Clinic | Setting | Provider organization | Health coach | Team composition | Panel size (Overall diabetics at clinic) | Main patient population | Workflow |
---|---|---|---|---|---|---|---|
1. | Urban | 2 clinics with ~5 clinicians serving low-income families | MA | Team of 2 clinicians and 2 MA | 119 (139) | Latino | MA panel management based on the Teamlet Model1. No home visits. Combining regular MA work with health coaching. MA sees 4 patients per day for health coaching on alternate days. |
2. | Urban | 7 clinics with ~50 clinicians serving low-income families | MA | Team of 6 clinicians and 4 MA. | NS (367) | Recent Chinese immigrants | MA works on weekly rotating schedule as health coach. Sees ~12 patients per day typically in post-visits to clinician. No home visits. |
3. | Small community | 7 clinics with ~40 clinicians serving low-income families. | CHW | Team of 2 clinicians and 1 CHW | 118 (334) | Latino | CHW works mainly office-based via panel management in Teamlet Model. Sees 6-8 patients per day. |
4. | Small community | 2 clinics with ~5 clinicians serving low-income families. | CHW | Team of 3 clinicians and 2 CHW | 137 (143) | Latino | CHW does office-based visits and post-visits based on Teamlet Model. Started small-scale home visits, planning 3-4 joint visits per day by 2 CHW. |
5. | Suburban | 7 clinics with ~40 clinicians serving low-income families. | CHW | Team of 3 clinicians and 1CHW. | 84 (377) | Latino | CHW works community-based with home visits of 25-30 minutes during 4 days per week. One day office-based for follow-up phone calls. Separate from clinic workflow. |