Transcript Sept 1oth Presentation-Finalx

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Using Data to Drive
Quality in Diabetes Care
This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity.
Faculty Disclosure
In compliance with ACCME Guidelines, I hereby declare:
I do not have financial or other relationships with the manufacturer(s)
of any commercial services(s) discussed in this educational activity.
Name: Kristine McVea, MD, MPH
Title: Chief Medical Officer
Disclaimer
The information provided at this CME activity is for continuing education purposes only
and is not meant to substitute for the independent medical judgment of a
healthcare provider relative to diagnostic and treatment options of a specific
patient’s medical condition.
AAFP Credit
This activity has been reviewed and is acceptable for up to __1__
(Prescribed or Elective) credit by the American Academy of Family
Physicians.
The AAFP invites comments on any activity that has been approved for AAFP
CME credit. Please forward your comments on the quality of this activity to
[email protected].
At the conclusion of this activity, participants should be able to:
Participants will learn how to link their strategic plan to data driven
initiatives at the department and individual clinician and staff level.
 Participants will understand how to make data meaningful and motivating
to all members of their diabetes team.
 Participants will learn how to analyze data on their diabetic patients to
determine who to target for more intensive intervention given limited
resources.

Where I Practice
 Free Clinic
 7 total staff
 No resources



9 Sites
Exponential Growth
58% Uninsured
Every Site is Unique and
Challenging!
If we can do it, you can do it!
The Golden Thread
Alignment of Purpose from Strategic Vision through
Execution at the Individual Level
Strategic Plan
Department
Dashboards
Individual
Report Cards
Employee
Performance
Our Strategic Plan
PROVIDER OF CHOICE
QUALITY & SERVICE
ACCESS
COMMUNITY
(SDOH)
STRATEGY MAP
OneWorld Villages:
A Network of Support Services
and Partnerships
Optimize
Capacity
Expand
Services
No Wrong Door to OneWorld
Lead in Key Quality,
Operational and Financial
Outcomes
Transform
Patient
Experience
Enhance reporting
and operational
Infrastructure
PEOPLE
Retain Talented Workforce
Grow and Develop
Staff & Leaders
Build MissionFocused Culture
FUND
DEVELOPMENT
Create a Qualified Candidate Pipeline
Increase
Fundraising;
Maintain Current
Grow
Infrastructure
Form Primary
Care Network
Attract
Commercial
Patients
Identifying Clinical
Quality as a Priority
for the Organization
Prioritizing and Defining Quality
At Department Level

Yearly Provider/Nursing/Support Staff Retreat
 Review Data, Discuss in Small Groups – Everyone
Participates!
 Nominate Potential Focus Areas
 Vote on SMALL, Do-Able Number

Subsequent Bi-Weekly Meetings
 Determine Measures of Success, Goals
 Define Action Plans
 Review Progress
Everyone Understands the Organizational Goal and Interprets
What that Means for the Department
Clinician Dashboard
Dashboard Detail
Metric Name
FP- HTN in Control (UDS) T12Mo
FP Adult Weight Assessment and Follow Up
(UDS) CYTD
FP - Weight SMG set if due CM
2014
Target
Jan
Feb
Mar
Apr
May
June
July
74%
70%
67%
68%
69%
70%
70%
70%
50%
55%
55%
52%
52%
51%
50%
49%
50%
32%
36%
31%
32%
33%
29%
25%
DEFINITION:
Numerator: Number of patients in the
denominator whose last systolic blood
pressure measurement was less than
140 mm Hg and whose diastolic blood
pressure was less than 90 mm Hg.
Denominator: Patients between 18 85 who have been diagnosed as
hypertensive prior to June 30 of the
measurement year and have been
seen twice during the reporting year.
Aug
Action Plan:
 Clinical Pharmacy BP Checks
 Provider Rechecks BP if High
Sept
Clinician Report Cards
Monthly Provider Performance Review
Diabetes
Kristine McVea
Measurements
DM HbA1C < 9 Past 12 Months
DM LDL Screening Past 12 Months
DM HbA1C less than 6 Months Past 12 Months
DM Eye Exam Past 12 Months
DM Hypertension Controlled Past 12 Months
DM Microalbumin Past 12 Months
DM LEAP Past 12 Months
If performance is favorable to the target, color the
box green. If it is not favorable to the target, color
the box red.
Current Numerator and
Denominator
2014 Target Numerator Denominator
81%
63
73
73%
74
86
87%
77
86
40%
56
86
76%
53
86
69%
64
86
68%
66
86
Month by Month
Progression
2014
May
84%
86%
91%
68%
63%
71%
77%
2014
June
86%
86%
90%
65%
62%
74%
77%
Sharing Clinical Performance
Considerable Variation Among Providers Within Same
Practice
• Identify Best Practices Within Your Organization
 Accelerates Learning

1.
2.
3.
4.
5.
6.
A1C Last 6 Months- Harry Diaz (96%), Kelly Houfek (88%), Hans
Dethlefs (87%)
Hypertension Controlled- Kelly Houfek (75%), Leah Jorgensen (74%), 2
Providers at 67% Michelle Christensen, Kris McVea
LEAP- Kelly Houfek (80%), Stephanie Hall (77%), and Ledy Davidson
(76%)
LDL in Last Year- Kelly Houfek (93%), Eloise Poyner (86%), Vicki
Bangert (83%)
Microalbumin- Kelly Houfek (91%), Vicki Bangert (86%), and 2
Providers at 82% Don Allison and Stephanie Hall
Optometry- 2 Providers at 74% Don Allison and Stephanie Hall, Hans
Dethlefs (69%)
Sharing Clinical Performance
Considerable Variation Among Providers Within Same
Practice
• Identify Best Practices Within Your Organization
 Accelerates Learning

A1C Last 6 MonthsHarry Diaz (96%), Kelly
Houfek (88%), Hans
Dethlefs (87%)
Hypertension ControlledKelly Houfek (75%),
Leah Jorgensen (74%),
2 Providers at 67%
Michelle Christensen,
Kris McVea
LEAP- Kelly Houfek
(80%), Stephanie Hall
(77%), and Ledy
Davidson (76%)
LDL in Last Year- Kelly
Houfek (93%), Eloise
Poyner (86%), Vicki
Bangert (83%)
Microalbumin- Kelly
Houfek (91%), Vicki
Bangert (86%), and 2
Providers at 82% Don
Allison and Stephanie
Hall
Optometry- 2 Providers
at 74% Don Allison and
Stephanie Hall, Hans
Dethlefs (69%)
Examples of OneWorld Best
Practices for HbA1c > 9

Schedule monthly follow up visits until < 9

Be Aggressive about med & insulin titration
 Almost everyone at this level needs Insulin –
Talk about it NOW
 Titrate Insulin up by 10%

Do not rely on BS values to titrate Insulin

Self Titration of Long Acting Insulin
(1 unit/day for am BS > 140)

“Just Try it for One Week” Approach to Insulin

Same Provider Every Time, but Take Care of Business
if you Cross Cover!

Praise Patients Whenever Possible
Using Report Cards
For Other Staff

Nursing Staff – LEAP Exams

Health Assistants – Retinal Photos

Diabetic Educators – Diabetic Huddles on Time
All Staff Members Understand How Their Personal
Performance Contributes to Organizational Goals
The Golden Thread
Alignment of Purpose from Strategic Vision through
Execution at the Individual Level
Strategic Plan
Department
Dashboards
Individual
Report Cards
Employee
Performance
Using Data to Characterize
Your Population
Using Population Data
To Prioritize

1750 Patients with Diabetes

298 Patients with HbA1c ≥ 9%

530 Patients on Insulin
That’s a lot of patients! How should the Diabetic
Educators and Case Manager spend their time?
Diabetic Educator Approach

Focused on Insulin
Users only

Called monthly

Over 10 attempts to call
some patients per
month

Controlled Diabetics
loved it, but no insulin
changes made
• Time wasted on
unmotivated patients
• Patients in control got
most resources
Case Manager Approach

Patients Not Seen for > 120 days

Started with the letter “A” each
month

Sometimes got thru “L”

Called from 8-9:00 am

Often pulled to answer phones

“Lost to follow up” patients
appeared each month

Lists run only monthly – needed to
consult EMR before calling
Oh Boy – Not effective on
so many levels.
Using Data to Prioritize
Resources

Diabetic Educators focus on “At Risk” patients
 New Diagnosis
 New start Insulin
 Active Insulin titration
 Out of Control or HbA1c > 8

MOTIVATED PATIENTS ONLY
 Instituted “Diabetic Huddles” with providers
quarterly to determine intensity of contact
Case Manager

Monthly, then Daily Report – Real Time
Work

Adequate time to Manage Population

Contacted by Phone (different
times/days) followed by Post Cards

Protocol for Inactivating “Lost to
Follow Up” patients

Developed “Supervision” Reports for
Oversight of Population Management
Last
Huddle
Huddle
Due
Last Huddle Comments
Case
Mgmt
Active
Active
Patient
Status
Last CM Communication Message For CM
Area
7/7/2014
10/7/2014
Huddle with Jorgensen and Katia. Plan #1)
Needs DM appt in Leah's "UNMC DM " clinic #2)
Needs BH/DE at f/u assess for motivation and
depression #3) Do not refill meds until she
comes into f/u appt
Active
i called today but the phone was off as it took me 07/29/2014
straight to VM. pt is due for a DM f/u. background:
pt has not been in clinic since Jan 28 2014. 1st DM
letter on 04/30/2014- pt hasnt contact OW. pt
contacted OW n has made 3 (7/02, 7/09, 7/23)
appts but has no showed to all of them.
07/17/2014 10/17/2014 Attempt to contact and schedule an appt
Active
Active
5/16/2014
Active
Active
06/05/2014 09/05/2014 Precontemplation, no follow up needed at this
Active
time
6/24/2014 09/24/2014 Pt missed his appt yesterday and has cancelled Active
appt scheduled for next wk. Continue insulin
titration and reschedule f/u appt
Active
called but it states, "the number you have dialed 07/29/2014
is disconnected". no other number listed, pt is due
for a DM f/u. Background: pt has a hx of failed
appts; no showed on 7/03, pt has a hx of drug use
and has many stressors. Pt is inconsistent with
meds and she is in pre-contemplation state
regarding her DM.
pt has returned mail- not deliverable address.
08/11/2014
Background: pt has failed last 4 consec appts. left
a msg with daughter on 6/03 but pt hasnt
contacted clinic. since pt is not being responsive,
we will wait until pt contact us
CM inactivated- Pt is in mexico
07/29/2014
04/23/2014 07/23/2014 PCP called pt today during huddle. Pt confirmed Active
he takes Metformin BID but did not fill script for
insulin. Scheduled appt for dm checkup for
4/30/14. Pt to bring BGs to appt.
Active
08/16/2014 PLAN: Case Mgr Gerson to contact pt to
schedule DM checkup. Pt is overdue.
BACKGROUND: Pt is on insulin.
Active
Comm
Date
pt is complaint with meds, watches diet, not very 07/25/2014
active. pt's A1c greatly improved 9.2 in June from
12.5 in May. CDE Jerry is communicating with pt
(last spoke on 7/07), no action from me required
at this moment
called today but did not answer, pt needs a f/u
07/30/2014
appt. Background: Pt's DM has only been under
controlled once since 2010. pt is noncomplaint
with meds, pt has a hx of financial issues and
donation status. Will offer 3 months of free visits
and meds to see if he can get more engaged.
Case Manager Empowered

Given “Carte Blanche” to offer appointments, financial
assistance, medications, transportation – Whatever it
Takes!

Case Manager offered:
 Appointment with PCP
 Anytime – even evening
appointment not usually
scheduled
 Free Visit
 Free Meds
 Transportation
Failed!

Patients still “NO SHOWED” their appointments
If you are working harder than your patient,
something is wrong
Characterizing our Population

Chart review of DM patients out of control:
 25% New Diagnosis or Working on Control
 25% Not Motivated
 50% Not Engaged, Not Reachable
MOTIVATION, not Education, Resources
were the Key!
Our Response

Training for Diabetic Educators, Providers, Case
Managers in Motivational Interviewing

Resource:
http://www.chcf.org/publications/2006/08/video-withtechniques-for-effective-patient-selfmanagement
Characterizing Your Population
“It seems like physicians are being more
aggressive with insulin use in our practice
compared to midlevels providers. “
Insulin Use
% HbA1c < 9
Midlevels
25%
80%
Physicians
45%
85%

Using insulin earlier made a difference!

Midlevels needed educational support to feel
confident with Insulin
Diabetes Population Data

Better Prioritize Resources

Coordinate Care

Identify Staff Training Needs

Chart Reviews or EMR Reports Can Both Provide
Valuable Information
Looking Beyond the UDS Can
Yield Valuable and Surprising Information
CME Credit Survey
This webinar series was funded by Bristol-Myers Squibb
Foundation Partnership for Diabetes Health Equity.
The following disciplines are qualified to receive credit for this
webinar: MD, DO, NP, & PA. Nurses can receive a certificate of
attendance.
If you are seeking credit for this webinar training, please click
the following link from your computer now:
CLICK HERE for CME Credit Survey
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This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity.