what |
Who? |
How? |
|
Case manager |
SW,RN,LPN,MID-level |
|
|
Provider |
Physician, mid-level & Supervised students: PA, MS4 MS2 |
|
|
Nutritionist |
DCHN,DRH,DUHS, health department |
|
|
Pharmacist |
CLIN pharm D? |
|
|
POC hgbA1c |
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 |
Model? |
Downloadable to PCP/case manager |
|
Foot care |
Reviewed with patient at visit by RN, LPN, provider, students (if passed online education training) |
|
|
Venipuncture BMP |
Provider |
Do we want CMP to include LFTs related to med monitoring for some? Those on lipid meds -yes |
|
Self-management Education |
Training modules |
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? |
|
Lap top |
What type lap top? |
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 |
E-browser |
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. |
|
e-scribing |
Who?? uninsured |
Neil's help with Dr Lobach |
|
Schedule for home visit linked with group visit schedule |
? IDX with practice partners. |
|
NOTES: |
1 Comment
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