1 “diabetes days” a practice efficiency strategy improving diabetes mellitus patient care...
TRANSCRIPT
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“Diabetes Days”A Practice Efficiency Strategy
Improving Diabetes Mellitus Patient Care Delivery & Outcomes
<Facilitator name and Credentials>
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Today’s Objectives
• Discuss Application of Care Change Concepts in Primary Care
• Review Planned Recall Strategy
• Review Batching Strategy: Diabetes Days “101”
• Discuss Sample Schedule and Tools
• Assess Best Practices for Implementation
• Determine Measures for Effectiveness
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INTRODUCTION AND CONTEXT
10 minutes Introductions and Program Overview
IMPROVING DIABETES CARE DELIVERY AND OUTCOMES
5 minutes Care Change Concepts
5 minutes Case Study
5 minutes Planned Recall and Batching Strategies
20 minutes Diabetes Days 10 Steps
5 minutes Monitoring Quality Improvement
10 minutes WRAP UP AND MEASURE EFFECTIVENESS
Today’s Agenda
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• The Challenge: Diabetes a complicated, growing disease:• Incidence and prevalence of diabetes in Canada continue to increase1
• Control is not improving: 50% of Type 2 Diabetes patients in Canada are not meeting their blood glucose targets 2
• Implications and burden for primary care practice: • Over 80% of type 2 diabetes patients will be under the care of their Family Physician
with an average of 8 visits per year2
• What is the solution?• Governments & CDA promoting interdisciplinary team approach &
enablers• MD, RN, NP, Diabetes Educators, Pharmacists, Family Health Teams and Primary
Care Networks
• Flow-sheets, registries, incentives etc….
• Informed & empowered patients
Diabetes Care in Family Practice
1. Canadian Diabetes Association. http://www.diabetes.ca/diabetes-and-you/what/prevalence2. Harris SB, et al. Diabetes Res Clin Pract 2005; 70:90-7.
Teams require practical, implementable approaches to care deliveryTeams require practical, implementable approaches to care delivery
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Therapeutic Goals
CDA Guidelines:1 • Goal of treatment is to minimize the risks of the macrovascular and microvascular
complications of diabetes by aiming for the following metabolic targets:
Ontario Ministry of Health: • Quality Targets for Primary Care Physicians: Example:2
1. The Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada., Can J Diabetes. 2008;32(suppl 1):S1-S201
2. Ontario Ministry of Health- Quality Targets for Primary Care Physicians: http://health.gov.on.ca/en/ms/diabetes/en/about_diabetes_care_rep.html
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Systematic Approach to Diabetes CareCDA Guidelines Recommendations
CDA 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Can J Diabetes. 2008;32(suppl 1):S1-S201
Teams require practical, implementable approaches to care deliveryTeams require practical, implementable approaches to care delivery
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TODAY’S TOPIC
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Principles of Access
Optimize the Care Team• Ensure that all members of the team are full scope of practice
• Physicians must educate patients so that patients understand the team approach
Care Delivery Model (Who Does the Work)1
• Identify the roles of the healthcare team, as well as the process for providing care and advice to patients using agreed upon guidelines
Identify and Manage the Constraint• Use standardized guidelines and protocols to increase care that
can be provided in alternate ways
1. Office Practice Redesign in Primary Healthcare: Access and Efficiency Workbook, 2011 Quality Improvement and Innovation Partnership www.qiip.ca, p. 7
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Care Change Concepts2
Delivery System Design• Define roles and delegate tasks among team members• Use planned proactive visits to support evidence-based care• Build “effective” care management functionality into practice• Assure continuity by the primary healthcare team• Ensure regular follow-up
Health Care Organization• Use effective improvement strategies for comprehensive system
change
Information Systems• Include clinically useful and timely information on patients in registry• Identify relevant patient subgroups and provide proactive care
2. Office Practice Redesign in Primary Healthcare: Access and Efficiency Workbook, 2011 Quality Improvement and Innovation Partnership www.qiip.ca, Appendix, 38
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Family Practice: Case Study
• Hamilton Family Health Teams – first wave FHT
• Aging patient population
• Focus on timely access to appropriate care, chronic disease prevention and management
• Practice advantage: inter-professional practice team
– Physician, 2 RN’s, Part time DNE, medical student
– 2500 rostered patients
– Preventative care, advanced access and after hours care
• Balance between acute and preventative care needed
Inter-professional support and incentives existed but process required to manage population of patients with Diabetes… “The How”
Inter-professional support and incentives existed but process required to manage population of patients with Diabetes… “The How”
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Planned Recall
URL: http://www.gpscbc.ca/psp-learning/module-overview/chronic-disease-management
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“Diabetes Days”
Planned recall: patient “batching” strategy• Goal to provide efficient, effective DM focused visits
• Leverage expertise of inter-professionals clinic team
• Optimize “Work Flow”
• Improve practice efficiency, effectiveness, patient health outcomes
• Scheduling strategy allows for
– Preventative care appointments
– Advanced Access appointments
– Joint scheduling (Physician, RN, DNE, Dietitian)
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The Solution: Diabetes Days 10 Steps
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Set up a DM Patient Registry
• Paper or Electronic
• Screen for patients using e.g. A1C >7%, LDL >mmol/L, BP >130/80 Hg etc
• Allows you to know who your patients are and track their visits and progress
See Practice Guide Page 52 -53See Practice Guide Page 52 -53
“DIABETES DAYS” STEP 1
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Staff Alignment
Team Alignment is critical:• Alignment should anchor to benefits diabetes days approach can
make to patients and providers
• Ensures each team member’s contribution is leveraged
• Coordinate around staff availability (RN, DNE)
• Standardize visits supported with agreed upon protocols, roles
• Standardized tools and materials agreed upon: EMR, Stamps, Flow Sheet, Diabetes Education Kit and Patient Materials
“DIABETES DAYS” STEP 2
See Practice Guide Page 66See Practice Guide Page 66
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Adopt Flow Sheet
Offering:
Tool to track activity and monitor patient progress
“DIABETES DAYS” STEP 3
See Practice Guide Page 69See Practice Guide Page 69
Sample
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If EMR: Establish visit protocols with EMR Stamps
• EMR allows for development of “stamps”, “favorite notes” or templates
• Applied to specific health issues
• Will guide care delivery by team
• Can be a short cut for documentation to ensure consistency
See Practice Guide Page 63-64See Practice Guide Page 63-64
“DIABETES DAYS” STEP 4
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Diabetes Days – Sample EMR Stamp
Initial Visit
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Diabetes Days – Sample EMR Stamps
DDay f/u today. See my DM sheets or flow sheet F1. Bloodwork results and medications reviewed with pt. including compliance. «yes»«no»Target organ damage - see problem list +PxHx above (MI/stroke/nephropathy/neuropathy/eyes/hypoglycemia/med intolerance)BP: • HR: • Wt:• Kgs WH: • last K030 - Oct 11, 2010 last Q040 - never doneFoot check pt checks feet B. I. D.« yes»« no»Hypoglycemia no, Lifestyle ?smoking, exercise etc discussedMood "Bothered in the past month by feeling down, depressed or hopeless" «n/a» «yes» «no» "Bothered in the past month by little interest or pleasure in doing things" «n/a» «yes» «no»Discussed DM pathophysiology, progression of DM, DM complicaitons, basic lifestyle management of blood sugars as appropriateTarget BGs ac and pc meals discussed -
Target (for most) N Range (if possible)Before Meals 4-7 4-62Hrs. After 5-10 5-8A1C ≤7 <6
Provided with - «Just the Basics,» «DM Hamilton,» «What is DM?,» «Managing DM,», «Highs and lows of blood sugars,» «Stand Up to Diabetes»Pt demonstrated a «good»«poor» understanding of discussion with appropriate comments and questions. Expect pt will make some changes.Issues identified: Not at target - «WT » «BP » «'lytes » «LFT's » «CK» «creat/eGFR » «HDL »«LDL » «ualb/creat » «FBG »«A1C »Pt may benefit from : F/u booked for: 3-4/12 with req. given to pt. for lab work and for them to make appt.Benefits and side effects of medications prescribed by me are discussed in detail with the patient. RBD of above
Patient did 75 fm GTT, FBS, A1C , and micro albumin/creatinine ratio. Result is (DMI) (IFG) (IGT)Discussed with patient and offered, Appointment with hospital pre-diabetic, Appointment with our dietician, Appointment with our DM Nurse Educator, DVD, and Government Stand up to Diabetes number to call. Pt told to repeat bloodwork in 1 year. Following appointments made.
IFG EGT Visit
Ongoing Management Visit
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Team Roles and Accountabilities
• Review patient needs based on patient types
• Establish team roles
• Activate plan to address any learning needs identified
See Practice Guide Page 35-37See Practice Guide Page 35-37
“DIABETES DAYS” STEP 5
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Diabetes Days:Schedule & Workflow
• Establish a coordinated schedule with the DHC team
• Involve all DHC Team members
• Establish workflow and room assignments
• Best Practice – do not book any other long appointments of physicals during this time
• Diabetes related visits only. Other issues to rebooked (within reason)
See Practice Guide Page 60-61See Practice Guide Page 60-61
“DIABETES DAYS” STEP 6
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Sample Joint Schedule (MD, RNx2, DNE)
Annual Physical Advanced Access
Diabetes Days (DM) Report Time/Calls
Diabetes Days Diabetic Annual Visit
Monday DIABETES DAYS Tuesday Wednesday Thursday DIABETES DAYS FridayTime rm 1 rm 2 rm 3 rm 4 rm 5 6 rm 1 rm 2 rm 3 rm 4 rm 5 6 rm 1 rm 2 rm 3 rm 4 rm 5 6 rm 1 rm 2 rm 3 rm 4 rm 5 6 rm 1 rm 2 rm 3 rm 4 rm 5 8:00 RN1/MD RN1/MD DNE RN2/MD RN2/MD ** RN1/MD RN1 DNE RN2/MD RN2 ** RN1/MD RN1 DNE RN2/MD RN2 ** RN1/MD RN1 DNE RN2/MD RN2/MD ** RN1/MD RN1 DNE RN2/MD RN2/MD **
8:15 Annual report time Annual
report time ** Annual
report time Annual
report time ** Annual
report time Annual
report time ** Annual
report time DM Annual
report time ** Annual
report time Annual
report time
8:30 Physical calls Physical calls ** Physicialcalls Physical calls ** Physical calls Physical calls ** Physical calls annual Physical calls ** Physical calls Physical calls 8:45 ** ** ** ** 9:00 diabetic diabetic reg appt ** reg appt reg appt reg appt reg appt ** reg appt reg appt reg appt reg appt ** DM DM DM reg appt ** reg appt reg appt reg appt reg appt 9:15 ** ** ** annual ** 9:30 diabetic diabetic ** ** ** DM DM ** 9:45 ** ** ** DM ** 10:00 dibetic dibetic ** ** ** DM annual DM ** 10:15 ** ** ** **
10:30report time
report time **
report time
report time **
report time
report time **
report time
report time
report time **
report time
report time
10:45Adv Acc
Adv Acc **
Adv Acc
Adv Acc **
Adv Acc
Adv Acc **
Adv Acc DM
Adv Acc **
Adv Acc
Adv Acc
11:00 ** ** ** annual ** 11:15 reg appt reg appt reg appt ** reg appt reg appt ** reg appt reg appt ** reg appt reg appt ** reg appt reg appt 11:30 ** ** ** DM **
11:45Adv Acc
Adv Acc **
Adv Acc
Adv Acc **
Adv Acc
Adv Acc **
Adv Acc
report time
Adv Acc **
Adv Acc
Adv Acc
12:00
lunch lunch
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lunch lunch
**
lunch lunch
**
lunch lunch lunch
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lunch lunch
12:15 ** ** ** ** 12:30 ** ** ** ** 12:45 ** ** ** ** 1:00 DM reg appt DM reg appt ** reg appt reg appt reg appt reg appt ** reg appt reg appt reg appt ** DM reg appt DM DM reg appt ** reg appt reg appt reg appt 1:15 ** ** ** annual ** 1:30 DM DM ** ** ** DM DM ** 1:45 ** ** ** DM **
2:00 DMreport time DM **
report time **
report time **
report time annual DM **
report time
2:15 ** ** ** **
2:30Adv Acc
report time **
Adv Acc
report time **
Adv Acc
report time ** DM reg appt DM
Adv Acc **
Adv Acc
report time
2:45 ** ** ** annual ** 3:00 reg appt reg appt ** reg appt reg appt ** reg appt reg appt ** DM reg appt ** reg appt reg appt 3:15 ** ** ** ** 3:30 ** ** ** DM DM ** 3:45 ** ** ** annual **
4:00Adv Acc
Adv Acc **
Adv Acc
Adv Acc **
Adv Acc
Adv Acc **
Adv Acc
Adv Acc **
Adv Acc
Adv Acc
4:15 ** ** ** report time **
4:30report time
report time **
report time
report time **
report time
report time **
report time calls
report time **
report time
report time
4:45 ** ** ** ** 5:00
after hours advanced
access
**
after hours advanced
access
**
after hours advanced
access
**
after hours advanced
access
**
after hours advanced
access
5:15 ** ** ** ** 5:30 ** ** ** ** 5:45 ** ** ** ** 6:00 ** ** ** **
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RN/DNE RN/DNE RN RN/DNE RN/DNE
Reg Reg Reg
Reg
Reg Reg
Reg
Sample Joint Schedule (MD, RNx2, DNE)
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Sample Clinic Work Flow: Diabetes Days Patient Type: Ongoing DM Management
Exam Room 1 –DM Patient A: 15 minsRN:•Examinations•Results of investigations•Discuss Patient Targets/Importance•Develop or discuss goals to reach Targets•Review and discuss patient self management•Review current treatment and medications•Update recordsPhysician:•Review Results and Plan with Patient and RN•Answer Patient questions•Completes any additional assessment or treatment changes required
Exam Room 2– DM Patient B: 15 minsRN:•Examinations•Results of investigations•Discuss Patient Targets/Importance•Develop Goals to reach Targets•Review and Discuss Patient Self Management•Review Treatment and Medications•Update recordsPhysician: •Review Results and Plan with Patient and AHCP•Answer Patient questions•Completes any additional assessment or treatment changes required
Exam Room 3 – DM Patient C: 30 – 60 minsDietician/Diabetes Nurse Educator•First appointment for newly diagnosed Patient •or yearly for ongoing patient managementPhysician:•Review Results and Plan with Patient and Dietician/Diabetes Nurse Educator•Answer Patient questions•Completes any additional assessment required
Exam Room 4 –Short Visit (if required)RN :Examinations as requiredPhysician:•Short Visit for acute issues only – no long appointments or physicals
MD moves
between rooms
See Practice Guide Page 60-61See Practice Guide Page 60-61
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Patient Communication
• Critical for patients to understand they are integral part of the Diabetes Care Team
• Regular preventative visits essential
• Goals will be mutually set, progress tracked
• Communicate role of all staff in DHC and value of each team member contribution
• Role of Patient: active participation, goal setting, labs completed prior to visits, meds each visit
See Practice Guide Page 62See Practice Guide Page 62
“DIABETES DAYS” STEP 7
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Patient Communication: The Basics
• Patient centered team based care strategy to improve patient health outcomes
• Healthcare team: Patient and Family, Physician, RN, DNE, Dietitian
• Importance of regular preventative care and patient self management
• Diabetes only issues addressed
• Labs completed prior to appointment
• Patient to bring medications to Diabetes Day visits
• Setting goals, tracking outcomes against targets at each visit
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Implement Diabetes Days
• Initially may take 3 – 6 months to establish
• Start with two appointments per “day”, increase as more patients are enrolled
• Initiate process for staff and patient feedback
See Practice Guide Page 91-92See Practice Guide Page 91-92
“DIABETES DAYS” STEP 8
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Monitor Effectiveness
• Determine criteria to monitor diabetes days effectiveness
– Patient health outcomes
– Process outcomes
– Patient satisfaction
– Provider satisfaction
See Practice Guide Page 93-95See Practice Guide Page 93-95
“DIABETES DAYS” STEP 9
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Quality Improvement: PDSA
• Establish PDSA objectives and timelines
• Establish outcome targets, measures and timelines
See Practice Guide Page 90See Practice Guide Page 90
“DIABETES DAYS” STEP 10
P PLAND DOS STUDYA ACT
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Clinic Diabetes Management Dashboard
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Pathways Dashboard: Narrative Report
• Key Changes
– Describe changes made in the way you care for patients with diabetes
• PDSAs
– List two or three critical PDSAs that helped you achieve the changes above
• Impact on Outcomes
– Describe how you believe these changes impacted particular outcomes you are monitoring
• What next?
– Describe what you will be doing regarding future improvements.
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Clinic Team Regroup
Q and A
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Wrap up
• Parking lot
• Measure Effectiveness – Complete CHE Evaluation Form and hand in prior to leaving