Transcript Delivery Design RWJ Disparities Diabetes Project

Delivery Design
“an improvement model of diabetes care”
a project funded by the Robert Wood Johnson Foundation
East Carolina University/Bertie Memorial Hospital
East Carolina Health-Bertie All-County Health Services
Paul Bray, MA., Skip Cummings, Pharm.D., Jolynn Harrell, RN
Keys to Delivery Design

Education with coaching (E-C) is the primary tool used to achieve patient self-
management

E-C is delivered by an advanced skilled non-physician clinical staff

E-C is delivered at the time of the (primary care provider) PCP visit

The physician’s and (Educator/coach) EC form a care team

The physician’s leadership is very important to the team’s success

Nurses and front desk support staff play important and expanded roles

There are 6 Steps to the delivery design; 4 steps PCP visit redesigned and 2
steps education-coaching
Step 1: Monthly QI (Quality
Improvement) Team Meetings
Team reviews 3-5 evidence-based clinic
panel outcome indicators including A1C &
BP,
 Team initiates corrective PDSA (Plan, Do,
Study, Act) cycles
 Team reports outcomes quarterly to
board of directors, or governing body

Example of chart used in QI Meetings
% DM Patients with A1c < 7 at Cashie Clinic
70%
60%
50%
40%
Goal % = >40%
30%
% Patients =<7
20%
10%
0%
Apr. 09
May 09
Jun.09
Jul.09
Aug.09
Sep.09
Oct 09
Nov.09
Dec. 09
200
264
273
204
276
267
213
214
216
Clinical Measures Reviewed in QI Meetings
NCQA= National Committee
For Quality Assurance
Targets: stretch goals for practices to
work toward;
-benchmark goals = NCQA Quality
Compass
Diabetes
Patient Count
HbA1C Management: Poor Control
greater than 9%
Phase
I
N/A
< 5%
Blood Pressure Management : <130/80
LDL Cholesterol Management: <100
mg/dl
> 70%
Diabetic Eye Exam
> 80%
Medical Attention for Nephropathy
> 90%
Influenza Vaccination
> 75%
Aspirin for DM patients over 40
> 85%
Lipid Test Documentation
> 90%
HbA1C Documentation
> 90%
Statin for DM patients over 40
> 70%
Tobacco Use Assessment
> 80%
Tobacco Cessation Intervention
> 80%
> 70%
Step 2: Nurse schedules all
patients through standing orders
for E-C & Labs

1.
2.
3.
4.
5.
6.
7.
Standing Orders
E-C with initial Dx of DM
E-C at minimum every 12 months
E-C visit asap for A1c >8
A1c q 3 months
Eye exam report every12 months
Lipid panel q 12 months
Shoes off every provider visit
•Nurse scheduling of education based on
clinic calendar
1. Same day if EC is on-site
2. Schedule EC for same day if follow-up PC visit is within 30 days
3. If follow-up is not within 30 days, schedule a brief PC visit and
EC same day
4. Empowerment of nurse to expedite urgent EC visits (A1c>8.0,
TRG >300, BP> 150/90, BS>200, open wound, or combination)
•Nurse linking EC, PCP & Doctor
1. Coordinates PCP introduction of EC to patient
2. Coordinates PCP brief visit to E-C session
3. Coordinates E-C during exam room waiting times
Step 3: Support staff scheduling
follow up and tracking

1.
2.
3.
4.
Follow-up appointments scheduled as
directed by PCP or EC
New diagnosis, 3-4 visits focused on key self-management
objectives
Follow-up visit scheduled for key learning objectives (i.e. glucose
testing, insulin management and bs goals)
New start insulin/medication or changes in insulin/medication
dose follow up within 2 weeks
Visits follow-up <30 days apart with a1c > 8
•Support Staff ( front desk, etc.) calls
and reminds all patients one day before
visits
1. Support staff calls and re-schedules all no-shows
2. EC calls patient after two no-shows
• Educator-coach empowered to reschedule
Step 4: Team consultations for most
patients






Hall-way brief case conferences
Brief visit by PCP in education
Brief visit by EC in exam rooms
Physician will ask “what is the clinical goal & SM
goal?”
Any team member is encouraged to schedule
case conference for difficult or puzzling patient at
monthly QI meeting
Educator-coach empowered to recommend
medication-insulin (depending on skill)
Step 5: Focused 1st E-C Visit
1.
2.
3.
4.
5.
6.
Use short intake summary questionnaire form
Chart consulted: confirm diagnosis, medications, labs, A1C, consult
progress notes
Seek quick understanding of issues & barriers; clarify why a
medication may not be working, determine patient’s knowledge
base, literacy, length of diabetes, ability to test blood sugars
Clarify blood sugar goals, basic nutrition knowledge, basic survival
skill knowledge
Key inquiry: what did you eat in last 24 hours, how did it affect
blood sugars?
Check office meter against patient’s meter: Do they have a
glucometer and are they competent in its use, are supplies
affordable, do they understand how to use results?
Step 5: 1st Visit (con’t)
7. Standard 1st visit self-management goal:

Check blood sugars as prescribed, return to next scheduled DM visit
with log and meter;

Begin to understand how portions of carbohydrates and activity impact
bs results.
Always have return visit in mind. Proceed to check-out, for
scheduling of next appointment --or add E-C visit to next physician
appointment.
8. Encourage next visit to be with care-partner
9.
At end of first visit: Patient should believe they can have control
over their diabetes and they should have some definition of blood
glucose – and how numbers impact health
10. Final words to patient ALWAYS, “what is your diabetes goal
today?”

Step 5: 1st visit (con’t)
11. Seek out physician for 2 minute hall-way consultation
12. Provide “introduction to diabetes” hand-out, provide score sheet
to record bs
Information gathered in the 1st visit is entered into EMR forms. These
forms can then report the progress a patient is making in diabetes
management both to the patient and the health care team. The
following two screen shot slides are reproductions of the clinic’s
EMR diabetes forms (in Centricity EMR).
Step 6: Follow-up 2nd to 4th to
ongoing visits
At least monthly visit until blood sugars
stable
 Prioritize key ADA (American Diabetes
Association) curriculum issues that are
preventing diabetes management
 Order of modules – based on intake
assessment – most problematic or crucial
to least problematic.

Step 6: 2nd visit and on (con’t)

1.
2.
3.
4.
5.
6.
7.
8.
9.
Work towards education in each ADA
curriculum module
Disease of DM, A1C, BS goals, Basic meal planning
Nutrition and Carbohydrate Counting
Nutrition and Heart Disease
Weight loss
Exercise
Dealing with diabetes, living with life style changes, psychological
impact
Self management and complications of diabetes
Medications and monitoring
Problem Solving
Step 6: 2nd visit and on (con’t)
End each session with self-management goal
(SMG), begin each session with review of
SMG, review of blood sugars, challenges
faced in self management.
 Implement Motivational Interviewing model
to enable self-confidence in ability to make
healthy change.
 Screen for Depression
 Problem solve Eye Exam

Step 6: 2nd visit and on (con’t)
The following PDF files detail the diabetes
curriculum used by the EC
http://nc-e-care.com/Teaching_points_Overview_Class.pdf
http://nc-e-care.com/Teaching_points_Intro_class_1-4.pdf
http://nc-e-care.com/Teaching_points_Nutrition_Class.pdf
http://nc-e-care.com/Teaching_points_Nutrition_and_Cholesterol.pdf
http://nc-e-care.com/Teaching_points_Medication_Class.pdf