HEART FAILURE PROJECT DIABETES REGIONAL PROJECT Heart Failure

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 6153 2255 1132 TOTAL

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 Stratification Screen CBG/A 1 C Education PCP/Follow Up

Diabetes: COMMUNITY COORDINATOR • Diabetes community health education • Meaningful Screening Tool Education Piece • Risk Stratification and Self Assessment • CBG testing / A 1 C • • 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 Pro. Care • Streamline involvement with population health, community navigation and faith based network • Integrate care between inpatient-outpatient-PCP