Large Clinic

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Large Clinic

• Prince Rupert
• (rural northwest community)
• 1 physician
• 120 patients with Diabetes

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Team Members Mike Ikari, MD Jennifer Porcher,
MOA Christa Keating, RN Shelley Movold, RD Elaine
Lohnes, Ex Therapist
Team Leader Contact Mike Ikari 250-624-9651
mikediabetes_at_hotmail.com
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AIM and Key Measures

• AIM
• To use the chronic care model to improve blood
  sugar control in patients with diabetes and
  ultimately prevent or reduce complications.
• To incorporate self management and encourage
  patients to achieve self management goals.

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KEY MEASURES

• Of the patients with Diabetes
• gt95 will have HgA1c once a year
• gt65 will have a A1C of lt7
• gt90 will have BP measured every 3-6 months
• gt60 will have BP of lt 130/80
• gt80 will have a lipid profile done annually
• gt70 will have an annual dilated eye exam
• gt90 will have an annual ACR
• gt80 will have an annual lower extremity exam
• gt70 will have a self management goal documented
  annually
• gt90 will have an annual flu shot

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Clinical Information Systems

• Status of Registry
• 120 patients with Diabetes
• 117 patients with completed flow sheet and data
  entered into the Toolkit

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Clinical Information System

• Barriers to the registry
• Summer holidays of team members and patients
  (difficult to coordinate schedules over the
  summer).
• Entering data-not all team members had access to
  the tool kit
• Coordinating services with other health
  professionals (i.e. optometrist and health unit
  for flu shot). Getting patients to go see them.
• Communication-will have meetings every 2 months
  now to improve communication.

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Decision Support

• PDSA cycles
• Clinic involving MD, RN, RD and exercise
  therapist. Self management and goal setting for
  clients.
• List of patients to the optometrist for his staff
  to call and book f/u appts with
• List of patients to PHN to have her staff call
  and book appts for flu shots
• Team meetings every 2 months to discuss progress
• DEP to contribute lists of patients to see at
  clinics too.

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Delivery System Design

• Assessment of how our first clinic went
• DEP did a mass mailout to all clients with
  diabetes to inform them of the new diabetes
  education classes available to attend
• DEP has put together a 1 year f/u letter to mail
  out 1 year after the last contact with a client
  to remind them to see their doctor and DEP for
  f/u regarding their diabetes
• The Large Clinic is sending out reminder letters
  for eye exams
• DEP RN/RD ordering labs if appropriate (i.e.will
  change the course of management).

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Self Management

• Team clinic-finding the goal the patient is
  interested in achieving.
• DEP classes-patients seeking out the areas they
  need more information on
• Advertising a local self management course

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Functional and Clinical Outcomes

• Measure Goal
  Current Level
• HgA1c once a year gt90 40
• A1C of lt7
  gt65 53
• BP measured every 3-6 months gt90
  45
• BP of lt 130/80
  gt60 52
• LDL done annually gt80 74
• annual dilated eye exam gt70 55
• annual ACR
  gt90 63
• annual lower extremity exam gt80
  15
• self management goal documented annually
  gt70 16
• annual flu shot
  gt90 0

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Key Measures
HGA1C
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Key Measures
Blood Pressure
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Key Measures
LDL
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Key Measures
Triglycerides
15
Key Measures
Flu Shot
Eye Exam
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Key Measures
Lower Extremity Exam
Self Management
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Key Measures
Microalbumin Screen
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Summary of Current Status

• More self management focused
• Communication has been our biggest barrier
• Plans include improving communication with more
  team meetings and connecting with other health
  care professionals to deliver better service to
  the patients.