Learning Session

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Learning Session 2May 12-14, 2005Atlanta,
Georgia
Cluster Southeast
Hazard Perry County Community Ministries, Inc.
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Hazard Perry County Community Ministries, Inc.

• Hazard, Kentucky
• Population Served
• -In 2004, 619 individuals were served with 2,348
  visits
• - of patients served with Hypertension-270,
  Diabetes-133, Heart Disease-38, COPD-44
• -All patients were homeless or were at risk for
  homelessness
• -Ethnic mix- 90 Caucasian, 10 African American
• -Thus far, in 2005, 104 DM patients are
  participating in the DM collaborative

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Team Members

• Mots Bishnoi, Senior Leader
• Beverly May, FNP, Medical Director
• Jennifer Weeber, Information System Coordinator
• Ruth Woolum, Team Leader

Team Leader Key Contact Info Ruth Woolum,
606-436-0051 email rosie_at_hpccm.org
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Providers

• B. May, FNP D. Ratliff, MD S. Pratt, ARNP
  V. Hopper, FNP K. Donahue, FNP J. Gripshover,
  FNP R. Podapati, MD I. Afaq, Psychiatrist V.
  Yalamanchi, MD A. Govil, MD C Krishnaswamy, MD
  D. Mongiardo, MD J.F. Gilbert, MD F. Koura, MD
  R. Alam, MD J.V. Chandarana, MD J. Pampati, MD
  S. Reddy, MD J. Jolly, DMD S. Napier, DMD K.
  Haynes, DMD N. Stone, DMD J. Caudill, DMD G.
  Combs, OD G. Williamson, MD R. Salisbury, OD
  D. Sizemore, OD C. Wooten, OD C. Varkey, MD
  P.R. Gowder, MD U. Shankar, MD K. Ayra, MD G.
  Stumbo, MD

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AIM Statement

• AIM Hazard/Perry County Community Ministries
  will redesign its system to provide improved care
  for diabetic patients.

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Selected Measures

• This will be accomplished through the
  implementation of the Care Model as evidenced by
• At least 90 of patients will have had at least
  two HgbA1c tests within the past 12 months (at
  least 91 days apart)
• A practice average HgbA1c of lt 7.0
• A least 90 of patients will have their blood
  pressure documented on all visits
• A least 60 of patients will have had documented
  blood pressures lt130/80 within the last 12 months
• At least 70 of patients will have documented
  self management goals
• At least 75 of patients age 55 and older will
  have current prescriptions for an ACE Inhibitor
  or ARB antihypertensive
• At least 70 of patients will have had documented
  LDL levels of lt100 within the last 12 months
• A least 60 of patients aged 12 to 70 will have
  had a random urine micro-albumin within the last
  12 months

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Self-management

• Implemented into our Delivery System
• Implementation of educational tool
• Implementation of self-management tool

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Community

• Implemented into our Delivery System
• Local mental health facilities are providing
  mental health services at our clinic
• Built relationship with two local primary
  healthcare facilities
• Partnered with Diabuddies to access a Certified
  Diabetes educator for our clinic
• We have created partnerships with 2 dental
  providers and 4 optometrists

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Healthcare Organization

• Implemented into our Delivery System
• Collaborative report submitted to BOD on monthly
  basis
• Collaborative report submitted to Quality
  Assurance Committee on a quarterly basis.

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Decision Support

• Currently testing
• We are contacting people who have not had a HbA1c
  test in the last 6 months
• We are contacting individuals who have not been
  to the clinic in the last 120 days
• We are collecting Random Blood Sugars on all new
  patients and diabetics who visit the clinic
• Implemented into Delivery System
• The LPN and nurse aide are flagging charts for
  providers if patient has not been prescribed an
  ACE inhibitor or ARB

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Clinical Information System

• Currently Testing
• We are in the process of performing a review of
  the smoking status of diabetic patients
• We are in the process of performing a review of
  the family history of diabetic patients
• Implemented into Delivery System
• The team audits the accuracy of the lab data
  entered into PECS as needed
• The nurse aide will monitor the accuracy of the
  lab log and ensure all lab results are properly
  filed in the patients chart

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Delivery System Design

• Currently Testing
• Assure that appointment systems support the needs
  of our patients including follow-up activities
  and multiple appointments on same day
• Currently testing a patient chart audit tool
• Implemented into Delivery System
• Implemented a QA chart audit tool for diabetics
• Implemented a peer review document
• Implemented reporting procedures for abnormal
  blood pressure and blood sugar readings

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Functional and Clinical Outcomes

• Measures Goal as of 3/31/2005
• 2 HbA1cs in last yr gt90 7.7
• Average HbA1c lt7.0 7.7
• SM goal setting gt70 11.5
• BP lt 130/80 gt60 43.3
• ACE/ARB for pt over age 55
• gt75 65.2
• LDL levels of lt100 gt70 50
• Random Urine Micro albumin
• gt60 51.9
• Registry Size gt100 104

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National Key Measures
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Senior LeadershipMaking the Case for Change

• We share the Diabetes Registry Summary Report and
  progress on the Collaborative and PECS system
  data entry at monthly board meetings.
• We share client stories that are published in a
  newsletter. This newsletter is circulated to area
  leaders, donors, partners, stakeholders and
  families.

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Communication Plan

• At the Center level
• Monthly staff meetings
• HCH Advisory Council meetings
• Board Meetings
• Patients
• QA committee
• At the Community level
• Community Newsletters
• Flyers at the clinic
• Local Health Fairs

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

• Information systems
• Scheduling systems
• Resources for time and equipment

• Clinical decision making
• Staff responsibilities
• Education for additional staff

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A story to share.the patient

• Sabrinas Home Visit
• HPCCM was recently selected as a part of the
  Southeast Diabetes Collaborative. Sabrina
  Feltner, Family Health Navigator, did a home
  visit with a 61-year old female who is
  participating in Disease Management and the
  Diabetes Collaborative. Sabrina provides patient
  education, outreach, evaluation of
  self-management goals and support. Sabrina asked
  the patient what she had had to eat over the last
  day or so. The patient responded
• Breakfast a can of peas and kool-aid
• Lunch a pack of Hamburger buns after
• scraping the mold off
• Dinner NOTHIING
• Breakfast NOTHING
• Sabrina came back to the Clinic and asked Etta
  Draughn, her fellow Navigator, if she had any
  idea where emergency funds for food would be
  available. Etta reminded Sabrina about the
  Abigails Cookie Jar money that a local donor
  gives to Community Ministries for the very same
  purpose.
• Sabrina and Etta used the Abigails Cookie Jar
  money to purchase groceries for the patient and
  took them to her home. The patient thanked them
  and said that she was going to tell her grandson
  that he could come visit her now as she had food
  to feed him.
• Seeing the patients in the Clinic is not enough.
  Home visits and enabling services are equally
  important. The patients receive the needed
  support and encouragement in their home between
  visits to maintain their self-management goals
  and help get better control over their illnesses.

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A story to share.our staff

• When we were chosen to participate in the
  Diabetes Collaborative we talked with the staff
  about our AIM statement, goals and expected
  outcome measures. We did not know how this
  project would change the way we deliver care to
  patients. In the beginning the staff viewed this
  as more work. At first, the DC team came up with
  the PDSA cycles. As the PDSA cycles and new
  assignments were completed, all the clinic staff
  realized that the overall care we provide to our
  patients has substantially improved as documented
  by the monthly DRSR. The DRSR has also enabled us
  to recognize our accomplishments and areas for
  improvement. Staff are energized and enthused and
  dont see PDSA cycles as more work, rather, they
  see it as means to improving patient care. The
  staff are now coming up with ideas for PDSA
  cycles that will assist us with achieving our
  objectives.

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A story to share.the organization

• We had recently moved into our new clinic space
  when we heard that we were accepted to
  participate in the Diabetes Collaborative. In the
  past, we did not have an information system to
  assist us with tracking demographic data, visit
  information or laboratory results.
• Now, PECS has enabled us to monitor clinical
  outcomes and share information about those
  outcomes with board members, stakeholders,
  providers and clients.
• The organization as a whole is becoming more
  energized about the collaborative as we monitor
  the Diabetes Registry Summary Report. The DRSR
  enables us to see how we compare to the national
  averages.