Care System Components | Defined via Local Diabetes Care Context | Existing Diabetes Care-Based Practices Pre-SMA (January 2005) |
---|---|---|
Supramacro | VHA Central Office | Initiatives on outpatient quality with necessity to figure out how to operationalize locally |
 |  | Advanced Clinic Access mandate to reduce waiting times; increase efficiency |
 |  | Chronic Disease Index (a series of performance measures) emerging as a priority |
 |  | Electronic medical record tracking performance measures & providing feedback |
Macro | Cleveland Dept. of Veterans Affairs Medical Center | Pursue current mandate: Advanced Clinic Access to reduce waiting times for appointments |
 |  | Meetings about intermediate diabetes care goals |
 |  | Wanted updates about how goals were going to be met |
 |  | Primary care clinics focus on medical training not quality care |
 |  | Longer-term major construction creating space constraints |
Mesosystems | Primary care clinics | Monthly reports about meeting diabetes care goals |
 |  | Monthly clinic meetings review & allocate resources |
 |  | No formal process to identify and refer high-risk patients |
 |  | Individual meetings with silo representatives |
 |  | Go to macro level for change if needed |
 | Other services | Primary care provider is additional signer on notes for patients |
 | Clinical pharmacy | Individual referral to education (meds and adherence) |
 |  | Medication algorithms (augment/adjust; problems) |
 | Health Psychologist | Referral to education: Medication adherence; barriers |
 | Nursing | Nurse manager meeting & viewed separately |
 | Clerks | Make appointments for follow-up/referrals |
Microsystems | Individual Units | One-on-one meetings with patient |
Intra-micro | ~1,500 with A1c > 9% | Come for individual visits (every 3 months recommended) |
Patient | High-risk | Follow-up with referrals to other services including: |
 |  | Pick-up new medications now and then see: |
 |  | Clinical pharmacist to change medications (1 month) |
 |  | Lab work prior to next visit |
Nurse | 2 Licensed practical nurses | Take vital signs, updates from patient, etc. |
 | 4 Registered nurses | Provide case management/education as referred |
Provider | Primary care provider with diabetes patient: | Expected to meet performance measures but limited support |
 |  | Worked individually with patient |
 | 8 Part-time attendings | Goals A1c < 9%; LDL-cholesterol < 100 mg/dL; systolic blood pressure < 140 mmHg |
 | 5 Nurse practitioners | Receive scores regarding % of patients meeting goals |
 | 1 Physician assistant | If patient not meeting measures, then educate patient via: |
 | Preceptors (5 new) | Referrals for Consults to one or more (variable) specialists → |
 | Residents (60/year) | Nurse; Clinical Pharmacist; Nutritionist; Endocrinologist/Diabetologist |
 |  | Clinic; Health Psychologist ; Diabetes Self-management classes |
 |  | *Primary focus: medications to get to goal |