GREETINGS FROM THE BOULDER VALLEY CARE NETWORK (BVCN) CARE COORDINATOR NURSE
The BVCN Diabetes Care Coordination Pilot Program has been actively involved with diabetic patients since the end of January. Thanks to the BCMS for this opportunity to bring you up to date on how it has progressed so far!
The primary goal in nurse interaction with patients is to facilitate follow through on their physician recommendations between visits, to assist in maximizing self management skills during those times, and to reinforce their doctor’s advice on office visit and lab frequencies. Once eligible Boulder Valley School District (BVSD) employees are identified, the physicians within the BVCN who are managing their diabetes are notified. Then, with physician awareness, the RN contacts the patients and offers them the free BVCN services. Participation is voluntary for patients and can be as little or as much as they want it to be.
During the initial patient visit, the RN communicates MD recommendations for next appointment and lab test due dates, as well as any other specific MD care suggestions; shares information on locally available resources, such as diabetic education classes and support groups; evaluates their current self-management situation & desired goals; and determines what level of nurse interaction patients want in the future. Some only request email reminders of upcoming local diabetes events; others want to meet again to develop self-determined health goals and a plan to reach them.
In Pilot Phase 1, 50 patients were identified via insurance claims through June, 2010 and contacted. Of those, 12 have been visited, most of whom are in continuous communication with the RN. Several have attended diabetes classes or have been connected to a diabetes educator or registered dietician as a result of the visit. In Pilot Phase 2, an additional 8 patients have been identified from the July, 2010 through December 2010 time frame. They will be contacted, along with those from Phase 1 who have either been found to be in poor control or who are overdue on their doctor or lab appointments. The Pilot Program will be completed at the end of June, 2011 at which time evaluation and expansion for the BVCN will be considered by the steering committee and medical directors.
In the future, if you are notified about a patient who is eligible for BVCN benefits, and feel he or she could use the help of nurse interaction between office visits, please consider personally promoting this service to him/her. Specific encouragement from you carries much weight with your patients and may be the best impetus to spur them towards more active health engagement.
Meanwhile, please visit our patient-friendly website, www.mybvcn.org. Watch for a list of local diabetes resources which will be mailed to PCP and Endocrinologist offices for distribution to your diabetic patients, even those who are not BVSD employees! And always feel free to call me with suggestions or questions.
Karen Haimes, R.N.
303-530-3405 X8 (office) 303-518-0420 (cell)
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