CBG/A1C Education PCP/Follow Up
Diabetes: COMMUNITY COORDINATOR
•Diabetes community health education•Meaningful Screening Tool• Education Piece• Risk Stratification and Self Assessment• CBG testing / A1C
• Taking the tool to the community/ health Fairs• Scheduling free Survival Skills 2-3 hour class in English and Spanish
Diabetes: TRAIN-THE-TRAINER MODEL
• 4 Hours Core Class and 3 Hours of Nutrition• 3 Hours shadow with clinical educator• Designed for organizations without any Nursing
Education Department or Diabetes Educators• End goal: Staff will develop beginning skills and
working knowledge on helping patients with diabetes
• Permian Regional Medical Center – Andrews• Pecos County Memorial Hospital – Ft. Stockton
Diabetes: FUTURE
• Regional Outreach/ Education in collaboration with PRMC and PCMHFS•Grow the current APN based providers for those
without PCPs and referred to ProCare• Streamline involvement with population health,
community navigation and faith based network• Integrate care between inpatient-outpatient-PCP