Diabetes Collaborative Final Congress February 17

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Diabetes Collaborative Final CongressFebruary
17 18, 2005

• Queen Charlotte Islands
• Masset

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Team Members

• Cindy Talarico, Diabetes Nurse Educator
• Susan Lyster, Masset Clinic Manager
• Vanita Lokanathan, Family Physician
• Shelly Crack, Dietician
• Sheena Howard, Public Health Nurse

Team Leader Contact Info Vanita Lokanathan
vanita.lokanathan_at_northernhealth.ca 250-626-4702
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Aim Statement

• Redesign office practice using the Chronic Care
  Model to improve the management of chronic
  illness, using Diabetes as a prototype for office
  system redesign.

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Key Measures

• 85 will have an A1C of lt7.0.
• 60 will have a BP of lt130/80 with the BP being
  measured every 3-6 months.
• 70 will have an LDL lt2.5, done annually.
•  70 will have an annual dilated eye exam.
•  85 will have an annual ACR (Results lt2.0M and
  lt2.8F).
•  90 will have an annual lower extremity exam.
•  85 will have a self-management goal documented
  annually.

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Clinical Information Systems

• Status of Registry in Masset/Pilot Population
• 129 patients with diabetes
• 125 with Type II, 3 with Type I, 1 unclassified
• 7 patients with CHF entered in toolkit
• 5 patients with chronic renal failure
• Persons trained to enter data in toolkit include
  Clinic Manager, Office Assistant, DM Nurse,
  Physician

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Profile Report
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Use of Toolkit in Planning Care

• Recall system used to book visiting specialists
  clinics (podiatry, optometry), invite for planned
  visits
• Sorting mechanisms (data extremes lists) used to
  prioritize for planned visits, group clinics
• Outcome data (runcharts) reviewed to assess
  effect of interventions (eg rate of foot and eye
  exam completion after specialist visits, rates of
  SM goal-setting after planned or group visits)

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Decision Support

• Training staff in lab data entry
• Diabetes Nurse Educator training home support
  workers on nutritional issues,
• Review for physicians of guidelines for frequency
  of lab testing and targets for BP, ACR as part of
  orientation to Encounter form
• Review of encounter forms with patients at Group
  Clinics, including photocopies for some
• Foot care course completed by several nurses
• Turnover of physicians others is major challenge

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Decision Support Foot Care

• Foot care course completed by a number of nurses,
  including
• Community Health Nurses
• Clinic Nurse
• Diabetes Outreach Nurse
• Diabetes Nurse able to offer more comprehensive
  foot care
• Increasing access to this service barrier to
  provision is cost of podiatry care
• Hook to recall patients for visit, offering
  opportunity to update services, review management

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Delivery System Design
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Types of Delivery System Change

• So far weve tried
• Individual planned visit with Diabetes Outreach
  Nurse or Physician
• Planned visit clinic with group education
  component
• Group visits
• Population management for one intervention ie
  registry used by PHN to call in for Flu
  Pneumovacc

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Individual Planned VisitsOne patient, 1 or 2
providers

• Diabetes outreach nurse and/or MD
• Patient selection based on
• Missing services on recall
• Outliers on data extremes (A1C)
• Objectives included
• Completing missing services
• Management review
• Self-management goal-setting

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Group Planned VisitsOne or Two Providers

• With nurse alone, or nurse doc
• Patient selection based on
• Missing services on recall (eg foot exam, flu)
• Outliers on data extremes (A1C, ACR)
• Complexity (eg those also on CHF registry)
• Those interested in group clinics
• Objectives of the clinic
• Update missing services (eg Cindys Flushot
  Foot Exam clinic)
• Direct communication between providers on complex
  patients
• Increased patient satisfaction with combined
  access to RN/MD one-stop shopping
• Group education component
• Self-management goal-setting

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A1C Extremes Recall Report
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Diabetes Clinic

• Physician, Diabetes Outreach Nurse, Community
  Health Nurse
• Patient selection based on Newly diagnosed,
  Missing services, Out of range values
• Format 4 hour session Group education on
  Diabetes basics and management by physician BP,
  medication reviews, foot care

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The Healthy Supersize MeGroup Visits

• 15-20 patients invited 13 attended (some with
  family)
• Multiple providers
• Diabetes Outreach Nurse
• Dietician
• Public Health Nurse (NICC counsellor)
• Doc
• Community members (Grocery manager, Organic food
  supplier)
• Patient selection based on
• Missing services
• Outliers on data extremes (A1C, LDL)
• Complexity (comorbidity)
• Smokers
• Patients already recruited for SM pilot

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Group VisitsStep-by-step Planning Process

• Group of Providers
• Decide on patient list
• Set aim for clinic
• Review plan of action
• Receptionist
• Book appointment phone then mail invitation
• Request bring glucometer log
• Office Manager
• Organize Lunch through hospital cooks (dietician
  recipes)
• For each patient print copies of
• encounter forms (2)
• patient education sheets
• self-management surveys,
• personal action plan/goalsheets

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Providers Aims for One Group Clinic

• Encourage group participation and discussion of
  goal-setting
• Support three people to set activity goals
• Support 3 people to set diet goals around healthy
  portions
• Support one smoker to set quit date
• Update missing services
• Decision support for community health nurse by
  teaching diabetic foot exam
• Address complex needs in patients with
  comorbidities (eg DM, CHF, renal)
• Increase awareness of community resources

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Group VisitsStep-by-step Care Process

• 1200 100 Healthy lunch
• SM support education for patients
• Decision support for hospital cook
• 100 200 Group Discussion
• Introduction to goal-setting concepts including
  doc sharing goal
• Round table of change behaviours attempted so far
• Community paticipants presentations
• Question and answer for providers and community
  participants
• List passed around for requests for 11 time with
  providers
• 200 -330 11 visits with providers
• Group sharing amongst those waiting to be seen
• 330 400 Study
• Providers review aims of clinic and preliminary
  results
• Review verbal feedback surveys
• Plan next group clinic

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Excited yet?
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Patient/Population Outcomes

• Steady gains in self-management goal-setting
• Spikes in completion of missing services (foot
  exams, BPs, flu shots)
• Helping to create the informed, activated patient
• Requests for SM tools such as pedometers or
  cascading sugars template
• Requests for flowsheets

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Patient Feedback on Group Clinic

• Almost uniformly positive, except for one
  participant who didnt feel enough 11 time
• Positives identified by patients
• Access to multiple providers
• Links to community resources
• Opportunity to interact with others with diabetes
• dont feel so alone
• can lead a normal life even if you have
  diabetes
• helps to see others are dealing with the same
  things
• all in the same boat
• something to learn from everyone

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PDSA for Flu Vaccination

• Aim Increase rates of vaccination for diabetics
• Problem No record in clinic chart of vaccination
  given by public health
• Plan Registry list given to PHN pre flu season
• Do PHN calling in all registry patients for Flu
  and Pneumovacc as reqd

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Flu Vaccine Runchart
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Outcome Data Flu Vaccination
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PDSA for Flu Vaccination

• Study
• A. Recorded vaccination rates increased from 11
  to 64
• B. Suspect actual vaccination rates also
  increased, as last years peak rate was 48
• Care coordination between clinic and public
  health, and maximizing roles (eg PHN assistant
  role in recall of patients) increased access to
  service
• Act
• A. Obtain toolkit access for some community
  providers
• B. Plan future care coordination initiatives (eg
  group visit clinics)

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90 will have an annual lower extremity exam.
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85 will have a self-management goal documented
annually.
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Self-Management

• Just the Basics CDA sheet selected and
  distributed to care providers as the consistent
  basic diabetes information sheet.
• The self management goal sheet from the CHF
  Collaborative is used consistently by the
  Diabetes Outreach Nurse and entered on the
  toolkit.
• A large binder of resources for patients with
  diabetes, CHF and renal disease has been created
  and distributed to care providers in Masset.
• Health Record books are being given to diabetes
  patients as we see them.
• Pedometers distributed to individuals who
  identify exercise as goal
• Participation in BCCFP SM pilot project with
  trials individual and group goal-setting
• Potential SMP peer leaders attending training
  session this month
• Team of providers doing goal-setting, including
  dietician, public health nurse, nurse and doc

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Community

• Relationships/Partnerships with
• Community health care providers
• Diabetes Outreach Nurse integral team member
• Dietician involvement in group clinics
• Public Health Nurse weekly PDSA meet, clinics
• Plan to involve Mental Health Physio in future
• Community of patients with chronic disease
• SMP training underway
• Community at large
• Links with grocery manager organic food
  delivery
• Plans to link with exercise programs, providers
  of other services at future group clinics (yoga,
  accupressure, massage)

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Spread

• Community health providers dietician, public
  health nurse, community health nurses, mental
  health worker
• Physicians in Queen Charlotte City
• Locum physicians in Masset (10)
• Med students x 2
• Nephrologist

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Functional and Clinical OutcomesMasset
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Functional and Clinical OutcomesQueen Charlotte
City
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85 will have an A1C of lt7.0.
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60 will have a BP of lt130/80 with the BP being
measured every 3-6 months.
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70 will have an LDL lt2.5, done annually.
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70 will have an annual dilated eye exam.
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85 will have an annual ACR (Results lt2.0 M and
lt2.8 F).
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A Story to Share

• FR 55-year-old woman, believes others
  perception of her to be a short, dumpy, fat,
  housewife.
• Sees herself as loving and caring, someone who
  wants to make the community Im in a better
  place.
• From Vancouver, Grade 12 education, married, one
  son, works as a receptionist.
• Medical history
• Type II Diabetes diagnosed 1993
• Other medical problems include obesity (BMI
  46.6), idiopathic cardiomyopathy, CHF, bilateral
  knee OA awaiting TKR, depression
• Meds for diabetes Glyburide, Metformin, Insulin

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A1C over the last year
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Over the last year

• Added Glyburide
• Participated in individual planned visits, 2
  planned visit clinics with diabetes nurse
  educator doc, one group clinic
• Self-management goal-setting as part of SM pilot
  project
• Prefers group clinic

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FRs Personal Action Plan of January 12th, 2005

• 1. What she wants to do
• Lose weight thru diet control
• 2. How
• Reduce coke (regular) from 3 cans per day to two,
  by cutting out coke at lunchtime, replacing it
  with Diet Sprite or water
• 3. Barriers
• Mood tends to drink more coke when stressed
• 4. Plans to overcome barriers
• Anticipates reduced workload job stress soon
• 5. Confidence
• 7/10
• 6. Follow-up plan
• With doc in clinic in 3 weeks
• 7. Update
• At follow-up visit following through with goal
  2 out of 3 days replaced Coke with half-cans
  and using 1 2/day

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Summary Next Steps

• Accomplishments
• Multiple cycles of change tested including all
  elements of CDM model
• Involvement of larger group in CDM planning to
  try and embed successful changes ensure
  sustainability, using PDSAs
• Improvements in process of care measures (ie
  completion rates) and some guidelines (eg BP)
• Delivery system changes implemented to improve
  process of care
• Patient and provider satisfaction
• Spread to multiple other providers
• Next steps
• Maximize and expand roles of team to support
  clinicians
• Focus on self-management support for patients
• Increase community awareness and involvement
• Challenges
• Turnover of providers
• Engaging larger group more actively in PDSA
  planning process

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The End