OnDemand: Integration of Care to Determine SDoH
Duration: One Hour
Integration of Care to Determine Social Determinants of Health
Alliance Medical Ministry (AMM) has a patient population that faces an array of social risks (low income, uninsured, language barrier, low health literacy). An interdisciplinary care team of social work, counseling, nursing and primary care providers work in concert with patients to lower barriers to care. Nearly 60% of AMM's patients only speak Spanish and a large percentage have uncontrolled diabetes. Low health literacy and therapeutic inertia were targeted in this group by creating the Diabetes Care Management model, which allows a social worker and nurse to closely follow patients with uncontrolled diabetes. With frequent contact between the care manager, patient and primary care clinician, patients can gain better glycemic control in a shorter amount of time. The addition of donated continuous glucose monitoring devices provides even more information, to better assist patients with uncontrolled diabetes.
- Federal, state and employer wellness organizations
- Health care decision makers
- Health care professionals
- Health plans
- Health systems
- Population health organizations
- Outline the benefits of interdisciplinary teams in managing chronic disease.
- Discuss the contributions of the disciplines involved in each patient's care, including:
- Behavioral health counseling.
- Social work referrals to existing care in the area.
- Partnering with community organizations.
- Focusing time with the primary care clinician by having care teams follow up between visits.
- Examine how to use patient interactions to engage patients in their health care.
- Implement the Diabetes Care Management model in their own patient population.
Nick Conde-Dudding, MSW
Alliance Medical Ministry
Nick Conde-Dudding, MSW serves as the social worker for Alliance Medical Ministry
(AMM) in Raleigh, NC. AMM is a primary care clinic that serves the working uninsured in Wake County. Mr Conde-Dudding came to the clinic in July 2019 and was the first social worker hired by AMM under a grant from the Office of Rural Health. Mr CondeDudding's role as a social worker at AMM is more of a non-traditional one as he has
been providing diabetes care management (DCM) to primarily Spanish-speaking
patients at the clinic on top of the more traditional role of connecting patients to
community resources to address SDOH concerns. He has also become the clinic's
handy-man and may be seen with a drill or screwdriver in his hand from time-to-time.
Mr Conde-Dudding received his Master of Social Work from Boston University and a
Bachelor's in psychology from Clark University in Worcester, MA. He has been
practicing in the field of social work for 25 years and has worked primarily in healthcare during this time in various settings (hospital, primary care, sub-acute brain injury unit, community-based case management) serving children and adults. He began his career in behavioral health (mental health/ drug and alcohol addiction) and finds his
background in counseling to be very useful when working with poorly controlled diabetic patients at AMM to help them achieve lasting behavioral changes. He cherishes being able to work in a team-based/holistic approach to care, which is the heart of the service delivery at AMM. Mr Conde-Dudding, who is fluent in Spanish, has worked with the Spanish-speaking community for 20 years while living in Texas and now in North
Carolina. In the past 7 years, he has worked exclusively with the uninsured in both
Durham and Wake Counties.
Mandy L. Horner, BSN, RN
Alliance Medical Ministry
Mandy Horner has been an RN since 2006 that has practiced bedside, acute care nursing mostly in Chapel Hill at the Neuroscience Hospital. She served in both the Stroke Unit and the in the Neuroscience ICU. She received her BSN from ECU in 2015 and decided to pursue more public health initiatives working with uninsured individuals in a primary care setting. Mandy went from volunteering then managing clinical staff to directing the entire clinic. She changed non-profit employment just before the pandemic to focus more on patient care than administration. She recently completed her Primary Care Nursing Certification and she is currently pursuing her Certified Diabetes Education Care Specialist Certificate. Her current role allows more time to spend in education visits with patients and providing clinical guidance/experience to future generations of nurses interested in primary care. She spends her free time with her four children and spouse of 17 years.
Sheryl Joyner, MD
Internal Medicine Physician
Alliance Medical Ministry
Dr. Sheryl Joyner is a Florida native. She has been practicing at Alliance Medical Ministry, a Raleigh North Carolina clinic for the working uninsured, since the doors opened in 2003. Prior to working at Alliance, Dr. Joyner worked for 10 years at a rural community health center in in Benson, North Carolina where she practiced both inpatient and outpatient medicine. Dr. Joyner earned her Bachelor of Arts from Randolph Macon Woman's College and her medical degree from The University of Miami School of Medicine. She completed her internship and residency in Internal Medicine and Pediatrics at UNC Hospitals in Chapel Hill in 1992. She is board certified in Internal Medicine and has a special interest in management of chronic diseases and diabetes prevention. She has a passion for mission-based medicine and providing care for the underserved. Dr. Joyner and her husband have three children and enjoy spending their spare time with family on the North Carolina coast and in the mountains.
In support of improving patient care, the National Committee for Quality Assurance is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), the American Nurses Credentialing Center (ANCC) to provide Interprofessional Continuing Education for the healthcare team.
This activity was planned by and for the healthcare team, and learners will receive 1.0 Interprofessional Continuing Education (IPCE) credit for learning and change.
This educational activity is approved for: 1.0 AMA PRA Category 1 CreditTM.
This educational activity is approved for 1.0 nursing contact hours.*
This live course grants 1.0 Continuing Education Unit (CEU) points for PCMH Certified Content Experts.
* Please note – You must attend the entire program to be eligible for total number of contact hours.
Disclosure of Relevant Financial Relationships
The National Committee for Quality Assurance (NCQA) endorses the Standards of the Accreditation Council for Continuing Medical Education which specify that sponsors of continuing medical education activities and presenters at and planners for these activities disclose any relevant financial relationships either party might have with commercial companies whose products or services are discussed in educational presentations.
For sponsors, relevant financial relationships include large research grants, institutional agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution. For presenters or planning committee members, relevant financial relationships include the receipt of research grants from a commercial company, consultancies, honoraria, travel, or other benefits, or having a self-managed equity interest in a company; or having an immediate family member or partner with such a relationship.
Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.
Relevant financial relationships exist with the following companies/organizations:
Nick Conde-Dudding: None
Mandy Horner: None
Sheryl Joyner: None
Additional Planning Committee Members:
Tammy Donnelly: None
This program was developed in part by NCQA staff.
This program received no commercial support.
- 1.00 AMA PRA Category 1 Credit™
- 1.00 ANCC
- 1.00 IPCE
- 1.00 Participation
- 1.00 PCMH CCE