Learning Session 1

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Chronic Disease Management

• Learning Session 1

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Objectives

• Use a population-based approach to identify all
  practice patients with a specific disease
• Create an electronic patient registry for
  patients with a specific disease (CDM Toolkit)
• Import data from EMR into Toolkit
• Use flow sheets and CDM Toolkit to provide
  evidence-based, guideline-directed care for
  chronic disease patients

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Objectives

• Implement a proactive, planned recall system
• Generate reports and run charts
• Analyze success of practice changes on improving
  patient care outcomes and processes of care
  adjust as required
• Learn from small scale tests of change so as to
  improve sustain changes
• Expand patient registry and planned recall to
  other patient populations

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Practice Support Program Team
Non-Physician Team
Physician Team

• Name
• Name
• Name
• Name

• Name
• Name
• Name
• Name

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Ground Rules

• Respect all ideas and opinions
• Share experiences
• On time back from break

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Expanded Chronic Care Model
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Prevalence of Chronic Disease in BC
Number of people
Source BC Ministry of Health, Knowledge
Management and Technology
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One in three British Columbians has one or more
chronic conditions
Source Medical Services Plan (MSP) and Discharge
Abstract Database (DAD) data, 2005/06
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The CDM Approach

• Population health approach
• Target multiple patients with same chronic
  conditions
• Planned proactive care
• Uses clinical practice guidelines and protocols
• Patients become active in own care

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Benefits for GP

• Care is proactive, not reactive
• Better use of time and resources
• Guidelines provide template for improved
  patient care
• Improved management of complex care patients
• Increased quality of life (work personal)
• Increased practice revenue

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Planned Care Billing Revenues

• Average GP currently only bills CDM incentive
  fees for 30-40 of eligiblepatients
• 14050 Diabetes
• 14051 CHF
• 14052 Hypertension

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Planned Care Billing Revenues

• Complex Care Fees
• Use toolkit to identify your complex care
  patients
• Use toolkit to help develop complex care plans
  and bill accordingly
• Prevention Fee
• Use toolkit to identify eligible patients for CV
  risk prevention

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Benefits for Patients

• Experience proactive care rather than reactive
  care
• Patients who need follow-up will get it
• Continuity of care
• Improved patient outcomes and quality of life
• Increased patient satisfaction
• Fewer and shorter hospital stays

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The Case for CDM
Most chronic diseases do not result in sudden
death Death is inevitable, but a life of
protracted ill-heath is not.
Source Preventing Chronic Disease a vital
investment WHO Global Report, 2005.
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Evidence-Based
of CHF Patients on Appropriate Meds
Provincial CHF Collaborative 2003-2004
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CHF Collaborative Results
100
Closing congress
Start of collaborative
75

Percentage
50
25
24
21
22
15
4
Had specific self-management goals for diuretics
Had documented ejection fraction
Established self-management goals
Were on ACE-I / ARB
Were on B-Blockers
Patients
Provincial CHF Collaborative 2003-2004
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CDM Module Payments

• Weighted higher than other modules because CDM is
  more work
• Do not affect ability to bill the CDM incentive
  fees (e.g., HTN, CHF, DM)
• Do pay for data collection and analysis

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CDM Funding
Learning Sessions
Action Periods
Potential Total 8,661.82
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CDM Funding Action Periods
Potential Totals (including learning sessions)
8,661.72
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The CDM Bundle

• Patient Registries

CDM Toolkit
Planned Recall
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(No Transcript)
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Key Deliverables

• Registry created for defined patient group (a
  specific condition)
• Use of flow sheets embedded in workflow processes
• Recall process implemented
• Records reflect patients receiving proactive
  care, per guidelines
• Program expanded to larger patient group

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What is the Toolkit?

• Internet-accessed software program for licensed
  physicians and delegates
• Tool used to provide up-to-date clinical decision
  support
• Tool used to help provide planned, proactive care
  

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Site Security

• 128-bit SSL Encryption
• Same strength used for online banking
• Client-side Certificates
• Ensures that the user is entitled to use his/her
  user id
• Data accessed is based on profile
• Only physicians or their authorized delegates can
  see patient-specific data
• Other users can only see aggregate reports

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Toolkit Benefits

• Capture patient data from flow sheet
• Maintain a patient registry
• Identify gaps in care
• Provide evidence-based care and systematic
  follow-up
• Measure improvements in patient outcomes

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Toolkit Benefits

• Support care for patients with multipleco-morbidi
  ties without data duplication
• Share data with colleagues
• Monitor results peer-to-peer and
  individual-to-group comparisons
• Compare data across patient and provider
  populations, over time

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Granting Access

• With access granted, MOA can
• enter data, run reports, print flow sheets,
  manage recall process, etc.
• Can also grant access to
• other physicians, nurses, diabetes education
  centres, etc.

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Data you can see

• Physicians
• Data for your own patients
• Other providers patients (if granted access)
• Detailed, patient-specific reports for all
  patients for whom you have access
• Summary reports for all patients and providers
  for whom you have access

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Data you can see
MOAs, Nurses, and other users provided delegate
status

• Patient data for patients to whom a physician has
  granted you access
• Detailed, patient-specific reports for all
  patients for whom you have access
• Summary reports for all patients and providers
  for whom you have access

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Data you can see

• Health Authority PSP Teams
• Summary reports for providers within
• your health authority
• your collaborative
• No access to individual patient data

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Data you can see

• Ministry of Health Administrators
• Summary reports for providers in toolkit
• Access administration for users
• No access to individual patient data

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Flow Sheets

• Diabetes
• Congestive heart failure (CHF)
• Chronic kidney disease
• Chronic obstructive pulmonary disease (COPD)
• Hypertension / CVD / CKD prevention
• Depression
• Chronic disease prevention (50-70 yrs)

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Toolkit Reports include

• Profile Report
• Data Extremes
• Key Measures
• Recall Report
• Run Charts

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Apply for Access Online

• Register online http//healthnet.hnet.bc.ca/has/r
  egagree/4614fil.pdf
• Read agreement complete fields on page 2
• Print a copy for your files
• Submit request

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Online Application
Physicians Clinic Name
Physicians Email
MOAs Name
MOAs Email
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Additional User Access
To request access for additional access
administrators

• Email Access Services at the MOH
• hlth.hnetconnection_at_gov.bc.ca
• Include your user ID organization ID
• Include name, email address, phone number, and
  fax number for individual each individual

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Choosing a Condition

• Eligible chronic condition must
• Be in the priority list (PHC Charter)
• Have a guideline
• Have a flow sheet in the Toolkit

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Choosing a Condition

• Choose an eligible condition
• plan to develop your register for all your
  patients with that specific condition
• If you have lt20 patients, select a second
  condition to focus on
• plan to add all of your patients with that second
  specific condition

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Care Gap for Chronic Conditions
of Recommended Care Received
Source McGlynn et al. NEJM 2003
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of Canadians with diabetes receiving care as
per guidelines
58 X
42 ?
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Diabetes in BC 1993-2016
Source Population Health Surveillance
Epidemiology, Ministry of Health, 2005
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Diabetes Mellitus
DM

• Inclusion Criteria
• Any patient with a previous diagnosis of diabetes
  mellitus
• Exclusion Criteria
• Patients with impaired glucose tolerance,
  impaired fasting glucose, or metabolic syndrome
• Patients with gestational diabetes

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Diabetes Targets
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Triple Whammy

• Glycemic control A1C
• Blood Pressure BP
• Bad Cholesterol LDL

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The Patient Registry

• A list of all patients with a particular
  condition
• e.g., diabetes mellitus or CHF
• Patients progress is tracked using flow sheets
• Use of flow sheets facilitates implementation of
  planned recall process

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Identify Eligible Patients

• Billing software
• Paper chart review
• EMR (can import into toolkit)
• Physician Profile Analysis Report (can import
  into toolkit)
• Lab result report (can import into toolkit)

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Physician Profile Analysis

• Secure and confidential report
• Practice demographics
• Complexity of patient population
• Identifies potential gaps in care
• Comparison to BC patients as a whole
• Highlights your chronic disease patients
• Diabetes, Hypertension and CHF

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Physician Profile Analysis
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Physician Profile Analysis
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Physician Profile Analysis
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Physician Profile Analysis
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www.bcguidelines.ca
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Baseline Data

• Include most recent data from the previous 12
  months of care
• If the most recent measure is earlier than 12
  months, leave it blank
• If no data available that fits the criteria for a
  specific measure, leave it blank

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Practice Team Activity

• Physician Coach
• Explain terms, abbreviations, etc. in charts.
  Let MOA complete flow sheet data unaided
• MOA Team member trainee
• Scan chart and enter data on flow sheets

• Review content of patient charts together
• MOA will then complete a flow sheet
• Review results together

You have 25 minutes for this activity
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P-D-S-A

• PDSA Questions
• What are you trying to accomplish?
• How will you know that a change is an
  improvement?
• What changes can be made that will
• result in improvement?
• PDSA Cycle
• Plan Do Study Act

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PDSA Example 1
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PDSA Example 2
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Fail to plan, plan to fail. Carl W.
Buechner
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S.M.A.R.T. Goals

• Specific .. what, when, who, etc.
• Measurable ... tool to track progress
• Attainable... ability to reach goal
• Resourced.. people, tools, time
• Timed . start and end dates

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Action Plan Measures Goals
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Action Plan Tasks
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Action Plan Team Activity

• Create your action plan with your practice team
  (e.g. each physician and MOA)
• Share your plan with your table work group

You have 35 minutes for this activity
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Action Period 1 Checklist(bring to Learning
Session 2)
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Materials for Action Period 1

• Website address to request access
  http//healthnet.hnet.bc.ca/has/regagree/4614fil.p
  df
• Digital Certificate Installation instruction
  sheet
• Blank flow sheets for diabetes
• Sample Action Plan worksheet
• Blank Action Plan worksheet
• Action Period 1 checklist

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Regional Support

• Ensure that all practice staff understand
  instructions for tasks in action period
• Act as a resource for challenges in implementing
  action plans
• Set up on-going visits or conference calls to
  ensure that all is on track

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Bring to Learning Session 2

• Action Period 1 Checklist
• Update on progress
• Lessons learned
• Good luck! See you at LS2