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Congratulations to the Access Health Louisiana care team at the St. Charles Community Health Center in Luling. They successfully tested 100% of their 440 diabetic patients seen in the clinic in February for hemoglobin A1C levels, a standard set forth as a best practice guideline by the American Diabetes Association. “The first step to managing any condition is to conduct baseline testing to see what a person’s levels are,” says Dr. Kevin Joseph of the Luling clinic. Dr. Joseph serves as Senior Vice President of Medical Affairs with Access Health Louisiana. “Diabetes can be a very sudden illness where you won’t feel the effects until its too late. Tools like hemoglobin A1C tests can help us detect diabetes early and really make a difference in the patient’s life.”
Providers at the St. Charles Community Health Center in Luling have recently adopted a “Team-Based” model of care which enables support staff to work at the top of their licensure in order to assist medical doctors and nurse practitioners to take better care of their patients. The new model is highly data-driven prompting Care Team Coordinators to identify patients in the team’s morning huddle that are in need of their A1C tests. Nursing staff queue up the orders for the providers prior to them even seeing the patient and participate in the visit with the provider acting as a ‘patient advocate’ to listen and answer questions for the patient. This ensures any additional evidence-based tests or referrals are addressed during the time of the patient’s visit thus reducing the need for multiple trips back to the office, such as diabetic eye exams, immunizations, or foot exams.
Front desk staff call patients that no show for their appointments or even call ahead of time to remind patients who are ‘likely to no-show’ based upon previous visits to ensure that they come in for care via a patient registry. Labs are performed in-house by an in-house phlebotomist to enable providers to have the most current lab values and readings on their patients prior to walking into their room for the visit in order to guide their decision-making and treatment plan.
“From our viewpoint, a patient is considered to be in poor control whether they have an A1C value greater than 9.0% or whether they have not had their routine A1C test,” states Chatrian Kanger, Director of Population Health at Access Health Louisiana. “If we don’t have their most recent test result, we don’t know how they are really doing so they are presumed as ‘poorly controlled’. This is the national viewpoint as well. So being able to say that we have a reading on 100% of our patients wins us half of the battle. Now, we can focus on getting those who are truly in poor control onto a more rigorous treatment plan or started on medication.”
For those patients who start on medication, Access Health’s in-house pharmacy allows patients to receive their maintenance medications via home delivery since medication adherence is key to controlling this chronic condition.
As added support, Access Health Louisiana offers free diabetes education classes for patients and their families. The classes are located in Luling at 843 Milling Avenue and at other AHL clinic locations. Classes are offered in both English and Spanish. For more information, call (985) 785-5800.