Transcript Assistive Infrastructure

Organization of Diabetes Care
Alireza Esteghamati,MD
Professor of Endocrinology and Metabolism
Tehran University of Medical Sciences
The Chronic Care Model
Improving Care for People Living
with diabetes
Objectives

Define the problem in today’s health care systems

State 5 useful aims to keep in mind while seeking to
improve care

Describe the development of the Chronic Care Model
(CCM)

List the 6 components of the CCM
Key Points
1. Diabetes is a chronic disease that requires proactive,
planned and population-based care
2. It takes a team. Diabetes care should involve a
interdisciplinary team working within the chronic care
model
3. Technology (telehealth, reminder systems, EMRs, etc.)
can be used to improve care
A New Health system for the 21st Century

“The current care systems can not do the
job.”

“Trying harder will not work.”

“Changing care systems will.”
Six Aims for Improving Health Systems

Safe: avoids injuries (no needless deaths, accidents, or injuries)

Effective: relies on latest scientific knowledge

Patient-centered: responsive to patient needs, values, and
preferences

Timely: avoids delays

Efficient: avoids waste

Equitable: quality unrelated to
personal characteristics (everyone, everywhere can receive )
Implications for How to Change Practice
7

If the problem is the system, and not the
individual “bad apples,” then the focus for
practice improvement needs to shift.

Need to make the right thing to do the easy
thing to do.
Usual Chronic Illness Care

15 minute visit, poorly
organized

Symptoms and lab results
focus of discussion and
exam, not preventive
assessment

Patient’s attempts to discuss
difficulties in living with the
condition are discouraged
Usual Chronic Illness Care

Focus is on physician’s
treatment, not patient’s role in
management.

Treatment plan is limited to
prescription refill and
encouragement to make
appointment if not feeling well

Visit ends with physician rifling
through drawers looking for a
pamphlet
Rationale for Population Based Care
The current care delivery system was design for acute
episodic care and does a poor job for chronic and preventive
care. Until there is fundamental system change we will not
do much better than the following:

Evidence based care given only 55% of time
– (NEJM. 2003;348(26):2635-2645)

Blood sugar is controlled in only 37% of patients with
diabetes
– (JAMA. 2004:291(3):335-342)

Blood Pressure is controlled in only 35% of patients with
hypertension
– (Ann Intern Med. 2006;145(3):165-175)
“Every system is perfectly designed
to get the results it gets”
Usual Care Model
Health System
Health Care Organization
Community
Resources and Policies
•Leadership concerned about the bottom line
•Incentives favor more frequent, shorter visits
•No organized QI
Clinical
•No links with community
Self-Management
agencies or resources
Support
No systematic
approach; didactic
in orientation
Uninformed,
Passive
Patient
Delivery
System Design
Reliance on short,
unplanned visits
Frustrating
Problem-Centered
Interactions
Decision Support
No agreement on
good care;
traditional
referrals
Information Systems
Don’t know pts or
what they need
Unprepared
Practice Team
Sub-optimal
Functional and Clinical Outcomes
Reality: Guidelines are NOT Followed
Care gap between diabetes management
guidelines and real-life practice
Real
Life
Ideal
Practice
Organizational and evidence-based
approach to treating chronic diseases
Chronic Care for a Chronic Disease
Acute and reactive
Proactive, planned, and population-based
The Chronic Care Model
To Change Outcomes Requires
Fundamental Practice Change
Reviews of interventions in several conditions show
that effective practice changes are similar across
conditions.
Integrated changes with components directed at:
•Influencing physician behavior
•
Better use of non-physician team members
•
Enhancements to information systems
•
Planned encounters
•
Modern self-management support
•
Care management for high risk patients
15
Chronic Care Model
Informed, Activated
Patient
Supportive,
Integrated
Community
Productive Interactions
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Satisfaction  Clinical Measures  Cost  External Review Measures
Themes in the Chronic Care Model

Evidence-based
– Valuing excellence (and evidence) over autonomy

Patient-centered
– Each patient is the only patient

Population-based
The Chronic Care Model
Community
Resources and Policies
Family Education &
Self- Management
Support
Health System
Health Care Organization
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Informed,
Activated Patient
Supportive,
Integrated
Community
Productive Interactions
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Elements of the Chronic Care Model
1. Delivery Systems
Design: The Team
2. Self-Management
Support
3. Decision
Support
4. Clinical
Information
Systems
5. Community
6. Health Systems
Chronic Care Model
Community
Resources and Policies
HealthHealth
System
System
Health Care Organization
Family Education &
Self-Management
Support
Delivery
System
Design
Clinical
Decision
Information
Support
Systems
• Specific goals in organizations strategic/business plan
• Senior leader support
• Organization adopts performance improvement model
•Provider incentives support organizational goals
Health Care Organization

Visibly support improvement at all levels, starting with
senior leaders.

Promote effective improvement strategies aimed at
comprehensive system change.

Encourage open and systematic handling of problems.

Provide incentives based on quality of care.

Develop agreements for care coordination.
22
Chronic Care Model
Community
Resources and
Policies
Family Education &
Self- Management
Support
Health System
Health Care Organization
Delivery
System
Design
Decision
Support
• Evidence-based guidelines
• Provider education
• Referrals and specialist expertise
• Guidelines for patients
Clinical
Information
Systems
Decision Support

Embed evidence-based guidelines into daily
clinical practice.

Integrate specialist expertise and primary care.

Use proven provider education methods.

Share guidelines and information with patients.
24
Chronic Care Model
Community
Resources and Policies
Family Education &
Self-Management
Support
Health System
Health Care Organization
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
• Emphasize patient/parent active role
•Collaborative care planning/problem solving
• Ongoing educational process
• Connections between family/patient and social support
• Standardized assessments of self-management
• Written management plan with goal setting
Self-Management Support

Formerly known as Diabetes Education

Shift from didactic diabetes education to a
patient-empowering motivational approach
Problem-solving and goal-setting
Self-Management Support

Emphasize the patient's central role.

Use effective self-management support strategies
that include:
assessment
goal-setting
action planning
problem-solving
follow-up.

Organize resources to provide support.
28
Chronic Care Model
Community
Resources and Policies
Family Education &
Self-Management
Support
Health System
Health Care Organization
Delivery
System
Design
Decision
Support
• Team roles and tasks (practice team, school, parents)
• Care based on accepted guidelines
• Primary care team assures continuity
• Regular follow-up care
Clinical
Information
Systems
Delivery System Design

Define roles and distribute tasks among team members.

Use planned interactions to support evidence-based care.

Provide clinical case management services for high risk
patients.

Ensure regular follow-up.

Give care that patients understand and that fits their culture.
30
Delivery Systems Design: The Team

Expertise of nurses, dietitians, pharmacists, and
psychological support

Team working with primary care physicians supported by
specialists

Disease management model that uses patient education,
coaching, treatment adjustment, monitoring, care coordination
Your diabetes care team may include a
…….
Local diabetes education centre
Optometrist or
ophthalmologist
Kidney
specialist
Your
doctor
Dentist
Physical activity
specialist
Your
nurse
You
YOU
Your
Family and friends pharmacist
Mental Health Professional
Heart
specialist
Your
dietitian
Foot care specialist
Other people you know who have diabetes
Chronic Care Model
Community
Resources and Policies
Family Education &
Self-Management
Support
Health System
Health Care Organization
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
• Registry to track clinically useful and timely information
• Registry reports/data for feedback
• Care reminders
• Assure timely planned follow-up
• Identification/proactive care of relevant patient subgroups
• Individual patient care planning
Chronic Care Model
Community
Resources and Policies
Health System
Health Care Organization
Family Education & Delivery
Self-Management
System
Support
Design
• Partnerships
• Key school contact identified
• Input
• Educational services available
Decision
Support
Clinical
Information
Systems
Community Resources and Policies

Encourage patients to participate in effective
programs.

Form partnerships with community
organizations to support or develop programs.

Advocate for policies to improve care.
36
Essential Element of Good Chronic
Illness Care
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
39
What characterizes an “informed, activated
patient”?
Informed,
Activated
Patient
They have the motivation, information, skills,
and confidence necessary to
effectively make decisions about
their health and manage it.
40
Informed, Activated, Patient
 Patient understands the disease process and realizes
his/her role as the daily self-manager
 Family and caregivers are engaged in the patient’s selfmanagement
 The provider is viewed as a guide on the side, not the
sage on the stage!
What characterizes a “prepared”
practice team?
Prepared
Practice
Team
At the time of the interaction they have
the patient information, decision support, and
resources necessary to deliver
high-quality care.
42
Prepared Practice Team
Has the:
Patient information
Decision support
People
Equipment
Time
To deliver:
Evidence-based clinical management
Self-management support
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
• Assessment of self-management skills and
confidence as well as clinical status.
• Tailoring of clinical management by stepped
protocol.
• Collaborative goal-setting and problem-solving
resulting in a shared care plan.
• Active, sustained follow-up.
44
Self-Management Education
Self-Management Education (SME)
A systematic intervention that involves
active patient participation
in self-monitoring and/or
decision-making
Key Points
1. Diabetes self-management education (SME)
improves health parameters
2. SME should teach behaviours as well as knowledge
and technical/problem-solving skills
3. SME should be patient-centred, tailored to the
individual, use a variety of teaching methods and be
regularly reinforced
Knowledge is Power

Empowering patients through selfmanagement education improves:
–
–
–
–
A1C
Quality of life
Weight loss
Cardiovascular fitness
Basic Knowledge and Skills







Monitoring health parameters (including SMBG])
Healthy eating
Physical activity
Pharmacotherapy and medication adjustment
Hypo-/hyperglycemia prevention/management
Prevention and surveillance of complications
Problem identification and solving
Not Just Knowledge: Work on Behavior!
Cognitive-behavioral interventions
improve self-management and metabolic
outcomes
 They may involve:

–
–
–
–
–
–
Cognitive re-structuring
Problem-solving
Cognitive-behavioural therapy (CBT)
Stress management
Goal setting
Relaxation
How should SME be delivered?
Interdisciplinary team
and/or peer-education
Personal contact with
healthcare workers
Combination of group
and individual sessions
Combination of didactic
and interactive
Steps
to Success
Evaluate and
support long-term
self-management
Implement a realistic plan
for skills training
Collaborate on decisions and
goals for action
Make informed consideration of
self-care options
Assess & identify personal self-care
needs
Self-Management Support
This section contains:



5A’s Self-Management support forms
Goal Setting form
Patient education handouts
Using the 5 “A’s” With Diabetes





Assess
Advise
Agree
Assist
Arrange
Using the 5 “A’s” With Diabetes
Assess: What does the patient know about
diabetes. Are they ready to learn? What are
their values and culture?

Advise: Prioritize an individual plan for your
patient in partnership with them.

Agree: Start with goals patient has identified
and assist them in creating ways to meet their
goals.
Using the 5 “A’s” With Diabetes

Assist: Develop a long-term plan for the
patients which is agreed upon by both patient
and provider. Assist patient in identifying
barriers to success.

Arrange: Continue to follow-up and assist
patient
Patient Name: ______________________
Date:___________
Self-Management Education – Diabetes
Assess patients knowledge, beliefs, behaviors, and clinical data.
Does patient have the desire to change behavior?

Yes

No
Advise about health risks and benefits of change - consider health literacy.
Topics Discussed:
 Diet
 HgA1c
 Eye Care
 Foot care
 Insulin
 Home glucose monitoring
 ADA standards of care
 Hypertension, CV disease
 Hyperlipidemia
 Medication compliance
 Kidney disease
 Exercise
 Aspirin
 Hypoglycemia
 Other
Agree on a goal based on patient priorities.
5A’s Self
Management
Support Form
*Patient Goal: ____________________________________________
Specific for
Diabetes
Assist To develop a person action plan.
1. Specific behavior changes
2. Identify barriers (? depression)
3. Options to address barriers
4. Follow up plan - When : ____________
How:  Phone  Other ___________
Educator Signature:_______________________
Arrange: to contact the patient between visits.
*Follow-up Contact:
Completed on - Date:___________
1. Results of Behavior changes
2. Barriers encountered
3. Options to address barriers
4. Follow up plan - When : ____________
How:  Phone  Other _________
Follow-up Signature:_____________________
*Required to bill Wellmark (Individual visit - S9445)
Patient Education Tools

Help patients
prepare for,
and know what
to expect from,
a diabetes visit
If you have DIABETES, here are some things you
can talk about with your health care provider
Choose to talk about changing any of these and add
other concerns in the blank circles.
Diabetes
Blood Pressure
monitoring
Taking medications
to help control
blood pressure
Self Management
Goal Setting Form
Skin care
Avoiding
strokes
or heart
disease
Diet
Depression
Losing weight
Daily foot care
Smoking

Diabetic Patient Goals and Progress
HOW WELL HAVE YOU MET YOUR DIABETIC
GOALS SINCE YOUR LAST VISIT?
1=Not Met, 2= Attempted to meet, 3=Somewhat Met/Some Progress,
4=Almost Met, 5=Completely Met
Goal
Start Date:
Visit
Date
Visit
Date
Visit
Date
Goal 1:
I will exercise (walk) 30 minutes _____ days
per week. If I notice chest pain, shortness of
breath or chest tightness, I will seek medical
attention.
Goal 2:
I will check my feet daily. If I notice a sore
or irritation I will seek medical attention. I
will visit the Podiatrist yearly, or as
instructed.
Goal 3:
I will follow my diabetic and low fat diet to
reduce my blood sugar and cholesterol.
Goal 4:
I will try to obtain my ideal body weight. I
will lose _____ pounds by my next office
visit.
Goal 5:
I will stop smoking.
Goal 6:
I will check my blood sugar as instructed and
will call if the results are consistently below
70 or above 150. I will bring my blood sugar
log book to every visit with my provider.
Goal 7:
I will talk about how I feel about having
diabetes to family, friends and/or a chaplain.
I will attend a Diabetes Support Group.
How can we help you meet your goals?
Visit
Date
Visit
Date
Visit
Date
Visit
Date
Visit
Date
Mercy Clinics, Inc.
Diabetes Education
--- Blood Sugar Goals
Keep your blood sugar under control to prevent damage to many parts
of the body, such as the heart, blood vessels, eyes and kidneys
For most people, good blood sugar levels are
What should my
blood sugar
numbers be ?
On waking (before breakfast)
Before meals
2 hours after meals
At bedtime
80 to 120
80 to 120
180 or less
100 to 140
How can I find out what my average
blood sugar is?
The hemoglobin A-1-c (HE-moh-glow-bin A-1-c) blood test shows the average
amount of sugar in your blood during the past 3 months. Have this test done at
least twice a year.
A test result of more than 7 percent is too high. At more than 7 percent you
need a change in your diabetes plan. Your doctor can help you decide what part
of your plan to change. You may need to change your meal plan, your diabetes
medicines, or your exercise plan.
Mark your
hemoglobin A-1-c
on this chart.
Keep your hemoglobin A-1-c below 7 percent
Patient
Education
Handout
Patient
Education
Handout
Mercy Clinics, Inc.
Diabetes Education
--- High Blood Pressure
Diabetes and high blood
pressure often go hand-in-hand.
If you have heart, eye, or
kidney problems from diabetes,
high blood pressure can make
them worse.
You will see your blood
pressure written with two
numbers separated by a slash.
For example: 120/70
Keep your first number below
130 and your second number
below 85.
High Pressure can damage your heart,
eyes, kidneys, and brain.
To lower my blood pressure I will:
Lose weight
Eat more fruits and vegetables
Eat less salt and high-sodium foods
such as:
o canned soups
o luncheon meats
o salty snack foods
o fast foods
Drink less alcohol
Walk for one-half hour on most days
Keep your blood pressure below 130/85
You may need to take blood pressure
medicine. An ACE inhibitor is the best
type because it can slow down kidney
damage by keeping the kidneys from
losing too much protein. Take your
medicine every day unless your doctor
tells you to stop.
Patient
Education
Handout
Mercy Clinics, Inc.
Diabetes Education
--- Diabetes and Diet
How Much Should You Weigh?
All foods can raise you blood sugar
The more you eat – the higher your sugar
Height
The most important diet advise is
 Don’t over-eat
If you are over-weight you should lose weight
The only ways to lose weight are:
 Eat less – smaller portions
 Exercise more – such as walking
If you take diabetes medicine you should not
skip meals – it can cause low blood sugar
5-0
5-1
5-2
5-3
5-4
5-5
5-6
5-7
5-8
5-9
5-10
5-11
6-0
Weight
Women
Men
137
140
143
147
151
155
159
163
167
170
173
176
179
144
147
150
153
156
160
164
168
172
176
180
184
188
Eat More:
 Vegetables & Fruits
-Five or more servings a day
 Fish and Chicken (without the skin)
Eat Less:
 Starches such as potatoes, rice, pasta, bread,
corn
 Milk and Yogurt
-Use Skim Milk
 Red Meat, Eggs, Cheese
Avoid:
 Fats – if any use olive or canola oil
 Sweats - no pop except diet
 Alcohol - never more than 2 drinks a day





Eat a wide variety of foods
Avoid salt
Don’t eat fried foods
Don’t add butter, sauces or dressings
Be careful in restaurants
-portions are too big
-there are too many fats and sauces
Patient
Education
Handout
Mercy Clinics, Inc.
Diabetes Education
--- How to use Insulin
The difference in insulin is the time that it is working after you inject it.
 Onset of Action: This is how long it takes for the insulin to start
lowering your blood sugar.
 Peak Action: This is the time after injection when the insulin will lower
your sugar the most.
 Duration of Action: This is how long it takes for the insulin to wear off
and no longer work to lower you blood sugar.
Type of
Insulin
Humalog
Regular
NPH
Lantus
Class of
Insulin
Short Acting
Short Acting
Intermediate
Long Acting
Onset of
Action
15 Min.
30 Min.
3 Hrs.
1 Hr.
Peak
Action
1 Hr.
2-3 Hrs.
6-8 Hrs.
None
Duration
of Action
3 Hrs.
6 Hrs.
18 Hrs
24 Hrs.
 The best way to use Insulin is to prevent your sugar from ever going too
high rather than lowering a sugar once it is too high.
 When you inject insulin you are trying to prevent your sugar from going
too high after your next meal or future meals.
The following table tells you what insulin to adjust if your sugars have been
out of control in the past few days.
Humalog
Regular
NPH
Lantus
Before
Breakfast
Before
Lunch
-
Breakfast H-log
Breakfast Reg
-
Bedtime NPH
Lantus
Before
Supper
Before
Bedtime
Lunch H-log Supper H-log
Lunch Reg
Supper Reg
Breakfast NPH
-
For example if your lunch time sugars have been:
 Too high - you should increase you breakfast Humalog (or Regular)
 Too low - you should decrease your breakfast Humalog (or Regular)
Patient
Education
Handout
The Chronic Care Model (CCM) Saves Lives
The CCM improves:
1.
2.
3.
4.
5.
A1C
LDL-C
Use of statins
Drug and hospital expenditures
Overall mortality
Key Changes for Diabetes
Self-Management
Decision Support
Use diabetes selfmanagement tools
that are based on
evidence of
effectiveness
Embed evidencebased guidelines in
the care delivery
system.
Set and document
self-management
goals collaboratively
with patients
Establish linkages
with key specialists
to assure that
primary care
physicians have
access to expert
support.
Train physicians and
other key staff on
how to help patients
with selfmanagement goals.
Provide skill-oriented
interactive training
programs for all staff
in support of chronic
illness improve-ment.
Follow up and
monitor selfmanagement goals.
Educate patients
about guidelines.
Use group visits to
support selfmanagement
Tap community
resources to achieve
self-management
goals.
Clinical
Information
System
Establish a registry.
Develop processes
for use of the
registry, including
designating
personnel for data
entry, assuring data
integrity, and registry
maintenance.
Use the registry to
generate reminders
and care-planning
tools for individual
patients.
Use the registry to
provide feedback to
care team and
leaders.
Delivery System
Design
Organization of
Health Care
Community
Use the registry to
review care and plan
visits.
Make improving
chronic care a part of
the organization’s
vision, mission,
goals, performance
improvement and
business plans.
Establish linkages
with organizations to
develop support
programs and
policies.
Assign roles, duties,
and tasks for planned
visits to a
multidisciplinary care
team. Use crosstraining to expand
staff capability.
Make sure senior
leaders and staff
visibly support and
promote the effort to
improve chronic care.
Link to community
resources for
defrayed medication
costs, education, and
materials.
Use planned visits in
individual and group
settings
Make sure senior
leaders actively
support the
improvement effort
by removing barriers
and providing
necessary resources.
Encourage
participation in
community education
classes and support
groups.
Make designated
staff responsible for
follow-up by various
methods, including
outreach workers,
telephone calls, and
home visits.
Assign day-to-day
leadership for
continued clinical
improvement.
Raise community
awareness through
networking, outreach,
and education.
Use promotoras and
community health
worker programs for
outreach.
Integrate
Collaborative Models
into the Quality
Improvement
program.
Provide a list of
community resources
to patients, families,
and staff.