Thomas Jefferson UniversitySidney Kimmel Medical College

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Chronic Care Management/Health Services Research

MISSION

To study and improve the quality of chronic disease management in Jefferson Family Medicine Associates and other primary care sites.

GOAL

To improve chronic illness care in a Level III patient centered medical home through quality improvement and research initiatives.

RECENT PROJECTS

  • Concept Mapping as a Tool for Engaging Stakeholders
  • Feasibility and Preliminary Outcomes of Guided Care
  • Identifying Patients at High Risk for Hospitalization
  • My Note Pad: A Tool to Facilitate Patient Engagement in an Outpatient Primary Care Setting
  • Psychosocial Predictors of Super Utilizers and Longitudinal Outcomes after Care Management
  • Relationship between Adverse Childhood Events and Adult Emergency Department Utilization
  • Telephone Assistance to Increase Adherence with Mammography Screening

DFCM RESEARCH TEAM

Victor Diaz, MD
Janis Bonat, CRNP
Nancy Brisbon, MD
Carmen Campos, MPH
Amy Cunningham, MPH
Kathleen Hilbert, RN
Marianna LaNoue, PhD
Dawn Mautner, MD, MS
Colleen Payton, MPH
Brooke Salzman, MD

CONTACT:  Victor Diaz, MD

RECENT PUBLICATIONS

Banerjee ES, Gambler A, Fogleman C. Adding obesity to the problem list increases the rate of providers addressing obesity. Fam Med. 2013 Oct;45(9):629-33.

Mautner DB, Pang H, Brenner JC, Shea  JA, Gross KS, Frasso R, Cannuscio CC. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Population Health Management. Popul Health Manag. 2013;16 Suppl 1:S26-33.

Careyva B, Salzman B, Plumb E, Kern S. Patient perceptions of a diabetes group visit experience. J Community Med Health Edu 2012;2(3):1-5.

Salzman B, Collins L, Hajjar ER . Chronic disease management: The changing landscape of primary care. Primary Care: Clinics in Office Practice. 2012;39(2): xv-xxi.

Reitz JA, Sarfaty M, Diamond JJ, Salzman B. The effects of a group visit program on outcomes of diabetes care in an urban family practice. J Urban Health. 2012 Aug;89(4):709-16Salzman B, Collins L, and Hajjar E (Editors). Chronic Disease Management. Primary Care Clinics in Office Practice. June 2012; 39 (2): 221-462.

Helitzer DL, LaNoue MD, Wilson B, Urquieta de Hernandez B, Warner T, Roter D.). A Randomized Controlled Trial of Communication Training with Primary Care Providers to Improve Patient-Centeredness and Health Risk Communication. Patient Education and Counseling. 2011: 82:21-29.

RECENT PRESENTATIONS

Collins-Fletcher K, Salzman B. Older Patients with Atrial Fibrillation and History of Multiple Falls: To Coagulate or not to Coagulate? American Geriatrics Society Annual Meeting, Orlando, FL, May 2014.

Liantonio J, Salzman B. Quality Improvement: How can we reduce ER utilization and Hospital Admissions in our Home Visit Population? American Geriatrics Society Annual Meeting, Orlando, FL, May 2014.

Salzman B, Scherzer R. A Care Model for Older Adults with Multimorbidity: Jefferson Guided Care Pilot. American Geriatrics Society Annual Meeting, Orlando, FL, May 2014.

Salzman B, Scherzer R. An Interprofessional Educational Experience Involving Older Adults with Multiple Chronic Conditions. American Geriatrics Society Annual Meeting, Orlando, FL, May 2014.

Mautner D, Troy B, LaNoue M. Guided by the Patient Voice: Learning from Stories. Population Health Colloquium, Philadelphia, PA, March 2014.

Diaz VA, Ratner RE, Ziring B. Impact & Implications: Assessing improvement and Identifying persistent barriers to optimal diabetes management. Jefferson School of Population Health and American Diabetes Association meeting. January 22, 2014. Philadelphia, PA.

Banerjee ES. Improving Screening for Metabolic Syndrome in the Formerly Homeless Population with Serious Mental Illness. North American Primary Care Research Group (NAPCRG) Annual Meeting, Ottowa, Ontario, Canada. November 2013.

Banerjee ES. Positive Deviants Overcoming Obesity.  North American Primary Care Research Group (NAPCRG) Annual Meeting, Ottowa, Ontario, Canada. November 2013.

LaNoue M, Mills GD, Weinstein LC, Sifri R. Patient Engagement Research Methodology. Peer-reviewed methodological workshop at North American Primary Care Research Group Annual Meeting, Ottowa, Ontario, Canada, November 2013.

Mautner D, Pang H. Brenner J, Shea J, Gross K, Frasso R, Cannuscio C. High Utilizers' of Healthcare Describe Childhood Instability and Importance of Relationships With Providers. North American Primary Care Research Group (NAPCRG) Annual Meeting, Ottowa, Ontario, Canada. November 2013.

Mautner D, Gross K, Brenner J, Hurley K, Troy B, Zimmerman A, LaNoue M. HealthCare Super Utilizers: Psychosocial Predictors and Longitudinal Outcomes After Care Management. Society of Teachers of Family Medicine Annual Spring Conference, Baltimore, MD, May 2013.                                                                                                                                                               

Reitz J, Sarfaty M, Diamond J, Salzman B, Brisbon N, Diaz V.  DISH: Evaluation of a diabetes group visit program. American Public Health Association Annual Meeting. October 31, 2012.  San Francisco, California.

Verma M, Sarfaty M, Simmons R, Crawford A. Knowledge and perceived barriers about Diabetic retinopathy and Dilated eye exam among patients with diabetes in an urban academic environment. American Public Health Association Annual Meeting. November 1, 2011. Washington, DC.

Verma M Sarfaty M, Simmons R, Crawford, AG.Knowledge and Perceived barriers about Diabetic Retinopathy and Dilated eye exam in patients with Diabetes (2011). School of Population Health Lectures, Presentations, Workshops. Paper 13.http://jdc.jefferson.edu/hplectures/13

Reitz J, Diamond JJ, Salzman B, Brisbon N, Bonat J,  Sarfaty M, Diaz V, Hilbert K. Intermediate Outcomes of Diabetes Group Visit Program in the Jefferson Family Medicine Associates (JFMA) Practice.  Society of Teachers of Family Medicine Practice Annual Spring Conference. April 27-May 1, 2011. New Orleans, LA.