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Case manager




Physician, mid-level & Supervised students: PA, MS4 MS2



DCHN,DRH,DUHS, health department



CLIN pharm D?
Local pharm?
Senior pharmacist
Physician alliance?
Pharm students Campbell


POC hgbA1c
POC micro/CR ratio

Could be done by provider, mid-level, RN, LPN?

Every 3 months for HbA1c; lipids dependent on levels and treatment; micro/CR ratio at least yearly - more often if hx renal insufficiency, etc ?

Glucometer tracking


Downloadable to PCP/case manager

Foot care

Reviewed with patient at visit by RN, LPN, provider, students (if passed online education training)


Venipuncture BMP

Home health

Do we want CMP to include LFTs related to med monitoring for some? Those on lipid meds -yes

Self-management Education

Training modules
RN, LPN, CNA, provider

Perhaps the education piece needs to be individualized to the patient, i.e. what questions or concerns they have today - patient driven...  So, we have materials available - computer, written, video or personal interaction ? need advice from Kathy P. et al?

Tracking next visit

To remind next visit ??

HAC option? Task?
Reminder system via computer
Correlate with attendance at group visits and medical home so that we aren't redundant...

Lap top

What type lap top?
Dell vs ACERvs lenovo

COULD BE netbook less expensive smaller.

Connectivity cellular broadband

Verizon vs AT&T vs alltell

Check which is best hear alltell good coverage in durham

Tracking metrics electronically

Practice partners lincoln
No access to care uninsured

I have recently been introduced to the IT person for Coach- to see what there systems involve they need to be integral part of this-I will also who is best to come talk to us from COACH as they have years of experience with the uninusured.


Who?? uninsured
Practice partners

Neil's help with Dr Lobach

Schedule for home visit linked with group visit schedule

? IDX with practice partners.


Total anticipated home visit time: 30 minutes per visit
-         Patient concerns/ POC testing/Review Meds
-         Discussion of POC results/ provider exam or evaluation/ medication titration
-         Follow up questions/education/ goal setting
-         Discuss follow-up care: ? reintegrate with medical home; start attending group visits; arrange follow-up home visit
Home visit components: DRAFT : 2-10-09 

1 Comment

  1. Anonymous

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