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Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.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