showed that compared to non-depressed children in a medical home, depressed patients in a medical home were more likely to receive medical care (p= 0.005), receive dental care (p= 0.02), have their vision tested (p= .0013), have at least one unmet health care need (p= 0.008), receive care from a specialist (p< 0.0001), have problems paying their medical bills (p< 0.0001), and experience frustration obtaining health services (p< 0.0001). After controlling for demographic variables, depressed patients were still more likely to receive medical care (OR= 2.27; 95%CI 1.30-3.81), receive care from a specialist (OR= 1.46; 95%CI 1.07-1.99), have problems paying medical bills (OR= 1.80; 95%CI 1.16-2.80), and experience frustration obtaining health services (OR= 2.19;. ConClusions: These findings suggest that the PCMH has a positive effect on primary and specialty care access for depressed children, but more work needs to be done to reduce the burden of seeking needed care.

The New Brunswick Diabetes Strategy was endorsed in June 2011. This 4-year strategy is based on the chronic care framework and integrates a wide array of actions within the health and community sector with the goal of improving "everyday pathways" for patients and providers. The strategy encompasses a variety of actions to target improved levels of A1C, LDL, blood pressure and foot care. A diabetes registry was created allowing fee for service primary care providers to receive a personalized profile of all the patients with diabetes in their practice and each patients latest A1C and LDL result as well as cumulative data on the average A1C and LDL in their patient population compared to those of their peers in the same geographical zone. Providers also receive a bright "pink sheet" in their lab reports anytime a patient has an A1C >7%, which lists the cumulative 5-year A1C's for that individual. Diabetes case managers have been hired to rotate through family practices to focus on patients with A1C's >8% and community health coaches work with patients on goal setting and follow through. Facilitation of provincewide implementation of hospital insulin order sets has been initiated to optimize inpatient diabetes care. A clinical innovation fund provides seed money to deserving hospital and community projects. Key features of this strategy include the affordability and sustainability of action areas with the goal of effective system change.

Nursing Management T e c h U p d a t eT he Institute for Healthcare Improvement (IHI) recommends the development of a rapid response team (RRT) to support the nursing staff to avert codes outside of the ICU. 1 However, patient outcomes are dependent on the bedside nurse making the right decision at a critical moment. What if technology could enhance the nurse's critical thinking rather than solely promoting task orientation? As noted in Figure 1, codes outside the ICU at Our Lady of the Lake (OLOL) Regional Medical Center in Baton Rouge, La., were 6.11/1,000 discharges, greater than the national standard of 2.53/1,000 discharges. 2 To improve our outcomes, we augmented our RRT (medical emergency team [MET]) by using the electronic medical record (EMR) to trigger help at the first documented sign of a patient's deterioration. Based on the implementation of the early warning system, our goal was to decrease codes outside the ICU by 50%. The early daysOur MET process was based on a recommendation from one of the hospital's intensivists, who had read of the success of an Australian medical team's management of post-op surgical patients after experiencing a negative clinical change. 3 A project team comprising ICU nurses, respiratory therapists, a performance improvement representative, and nursing management met to determine the make up of the team. Based on the size of the organization and the need to keep ICU nurses at the bedside taking care of patients, the decision was made for the house manager to comprise the nursing complement. Only when there weren't two house managers on duty would an ICU nurse augment the team. The decision to use house managers was advantageous because they're advanced cardiac life support certified, aware of current bed status, required no additional fulltime equivalents, and didn't compromise patient care.The MET process was based on set criteria as documented in Table 1. After the MET was up and running, there was one drawback noted: Sometimes the nursing staff called the MET too late, resulting in a code outside the ICU (see Figure 1). To identify patient deterioration in a timely manner and increase our MET calls/1,000 patient discharges, an automatic notification system was developed devoid of staff nurse MET activation.Developing automated notification OLOL is highly mechanized and an early adopter of the EMR. Because hospitalized patients show a critical status change up to 6 to 8 hours before a need for resuscitation, automation could detect gradual declines in status even before the nurse realized that the patient was getting into trouble. 4 A project team comprising nursing management, information services, and computer support was commissioned to develop an automatic MET trigger. The team met over a period of months to develop the early warning signal. Over a period of time, the team developed the automatic trigger process based on key documented parameters, such as vital signs and oxygen saturation. When one of the critical behaviors was met, the house manager received an ele...