Provider Tips and Provider Tips and ToolsetsToolsets
Rural Quality Program ConferenceRural Quality Program Conference Office of Rural Health Policy Office of Rural Health Policy
Health Resources Services Health Resources Services AdministrationAdministration
September 2, 2009September 2, 2009
Kathy Reims, MDChief Medical OfficerCSI Solutions, LLCClinical Assistant Professor, UCHSC
Eugene Maynard, MD
Rural Quality Project Participant Benson Area Medical Center
Benson, NC I do not have any relevant financial relationships to disclose
ObjectivesObjectivesProvide practical tools and tips to
improve performance on OHRP CVD measures◦General approach ◦Hypertension and Lipid control◦Integrated Smoking Cessation Toolkit
Tools to Improve Tools to Improve PerformancePerformancePatient FactorsCare Team FactorsSystem Factors
Patient FactorsPatient FactorsAwareness*Education* Commitment to Care Plan
◦Patient confidence in managing condition*
◦Side effects◦Practical considerations◦Psychosocial impacts*
Assist Patients with Care Assist Patients with Care PlansPlansSelf-Management supports* Proactive follow up*Care Team is accessibleDAP programsPay attention to medication
regimensMedication reconciliationScreen for literacy*, depression*,
substance abuse
Care Team FactorsCare Team FactorsEvidence-based care*Planned Care
◦POS prompts and reminders*Protocols
◦Trained Staff*◦Delegated work*
Outreach and proactive follow up*Expand the team: pharmacist,
promotoraOptimize the team: designated roles or
FTE*
System FactorsSystem FactorsAccess
◦Group visits*◦Email or Web-based◦Convenient, timely appointments
Continuity of care Population management*Coordination of care Effective use of technology*
Awareness: BP Control Awareness: BP Control RatesRates
Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74
National Health and Nutrition Examination Survey, Percent
II1976–80
II(Phase 1)1988–91
II(Phase 2)1991–94 1999–2000
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34
Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.
Awareness: Guidelines
Patient Education Patient Education
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/dash_brief.pdf
Education and Patient Education and Patient Reminders:Reminders:BP Wallet CardBP Wallet Card
BP Wallet Card BP Wallet Card
Education and Patient Education and Patient Reminders:Reminders:National Cholesterol Education National Cholesterol Education Program Program
http://www.nhlbi.nih.gov/health/public/heart/chol/wyntk.pdf
HTN & Lipid Patient HTN & Lipid Patient EducationEducationhttp://www.nhlbi.nih.gov/health/
index.htmhttp://www.americanheart.org/
presenter.jhtml?identifier=1516http://familydoctor.org/online/
famdocen/home/common/heartdisease/risk/092.html
http://www.webmd.com/heart-disease/guide/heart-disease-prevent
Patient Self Management Patient Self Management
http://www.ama-assn.org/ama1/pub/upload/mm/433/phys_resource_guide.pdf
BUBBLE DIAGRAM
If you have diabetes, here are some things many individuals try to do for their health. Would you like to set any goals concerning any of them?
Blood glucose monitoring
Taking medications to help control blood sugar
Losing weight
Daily foot care
Depression
Smoking
Skin careTaking insulin
Diet
Goal Setting ToolsGoal Setting Tools
www.healthdisparities.net
Plan the Visit: FlowsheetPlan the Visit: Flowsheet
•Organize key information•POS Reminders•Share the work•Huddles
Plan the Visit: Electronic Flow Plan the Visit: Electronic Flow SheetSheet
Delegated Work: Standing Delegated Work: Standing OrdersOrders
Standing OrdersStanding Orders
Evidence-based care:Evidence-based care:JNC VII Reference CardJNC VII Reference Card
JNC VII Reference Card, JNC VII Reference Card, side 2side 2
Evidenced-based CareEvidenced-based CareATP III Palm Interactive Guideline
Tool http://hp2010.nhlbihin.net/atpiii/atp3palm.htm
CVD Risk Calculator http://hp2010.nhlbihin.net/atpiii/calculator.asp
ATP III At-a-Glance Desk Reference http://www.nhlbi.nih.gov/guidelines/cholesterol/dskref.htm
Staff Training: Staff Training: Lunch and LearnsLunch and Learns
JNC VII Slide Set http://hp2010.nhlbihin.net/nhbpep_slds/menu.htm
AAFP Ask and Act Program http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/toolkit.html
ATP III Slide Set http://hp2010.nhlbihin.net/ncep_slds/menu.htm
Staff Training: Staff Training: Unified Health Communication Unified Health Communication 101: Addressing Health 101: Addressing Health Literacy, Cultural Competency, Literacy, Cultural Competency, and Limited English Proficiencyand Limited English Proficiency
Improve your patient communication skills
Increase your awareness and knowledge of the three main factors that affect your communication with patients
Implement patient-centered communication practices
Optimize your Team: Optimize your Team: Case Manager RoleCase Manager Role
Plans and integrates care for people with diabetes and other chronic diseases
Liaison with other community resources Provide good documentation in patient record, all
patient contact attempts, and all telephone and written communication with patients
Log in binder the appointment date/time/location; check off if the letter was sent, phone call made, films requested
Reviews charts for what is needed (with help of other team members)
Coordinate with other team members Help with referrals and links to community
resources as needed Helps counsel around self-management goals
Optimize your Team: Optimize your Team: Outreach Log Outreach Log
Manage your Population: use Manage your Population: use your datayour data
Health Literacy Screen Health Literacy Screen
Newest Vital Sign http://www.pfizerhealthliteracy.com/pdf/FH_vitalsigns_040605.pdf
Depression ScreeningDepression Screening
http://www.commonwealthfund.org/usr_doc/PHQ2.pdf
PHQ -9 http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/
Why Process Map?Why Process Map?Creates a visual snapshot of the
current flow of the process Allows you to “see” opportunities
for improvementFacilitates identification of process
variations, duplications and wasteAdds a discipline to improvement Allows involvement of all key
players
Patient given order for fasting lipids
RN enters patient name and date into log (in lab)
Returned results are processed by lab staff and results entered into log
Lab gives results to PCP PCP orders follow up visit
Lipids at target?
Results notification mailed
Yes
No
RN schedules appointment
But what about….?
Patient given order for fasting lipids
RN enters patient name and date into log (in lab)
Lab gives results to PCP. PCP orders follow up visit.
Lipids at target?
Results notification mailed
Yes
No
Log checked q 2 weeks for follow up phone calls needed
Returned results are processed by lab staff and results entered into log
RN schedules appointment and places reminder in tickler file
Front desk checks tickler and reports no-show appointment to RN
Gaps addressed:
1. Follow up for Lipid results that have not been returned
2. Ability to track if patient received timely follow up on elevated lipids.
Smoking Cessation ToolkitSmoking Cessation ToolkitAn Integrated Approach