Transcript Slide 1

Raising the Bar in Chronic Disease
Management
A Diabetes Program in Family Practice
Anne Barber RN(EC) MScN
Michele MacDonald Werstuck, RD MSc CDE
Lisa McCarthy, RPh BScPhm Pharm D
Inge Schabort, MB ChB CCFP
Disclosure
• The presenters perceive no conflict of interest
with this presentation.
• Slides will be available at:
www.stonechurchclinic.ca
Objectives
• To help you...
– Identify your patients with diabetes
– Start a diabetes clinic /diabetes day
– Build a diabetes team
– Experiment with group medical visits
– Access resources to get you started
Who are we?
• Provide primary care for nearly 30 000
patients in Hamilton and surrounding area
– 2 clinical teaching units affiliated with
McMaster University and Hamilton Health
Sciences
Who are we?
Stonechurch
MFP
Physicians
16 (12.7 FTE)
13 (7.5 FTE)
Family Medicine
Residents
32 (10-12 full-time at
any one time)
34 (12-13 at any one
time)
RN(EC)s
4 (3.5 FTE )
4 (4.0 FTE)
Dietitians
2 (1.0 FTE)
1 (0.8 FTE)
Mental Health Therapists
3 (2.6 FTE)
3 (2.4 FTE)
Clinical Pharmacists
2 (0.8 FTE)
2 (0.8 FTE)
Consultants
Palliative Care, Psychiatry, Geriatrics, Internal
Medicine
Starting a Diabetes Program
• Step 1: Identify your patients with
diabetes
– Do you currently track your patients with
diabetes (paper, EMR)?
– Is your registry accurate?
– What criteria did you use to create your
registry?
Step 1: Identifying Patients with
Diabetes
• Lessons Learned:
– Tidy up data
– Team meetings to reinforce consistent data
entry (EMR), documentation
– Those with confirmed diabetes enter into your
registry
How do you screen for patients
with diabetes?
• Periodic health exam
• Patients with other chronic diseases
• Maximize screening during opportunistic
encounters
• Whatever your strategy, think
sustainability
Step 2: Maximize your
Interprofessional Health Team
1. Determine which practitioners are
available.
2. Decide essential components for patient
care.
3. Discuss your roles.
Bottom Line
“The vast majority of people don’t need glitzy
miracles; we need sound, evidence-based,
timely, respectful and well communicated
primary health care from a team dedicated to
getting it right.”
Steven Lewis, a Saskatoon-based health policy
consultant and part-time academic
Interprofessional Diabetes Team
The Need for Teamwork
• Consider:
– Number of patients with diabetes
– Number of visits per patient per year
– Can be overwhelming to manage alone
MYTH:
Stress has no effect on diabetes.
FACT:
Stress can increase your blood sugar and throw
your diabetes out of control. Ask for help with
stress management.
Step 3: A Diabetes Clinic (Day)
Should your practice have one?
1. What resources are available to your
patients with diabetes right now?
2. What Diabetes Education Clinic (DEC)
services exist?
3. Do you have providers with a keen
interest in diabetes management?
Diabetes Clinic Cont`d
• Who will you service?
– Determined by:
• Patient needs
• Skills of your team (e.g., comfort with managing
insulin)
• What resources already exist within the community
Preparing for Your Diabetes
Clinic
1. Referral system
2. Triaging system
3. Team meetings
– e.g., case review, team building
4. Debriefing
Time for Team Education
Offering a Diabetes Clinic:
Equipment
• Insuiln (consider in-house supply)
• Equipment
– Glucometers, one-time use lancets, ketone
tests (blood and urine)
• Hypoglycemic Emergency Kit
– Glucose tablets, juice boxes, injectable
glucagon, instructions about how to use kit
Offering a Diabetes Clinic:
Resources
• If it exists, use it (with • HHS patient education
library
permission, of
course)!
• www.stonechurchclinic.ca
– Goal setting sheet
• Don`t forget team
– Diabetes Clinic Follow-Up
education, training
Visit (list of expectations,
with resources
what to bring)
– Starting with Bedtime
Insulin
– Diabetes Passport
Step 4: Using a Diabetes
Flowsheet
• A management MUST!
• Try using different flowsheets to find your
favourite
• If using EMR
– Link flowsheet with disease registry and
incoming labs
Step 5: Maximize Use of
Templates
• For example:
– Stamps for documentation (electronic or
paper)
– Frequently used patient education materials
• Goal setting, action planning sheets
• Hypoglycemia
• Starting insulin therapy
Diabetes Group Medical Visits
What It Looked Like
• Introductory Session
– (planned 20 minutes, really 60 min!)
– Evolved into discussion with patients
• Patient sharing of experiences
– (planned 20-30 minutes, could have been
longer)
What It Looked Like Cont’d
• ‘The Circuit’
– Planned 30 min, Really 45-60 min
– Stations for: vitals, foot exam, doctor check-in
– Floating IHPs to do goal setting while awaiting
the circuit
• Group Wrap-Up
– Planned 10 minutes, Really cut short!
How We Did It…
1) Find and prepare patients
2) Determine roles, logistics
3) Preparation!!!
4) Deliver
5) Document and Debrief
6) Plan for the next one
Finding Patients
• Identified potential patients through EMR
– Assumes disease registry or some other
mechanisms to identify
• Physician vetted list
• RPN reached out to recruit
• Reminder calls day before
Preparing Patients
• Persuasive RPN 
– Do labs week before, bring all medications,
supplements etc., blood glucose records, 3
day food diary, glucometer, told vitals and feet
would be examined, consent and
confidentiality required
– Biggest Draw: extended visit with THEIR
family doc!
Preparing Ourselves
• Define roles
– IMPACT BC Guide
• Logistics
– room set up, finding time (evening?), booking
space and equipment
Preparing Ourselves Cont`d
• Planning the Visit (many team meetings)
– Presentation
• Intro, what to expect from group visit and for future
care, patient sharing of experiences, goal setting
– Detailed chart review,
• Prepare labs, flowsheet for physician
– (most time consuming)
What We Learned
• Minimum 15-20 patients registered
• Patient packages helped to speed up
process
• Factor in preparation and documentation
time
• Patients Loved this Experience!
Group Introductory Visits
• Building on prepared patient concept
• Initial session offered to patients referred
to DM clinic
– Introductory diabetes education
– How to prepare for follow-up visits
• What to expect
• What to bring
Resources
• Visit our website
– www.stonechurchclinic.
ca
• Hamilton Health Sciences
Patient Education Library
– www.hamiltonhealthsciences
.ca
• Canadian Diabetes
Association
• The Diabetes Food Guide
– www.diabetes.ca
– www.centretown.chc.org
• Dietitians of Canada
– www.dietitians.ca
Thank you!
Slides will be available at:
www.stonechurchclinic.ca
Contact Information:
[email protected]
[email protected]
[email protected]