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How various Providers within the Gotham ACO group coordinate in diabetes management?

How various Providers within the Gotham ACO group coordinate in diabetes management?

Specifically, as it relates to Diabetes management, the Providers within the ACO providers frame work that will be involved in diabetes patient care will entail coordinated care between:

• The Gotham medical center comprising of Endocrinologist, Nurses, Physician Assistants that are involved in ambulatory and inpatient care as well as the Medical Center critical care unit and emergency unit which provide care within the hospital.

• Gotham Patient Centered Primary Care which consists of patient centered medical homes and community clinics that provide preventive and primary care services aimed at early detection and prevention of DM. These services are delivered at various Family Health Centers and Community Safety-Net Clinics which operate on a walk-in basis where patients can receive care without prior appointment.

• Other units include Nutritional and Educational Outreach Unit, School Clinics, Discharge Social Workers, Care Managers, Long term care units and Home Care Unit

These units coordinate and integrate care of DM from prevention, early diagnosis to good glycemic control in ensuring good diabetic management.

The ACO involved in a particular diabetic management aims at integrating care through collaboration among stakeholders. A major part of the Gotham ACO unit consists of community and home-based effort educational programs focused on life style modification and nutritional education.

At present, the preventive services amongst the providers in The ACO unit involved in diabetes prevention in the Bronx includes

• CMO [define] sending individual letters to patients managed within the ACO with an A1c level greater than 9%

• Outreach workers with designated educational materials communicated with diverse needs of the population based on cultural, language and educational level needs

• Diabetes Team that works with local parks department to offer free recreational centers membership to identified diabetics

• Weekly farmers market on Gotham ground to offer vegetable and fruits to neighborhood and has partnered with community groups to support the presence of green market throughout the Bronx

• Five Certified diabetes educators that rotate through Gotham medical group sites to provide education and community counseling to support patient self management

• Chronic Care Management program at the CMO that provides centralized support to the educators for ongoing patient support between office visits

• Development of Public health initiative in the community that targets childhood obesity through collaboration with public schools

• Integration of care via collaboration with Gotham Health Information Technology department. Each diabetes patient at Gotham has a unique patient identifier that is tied to his or her life time electronic record. The unique patient identifier is used throughout the ACO network. Patient is managed in a Patient Centered manner. Once a diabetic patient is identified, HER uses the Patient identifier PIN to track multiple visits, monitor prescription pattern, admissions and readmissions, ER visits, education sessions given, home care visits amongst other things. The identifier pin is also used to track patients for administrative and payment purposes.

• The Gotham CMO uses its network management expertise to focus on coordinating and improving the care of diabetic patients across the continuum of care from preventive, acute and ambulatory care. Gotham employs the use of their network managers to help coordinate diabetic care transition, provide patient education, manage diabetes, increase access to specialty care, inpatient and ambulatory care for diabetes patients, and provide on-set care. The skill of network management developed by CMO are carried forward and integrated throughout the Gotham ACO delivery system into multiple care settings.

The IT team uses a secure HIPPA-compliant, internet-based messaging service (branded to improve communication between the patient and the Provider. Patients can communicate with the practice offices and email their providers to discuss non-emergent issues (Chase, 2011).

Gotham ambulatory settings, Physicians and other ACO units and administration use the Clinical Looking Glass technology to develop provider-specific report on patients with diabetes. At the primary care center, each provider/Physician receives diabetes registry that tracks each patient including patient last visit date, hemoglobin A1C tests, cholesterol tests, blood pressure reading in addition to other relevant screenings and tests pertinent to diabetes management. Each Physician or healthcare provider receives all individual patient results and can compare the patient experience to that of the group average for their patient panel and for the clinic site overall. The cost of management of a single episode of care is reimbursed to each member of the ACO in a bundled payment form.

The providers involved in the care of a particular diabetic patient can access the system using the Clinical Looking Glass (CLG) for their specific panel to track glucose control level for the diabetes patient over time. The Clinical Looking Glass is able to define the time period that a patient has been in desired glucose range and correlate performance with associated medication, weight, adherence, to office visit, intermittent or recurrent illness.

The Gotham ACO also collaborates with other health systems in The Bronx with regards to data sharing. The various coordinated units comprising of the Bronx patient centered ACO collaborate for data sharing through the Bronx Regional Health Information Organization, which is the vehicle for a Bronx-wide electronic exchange of Healthcare Information. All the ACO providers which comprise of most Bronx Borough Hospitals, Federally Qualified Health centers (FQHC), ambulatory health centers, Home Care Agencies, Nursing homes and Community based organizations all coordinate to provide patient centered care in general which also includes management for diabetes patients (Chase, 2011).


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