Partnership for Diabetes Health Equity (PDHE)

3-Element Model Learning Collaborative Charter

Texas Health Resources Azle, Azle, TX

Problem Statement, Aim, Goals and Objectives, and Guidance

Problem Statement
Texas Health Azle has a high population of patients with diabetes who do not have access to primary care. As a result, they are forced to use the emergency department as their only access to medical care. Over 53% of the patients seen in the Texas Health Azle emergency department are either unfunded or Medicaid patients. The Healthy Education and Lifestyles Program (HELP) is designed to help address this inequity. For the patients who attend regularly, there is great improvement, including 94% reduction in in-patient stays and 87% decrease in emergency department visits. However, there are many more patients who qualify for HELP, but are not taking advantage of the program. Also, when patients are attending regularly, the outcomes are much better than for patients who do not consistently attend.
Broad Goals
To increase the clinical outcome goals while showing an increase in participation and engagement in the HELP program by the unfunded diabetic population.
  • Increase the number of new self-pay patients seen in the ER to attend HELP sessions by 5%
  • Target 10 unfunded diabetic patients who frequently utilize the emergency department (ED) for referral to the HELP department.
  • Offer free gift at first appointment; The ED Navigator will communicate with patient referral about initial free gift prior to September 28, 2015 by offering a glucometer and 30 day testing strips
  • 80% of our HELP diabetic patients will attend at least 50% of their scheduled HELP session visits which will improve our engagement.
  • Enter patients who attend 2 sessions per quarter into a gift drawing, (equivalent to 6 out of 12 visits annually).
  • 10 patients who don’t attend HELP regularly will be selected and offered a coupon for a free Food Hub bag or meal between the months of September-November
  • Connect Patients to Safe Harbor and Community Resources to reduce barriers to attending the HELP Sessions.
  • 70% of HELP patients will achieve individualized targets;
  • biometric goals of:
  • A1C < 9
  • Blood Pressure 140/90
  • Self-Management Goals
  • Attendance
  • ED and Inpatient visits

Proposed Aim
To improve the health of the unfunded, diabetic patients by improving the self- management skills and the individual bio-metric scores through access to clinical and non-clinical resources thus removing barriers to good health.
Target Population
To improve the health of the unfunded, diabetic patients by improving the self- management skills and the individual bio-metric scores through access to clinical and non-clinical resources thus removing barriers to good health.
Objectives
INCREASE ACCESS TO ROUTINE CARE FOR CHRONIC DISEASES TO REDUCE OVER-UTILIZATION OF EMERGENCY DEPARTMENT. INDICATOR: 81% Decrease in the emergency department visits after a patient joins HELP. Prior to becoming a HELP patient, there were 114 visits to the ED in the HELP population. After joining HELP, ED visits have been reduced to an average of 22 visits per year for all of HELP patients, or .25 visits per patient per year, Comments: The baseline was determined by chart audits one year prior to joining HELP. The post-HELP number was determined by chart audit per year on the patients in the HELP program. In 2013 and 2014, there were 15 and 33 ED visits, respectively. In 2015, the annual projected number is 26 ED visits.
OUTCOME 2: TO INCREASE INDIVIDUAL’S SELF-MANAGEMENT SKILLS TO DECREASE COMPLICATIONS LEADING TO INPATIENT VISITS. INDICATOR:94% Decrease in inpatient admissions for the HELP patients. Prior to HELP, there were 31 inpatients admissions. After joining HELP, the in-patient admissions decreased to an average of 2 in-patient admissions per year for all 84 patients. Comments: The average charge per patient for 31 inpatient admissions prior to joining HELP was $39,479. Based on a review of patient records, there were 7 inpatients stay in the HELP population over a three-year time frame after joining HELP, with an average charge of $20,951.
OUTCOME 3: TO IMPROVE THE INDIVIDUAL’S HEALTH BY IMPROVING ACCESS AND SELF-MANAGEMENT SKILLS.

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