Instructions

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Instructions

• A few of the slides you created for your previous
  storyboard might remain consistent, (i.e. Aim
  Statement, list of key measures, list of team
  members.) The exception would be if the
  directors provided comments/edits to any of these
  areas on your monthly report. You need to
  remain consistent and have the AIM statement,
  list of key measures, etc as they appear on your
  monthly report.
• You will have submitted two monthly reports by
  learning session two. You are either TESTING
  ideas under each component of the Chronic Care
  Model and/or have already IMPLEMENTED changes
  under the components of the Care Model.
  (remember, that means that the change would not
  go away in your organization if you ended
  participation in the Collaborative process
  today!!) The tests of change and changes
  implemented is the new information you will be
  sharing at learning session two. Most of the
  information youll need is already in your
  monthly report. Keep the description short and
  to the point but with enough description that the
  reader can get the major points from your
  storyboard.
• Update your data and insert the graphs from your
  excel file on slides as demonstrated on slide 13
  and 14. Make the graphs large enough so that
  they are easy to readno more than 2 to a page,
  if possible. Therefore, you will need more than
  2 slides to display your progress for all
  measures that you are tracking. DO NOT SUFFER
  IN SILENCE ! Please post a ticket to the Help
  Desk on SharePoint as soon as possible if you
  need help accomplishing this step.

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Learning Session 2May 12-14, 2005Atlanta,
Georgia
Cluster Northeast
DFD Russell Medical Center
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DFD Russell Medical Center

• Leeds, Monmouth, and Turner Maine
• 10 medical, 2 mental health providers
• Family practice, OB, mental health
• Population Served
• 457
• 1 Hispanic

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Team Members

• Name Title Role on Team
• Laurie Kane CEO Senior Leader
• Diane Handler PA-C Provider Champion
• Denise Fahey COO Team Leader
• Melissa Gauthier MA
  Registry Key User
• Max Barus MD Clinical/tech Expert
• Tia Knapp PAC Community Support
• Kris Rubino Admin. MIS Contact
• Assistant
• Sharon Hathaway RD ADEF dietary instructor
• Team Leader Contact Email
  Telephone
• Denise.fahey_at_dfdrussell.org 207-524-3501

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AIM Statement

• AIM
• 75 of DFD Monmouths diabetic patients will
  have documented self management goals.
  Additionally, 70 will have their last BP lt
  130/80

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Selected Measures

• Average HbA1c of 7.0 for DM Patients
• 90 Dm Patients with Two (or More) HbA1c in Last
  12 Months (gt90 days apart)
• 70 Dm Patients with SM Goal Setting in Last 12
  Months
• 40 DM Patients with BP lt130/80
• 70 DM Patients with LDL lt100
• Cardiac Risk Reduction Option 1 60 Patients on
  ACE inhibitors or ARBs age 55 or older
• Cardiac Risk Reduction Option 2 70 Patients on
  statins age 40 or older
• Optional
• 50 DM Patients will have a Depression Screening
  in Last 12 Months

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Self-management

• Currently Testing
• SMG follow-up by MA with patient after provider
  visit
• Self management goal handout at the time of
  check-in
• Assistance provided to low literacy patients
• SMG goal F/U at every visit
• Implemented into our Delivery System
• Utilizing newly developed self management goal
  tool
• MA discussion of SMG with patient pre-provider
  visit
• Utilizing DFD MA staff as lay Move More
  educator

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Community

• Currently Testing
• Legislation to increase ADEF reimbursement
• Referral to PAC for community assist linkages
• Community awareness projects
• Move More Diabetes community kick off
• Implemented into our Delivery System
• Community resource handout to assist patients
  with SMG

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Healthcare Organization

• Currently Testing
• Spread of Collaborative process to other Monmouth
  providers
• Spread of Collaborative process to other Monmouth
  support staff
• Implemented into our Delivery System
• Quality Assurance Plan includes Care Model
• Collaborative team report submitted at monthly
  BOD, support staff and provider meetings
• HDC patient awareness project
• Inclusion of quality measures in provider
  incentive program

10
Decision Support

• Currently testing
• Utilization of revised diabetes protocol
• Development of diabetes standing orders for
  protocol driven labs and referrals
• Posted standing orders on computers in all
  Monmouth exam rooms
• Glucometer support program
• Implemented into Delivery System
• ADEF program
• Referral to PAC for financial assistance to meet
  DM patients health care needs

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Clinical Information System

• Currently Testing
• Use of Crystal reports for monthly reporting
• Implemented into Delivery System
• Diabetes tracking system for patient recall
• Addition of self management goals to the diabetes
  registry
• Separation of data flow from billing system to
  EMR for accurate PCP and location of care
• Use the registry to track, report and communicate
  results and outcomes of care effectiveness over
  time and across providers and populations

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Delivery System Design

• Currently Testing
• Care Model implementation support
• Creation of EMR DM recall letter
• Implemented into Delivery System
• Care Model Implementation (Depression)

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Functional and Clinical Outcomes

• Measures Goal as of 5/2005
• Registry size 115
• 2 HbA1cs in last yr 90 88.7
• Average HbA1c lt7.0 6.8
• Documented SMG 75 23.5
• BP lt 135/80 70 45.2
• LDL lt 100 70 58.4
• ACE/ARB inhibitor patients 55 60 80.5
• Statins patients 40 70 52.8
• Depression Screening 50 31.3

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National Key Measures
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Senior LeadershipMaking the Case for Change

• Our CEO is an integral member of our Diabetes
  Collaborative Team and attends all HDC meetings.
  Our BOD, providers and staff are updated monthly
  with data generated from the weekly Collaborative
  meetings and monthly reports.
• DFDs HDC awareness project has included the
  display of our DM storyboard in the patient
  waiting room, direct mailings promoting ADEF
  classes and presentations delivered by the CEO.

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Communication Plan (How are you communicating
your progress at the center level and within your
community)

• At the center level
• Waiting room Storyboard display
• Board of Directors meetings
• Provider meetings
• Management meetings
• Staff meetings
• Staff trainings
• At the Community level
• Move More partnership
• ADEF legislation
• Wellness mailings promoting ADEF classes
• Marketing plan promoting Care regardless of
  ability to pay

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Anticipating Barriers and Issues
Those that the team can resolve
Those that leadership needs to address

• Adopting best practices with providers
• Integrating changes to work flow
• Coordinating community resources
• Accuracy in reporting

• Future funding for Care Model integration
• Supporting best practices
• Legislative changes
• Decreasing barriers to care

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A story to share.the patient

• Since joining the Collaborative we have
  introduced the Self Management Goal as a
  component of Diabetes care. We have encountered a
  variety of responses from patients in introducing
  the new concept to their care. One patient who
  was recently diagnosed was initially very
  discouraged and felt helpless. She was enrolled
  in our new ADEF classes and began seeing the
  benefits of Self Management Goals. She decided to
  utilize Move More , a Diabetes exercise support
  program, to improve her exercise plan. She was so
  inspired by the benefits that she experienced
  that she is now becoming trained as a lay Move
  More educator.

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A story to share.our staff

• Initially, some staff were less than enthusiastic
  for yet another project. As we began to spread
  the testing of PDSA cycles to additional
  providers and support staff at our Monmouth site
  our efforts in keeping staff informed during the
  pre-work and early stages of the Collaborative
  paid off. At our very next Collaborative meeting
  the MA on the team came with many questions and
  ideas generated from staff over the week. A far
  from apathetic group!

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A story to share.the organization

• Over the past few years we have made an effort to
  keep staff informed of our involvement as an
  organization in the Collaborative process.
  Initially, we used broad terms to educate staff
  including Care Model, reducing disparities, self
  management goals, outcome measures and PDSA
  cycle. In joining the HDC we are now providing
  monthly reports to clinicians on outcome measures
  that are both organization and provider specific.
  We are beginning to see staff become familiar
  with the process and the Collaborative philosophy
  of reducing disparities. Providers now seek
  monthly outcome measures of their patient panel
  and have those measures tied to their incentive
  program. In addition, MAs are interested in
  finding solutions to improvement documentation of
  patients yearly eye exam.