Get smart with your Diabetes Patients

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Get smart with your Diabetes Patients

• Dr Job Kayode Ojo (Principal) Rachel Scott
  (Practice Nurse) - RN

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Roleystone Family Medical Centre
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Roleystone Family Medical Centre

• 2 GPs (1.2 FTE) 2nd GP currently on maternity
  leave
• 1 Practice Nurse (0.5 FTE)
• 3 Receptionists (1.4 FTE)
• 1 Practice Manager (0.2 FTE)
• 2,500 active patients
• Mixed billing (HCC holders and children under 16
  bulk billed)
• Middle class, lots of families

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History of the Medical Centre

• Started about 2 years ago as solo GP
• Always knew that a nurse was required (three half
  days initially, then half time)
• Paperless from the start
• 10-15 years ago, building was once used as a
  practice, but was then used by another business
• Completely new patients, some followed from
  previous practices.

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About me

• Trained in Nigeria South Africa
• Worked in Nigeria, Mozambique South Africa.
• Worked in country WA for 5 years.
• Started RFMC 2 years ago with the goal of caring
  for the total man (i.e spirit soul and body)

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Software - Genie

• Easy to use
• Medical software and billing together
• Good in-built NPCC extraction tool
• Excellent search facilities
• Phone support good from Genie head office, but
  experience not as good with local support.

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Why we signed up for NPCC

• sold by previous NPCC experience with Division
  (I worked at a Wave 1 practice)
• Practice was just starting NPCC gave a good
  foundation for CDM.
• Opportunity to engender team spirit.
• Helps in the organisation structuring of a
  practice, esp. PDSA concept.

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Motivation

• NPCC involvement opportunity for the practice
  to improve level of care/efficiency
• Financial rewards for care already given (I was
  already doing most of the things, but not
  claiming for them).
• The practice manager Nurse were very
  encouraging. Lets do it, this is what youve
  always done anyway

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The EvidenceWhy we wanted to act.

• The UKPDS 35 Study (BMJ 2000 (321) 405-411) shows
  that each 1 of ? in HbA1c associated with
• 21 ? in deaths related to diabetes
• 14 ? in MI
• 37 ? in microvascular complications
• 43 ? in amputations

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The Team
PN Rachel Scott
PM Colleen Nagel
Dr Job Ojo
Tracey
Alison
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About Me

• Trained in UK
• Varied nursing roles in UK Australia
• Involved in UK NHS CDM targets in 2004
• In practice nursing since 2003
• At Roleystone FMC since its inception 2 years
  ago
• Married with 3 kids (school aged)

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Team meetingsStep one

• Regular monthly lunch time meetings with the
  entire team
• Staff are paid for attending
• Agenda
• Sharing of ideas learnt at NPCC Learning Workshop
  in Melbourne
• Staff have input understand reasons for
  diabetic management

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Getting started

• Register already set up
• Data cleaning
• eg. HbA1c not always entered correctly (ie. Blood
  tests done before practice opened).
• Getting used to data extraction tool in Genie
• Development of recall system.

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The GPMP

• On newly diagnosed patients
• Done on all diabetes patients flagged for
  reviews
• Time consuming - Receptionist help with faxing
  referrals, scanning etc.
• Six monthly reviews
• There is a sample of the file circulating now if
  youll like to have a look.

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SIPs

• Recall for 12 months from previous SIP
• Diabetic check incorporating it as an opportunity
  for DM education/review
• Checking management is adequate up to date.
• Checking on patient compliance / adherence.
• Also opportunity to check need for Allied review,
  If required.

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Recalls

• Every 3 months for new patients unstable
  patients.
• 6-12 monthly for the stable and compliant
  patients.
• Letters are sent out to patients-with pathology
  forms if appropriate- at due periods as reminded
  by the recall system on Genie.

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Streamlining our Systems

• Full blood profile for all patients over 40 and
  those under 40 with risk factors
• BP checked at each visit
• Strong on patient education both GP nurse
• Newly diagnosed provide brochures/information

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The visit with the nurse

• Half hour set aside before seeing the GP ( with
  significant others if feasible)
• General screening (BP, BMI etc see file)
• Checking that all blood tests are up to date
  (esp. HbA1c, ACR)
• Patient education (Life coach) / empowerment
  how to lower their risk factors - diet, exercise
  etc
• Preparation for probability of drug intervention

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The visit with the nurse

• Arrangement of referrals to Allied health
  podiatrist, optician, dietitian
• Encourage to join Diabetes Australia, get
  glucometer start blood glucose monitoring

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The sick role

• Consultation model
• Entering the sick role has certain obligations
  privileges. The individual is exempted from
  normal social obligations and is not held
  responsible for his or her incapacity. On the
  other hand the sick person is expected seek
  professional help and to make every effort toward
  recovery Ian McWhinney
• Every patient who seeks help has expectations,
  (feelings and fears) based on his or her own
  understanding of the illness- Ian McWhinney

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The visit with the GP

• Whole of patient approach find out the context
  of the presentation
• Opportunistic health education
• Life scripts
• Establish trust/therapeutic alliance.
• See patient in the context of the family /
  community
• Treating the whole patient and not just a
  pathology.

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The visit with the GP

• Early drug intervention
• Explain HbA1c to them- very important
• Collaborate with patient (co-labouring)
• Extensive discussion about Diabetes (QA
  session/Foundation phase)
• Explanation of possible complications (worst and
  best case scenarios)
• Diet Exercise

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Challenges

• Well controlled patients becoming complacent (I
  dont think I need the medication anymore my
  sugar is constantly lt7 in the morning)
• Refusing to comply / start medication
• Side effects from medication (pre-warn)
• Men are more likely to have poor control

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of Patients with Diabetes withHbA1c lt7
73.4
Highest nationally
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of Patients with Diabetes with Cholesterol
lt4mmol/l
29.7
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of Patients with Diabetes with BP lt130/80 mm
Hg
65.6
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Patients with Diabetes that have had Diabetes
SIP claimed within the last 12 mths
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Benefits to Patients

• Some patients have experienced a remarkable
  decrease in cholesterol levels (eg. from gt8 to
  lt4), as well as BP
• Improvement in general well being
• Decrease hospital/surgery visitations (working
  myself out of business?)
• Patient empowerment - taking responsibility for
  their own health
• Patients confident they are looked after

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Benefits to GP

• Helps to get remunerated for what Ive always
  done (MBS item numbers) didnt have time to
  look into it before. Thanks to NPCC
• GPs embraced computer
• I learnt more about what I can do with Genie from
  rare opportunity at Melbourne to speak to
  colleagues using Genie.
• automatically code now
• BP figures are put in right places
• ? Uniformity allows same level of access to all
  GPs

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Benefits to Nurse/Receptionists

• NPCC helped our practice Nurse to learn the
  Australian system of general practice, faster
  than she would have otherwise (MBS, EPS)
• The front office and the clinical team started
  working as a team. Thanks to PDSAs!!!

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Factors for success

• Protected time each week
• Fully utilise computer system i.e. paperless
• Have a computer system that supports NPCC data
  extraction
• Team approach within the practice (i.e. regular
  team meetings good rapport between staff
  members)
• GP who are willing to try and influence their
  peers
• Willing to engage with the collaborative method
• Enthusiasm!

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Factors for success

• Motivated by opportunity to genuinely help people
  let patients be part of their management
  (Patient involvement)
• Combination of approach GP/nurse
• GP (open, frank, sometimes too frank)
• Nurse (has time to spend with patients
  reinforce what GP said)
• Easy access to Nurse, when GP is not available
• Realized the potential of a practice nurse make
  it viable through MBS item numbers
• Nurse loves her job has people skills
• Biopsychosocial approach

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Where to from here

• Clinics for chronic disease management, such as
  diabetes and asthma
• Continue measuring quality improvement through
  PDSA cycles.
• Continue to improve quality of care given to
  patients
• Improving/maintaining the standard using the NPCC
  experience.

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Final thoughts

• An ounce of prevention is worth a pound of cure
• Mark Twain
• A merry heart does good like a medicine but a
  broken spirit dries the bone.
• Prov. 1722
• Anxiety in the heart of man causes depression
  but a good word makes it glad.
• Prov. 1225

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Questions