Caring for Diabetes and Hypertension Patients in the Patient Centered Home

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Members of the patient-centered team include Lorraine Nelson, manager; Mallory Hancock, administrative assistant; Catherine Van Doren, RD, CDE; Rachael Carroll, APN; Yolanda Jorge, APN; Mary Rose Belostrino, LSW, social worker; Joan Gleason Scott, assistant vice president, Quality and Safety Management; and Eric Greene, Data Analytics.

Members of the patient-centered team include Lorraine Nelson, manager; Mallory Hancock,
administrative assistant; Catherine Van Doren, RD, CDE; Rachael Carroll, APN; Yolanda Jorge,
APN; Mary Rose Belostrino, LSW, social worker; Joan Gleason Scott, assistant vice president,
Quality and Safety Management;and Eric Greene, Data Analytics.

Focusing on medical and social needs are fundamental to caring for patients. It is also key to providing care in the patient-centered medical home model, which is a model for delivering family-centered, comprehensive, continuous and coordinated care.

The patient-centered medical home at the Center for Diabetes and Hypertension, located at the Saint Peter’s Family Health Center in New Brunswick, provides primary care and follow-up care; information and education about managing medications; living and coping with chronic disease; nutrition counseling; foot, skin and eye care; and information about community resources.

The patient-centered medical home serves adults 18 years of age and older and non-pregnant women who have diabetes and hypertension and have no insurance or are underinsured. The short term goal of the program is to identify patients with both conditions and provide them with the care and resources they need in one convenient location. The long term goal is to reduce hospital admissions and emergency room visits.

It is largely known that diabetes has reached epidemic proportions. In particular groups, and also in communities where people do not have access to care, the patient-centered medical home is important because the fundamentals of care are provided to patients who need it but lack access to it.

At Saint Peter’s, a nutritionist and advanced practice nurse lead the team in providing continuing education and support. After patients meet with a primary care physician at the Center, appointments are scheduled for a nutritional consultation and a separate session where patients are taught about diabetes and what patients can do to manage the disease on their own. Visits are not rushed; These visits last an hour. It’s at this stage that barriers are identified to successful self-management and treatment. Patients are invited to attend the Spanish-language support group, or the English-language group that meets once a month at the Center, which is located at How Lane. The nutritionist sets the agenda based on the patients’ needs and topics range from managing stress to basic everyday concerns such as food shopping and cooking healthy foods.

Why diabetes and hypertension?

According to research, underserved populations are more at risk for developing
diabetes and hypertension as a complication of five factors:
• an increase in obesity
• lack of compliance with medication
• financial concerns
• lack of understanding of disease processes
• lack of understanding about the relationship between lifestyle and developing diabetes with hypertension.

Published courtesy of Anne Marie Van Hoven, M.D., an endocrinologist at Saint Peter’s University Hospital.  For more information about the Patient- Centered Medical Home at Saint Peter’s
Family Health Center, call 732-339-7672.

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