Washington State Collaborative Learning Session 3

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MOVING THE MOUNTAIN The Tacoma Family Medicine
Experience in System Change
Presented by Janelle Guirguis-Blake, MD
Angela Conklin RN
Washington State Collaborative Learning Session
3 September 11-12, 2006
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Tacoma Family Medicine/MultiCare Health System

• Residency training program
• full-scope Family Physicians for rural and
  underserved communities.
• 10 Faculty Physicians and 24 residents
• Location downtown Tacoma
• One of several MultiCare clinics wide geographic
  area from Kent south to Pierce County and
  Steilacoom.
• Patient population diverse and multi-cultural.
• TFM serves as MultiCare Health Systems main
  non-hospital point of health care access for DSHS
  patients.
• Collaborative pilot 175 current patients, seen
  in the clinic in the past year, cared for by all
  clinicians (34), age 18-75 years, multicultural.

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Aim Statement

• Tacoma Family Medicine Residency Clinic will
  create a comprehensive chronic disease management
  program for Diabetes Mellitus to include
• Planned Visits
• Group Visits
• Self Management
• Connection with Community Resources
• Residency Education
• Implementation of this program will result in
  achieving goals as identified.

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Measures

• Most recent HbA1c lt 7.0
• Average HbA1c for patients with A1c reading in
  the last year
• Most recent BP lt 130/80 mmHg
• Most recent LDL lt 100mg/dl
• Average LDL for patients with LDL reading in the
  last year
• Documentation of Self Management goal
• Tobacco-cessation counseling
• Daily Aspirin Use
• Neurosensory foot exam in past year

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The Planned Care Model
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Key Changes in Self Management Support and
Delivery System Design
Health System
Community
Organization of Health Care
Resources and Policies
Self Management Support
Clinical Information Systems
Decision Support

• Delivery System Design
• Divided Patient Lists on Electronic Health Record
  (EHR)
• Front Office staff call patient based on protocol
  for appt.
• Staff message sent to nursing
• Nursing has phone Diabetic visit or Office
  Diabetic Nurse
• Labs ordered
• PCP visit
• Scheduled for 3 month visit and/or Group visit

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Informed, Activated Patient
Prepared Practice Team
Productive Interactions
Mrs. Cs Diabetic Visit Front Office Staff member
runs patient list and notices that Mrs. C. hasnt
been seen in the clinic for a diabetic check in
the past year, although she has been seen in the
urgent care for a sinus infection just 1 month
ago. Front Office staff person call Mrs. C., and
talks with her about scheduling an appointment
for a Diabetic Nurse Visit and an appointment
with her provider. Mrs. C is scheduled to see the
nurse on Thursday morning and scheduled to see
her provider the following Tuesday. The Front
Office staff sends a staff message to the nursing
pool informing them of the upcoming appointment.
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TFM WAC Diabetic Front Office Work Flow

• STEPS
• Click on Patient List from Tool Bar.
• Expand the Shared Patient Lists by clicking on
  the sign.
• Select the list you will be working.
• (see next slide for list descriptions and
  individual WFs)
• To make an appointment, double click in the Next
  Appt Date column.
• The report at the bottom of the screen will show
  you
• Past and Future Appointments
• The Lab Alert
• When you have completed the appointment,
  highlight the patient and click on the remove
  button.

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• If attempt to contact patient is unsuccessful,
  due to incorrect phone number, lack of phone,
  etc., schedule an appointment per protocol and
  send a letter to the patient regarding
  appointment, include appointment card with letter
  sent.
• If a patient has stated they are no longer
  receiving care here, have changed PCP/clinic,
  please contact (Admin Asst.) regarding this info.
• Telephone Scripts for Front Office Staff
• For Lab Alert Appointments
• Hello Mr/Mrs./Ms. (pt. name), This is
  (receptionist name) from Dr. (PCPs name) We
  need to schedule a short appointment for you with
  Dr. (pcp) regarding your diabetic lab work. You
  will also be receiving a telephone call from one
  of Dr. (PCP) nursing staff, regarding some labs
  that you will need to have completed, that will
  be ordered for you.
• Can you schedule that appointment now?
• Thank you, please remember to bring your diabetic
  log book to your appointment.
• For Past Due Appointments
• Hello Mr./Mrs./Ms. (pt. name). This is
  (receptionist name) from Dr. (PCP name) office.
  We have noticed that you havent been seen for
  your diabetes care in the past year. I would
  like to schedule a Diabetic Nurse Appointment and
  an appointment with Dr. (PCP name) for you at
  this time.
• Thank you, please remember to bring you diabetic
  log book to your appointments
• For Now Due Appointments
• Hello Mr./Mrs./Ms. (pt. name). This is
  (receptionist name) from Dr. (PCP name). We see
  its time to schedule your next 3 month diabetic
  check. Id like to schedule your Diabetic Nurse
  appt. and your Dr.s visit now.
• Thank you, please remember to bring your diabetic
  log books to your appointments.

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Mrs. Cs Nurse Visit

• Mrs. C. arrives for her nurse visit. The nurse
  has already reviewed her last labs and
  immunizations. The nurse visits with Mrs. C,
  completes her history, reviews and administers
  immunizations, orders lab work needed based on
  protocols and standing orders. The nurse also
  reviews her medications documenting any changes.
  The nurse then does a foot exam including a
  monofilament exam. She reviews with Mrs. C. the
  importance of good foot care.
• Towards the end of the visit, the nurse and Mrs.
  C. talk about her self-management goals on what
  Mrs. C. feels like she would like to work on and
  accomplish.
• The nurse reminds Mrs. C of her upcoming
  appointment with her provider and also gives her
  a brochure on Diabetic Group visits, and
  instructs her to stop by the lab on her way out.
  The nurse also enters any referrals Mrs. C may
  need such as eye exam, etc.

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• Before the patient is roomed, look at the
  patients chart and HM alerts to see what labs and
  immunizations are needed. Check when the patient
  has had their last eye exam and diabetes
  education.
• Room the patient.

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• Open the Diabetes Nurse Only encounter.
• Review Allergies in the Allergy Activity
• Open the TFM WAC Diabetes Smartset.

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• Select a reason for visit, labs, procedures,
  immunizations, other orders, progress notes,
  diagnosis, follow-up, and LOS. (Some may be
  defaulted with red check)
• Accept/Sign the Order

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• The order for the foot exam will appear.
• Answer the questions with the pre-defined
  answers.
• Add comments if necessary
• Click Accept
• Open the Foot Image (38) and document the status
  of the petal pulses
• Intact All pulse sites are positive
• If negative site document the site with a
  number and description.

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• In the Visit Navigator, complete the Vitals
  sections.
• In the Nursing Notes section, enter any
  additional information the patient has. (Brief)
• Continue to the Review Section
• Read the next appointment date to the patient
  from the Appt Rpt
• Review current medications and previous test
  results with patient
• Review immunizations with patient and determine
  which ones the patient will accept.
• Move on to Documentation Section

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• Review Dx and Orders in Order Entry
• Click on Quick Questions which will open the
  section. Enter the answers to the questions, and
  perform the glucose test.
• Open Progress Notes topic and F2 through the
  options to complete the preconfigured notes.
• If needed (based on questions in the notes) place
  order (order entry) for eye exam and diabetes
  education. Obtain ROI for any test results not
  completed at a MultiCare clinic.

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• Click on Enter Results and enter the glucose test
  results. Route the results to the provider seeing
  the patient for the next diabetes visit (see Appt
  Rpt topic).
• Click Accept
• Open the Goals topic
• Click on the Go To hyperlink.
• Select the Diabetes Self-Management Goals letter.

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• Ask the patient if they are willing to work on
  the items listed on the next slide, and use the
  corresponding smart phrases to fill in the
  information
• Save and Print the patients goals.

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TFM WAC Diabetic Back Office Work Flow

• STEPS
• Open the Pt. Instructions topic and print any
  McKesson clinical references needed.
• Administer and document any Immunizations
  ordered.
• Under LOS Follow-up, CC the chart to the
  provider who will be seeing the patient for the
  next diabetes visit (see Appt Rpt topic).
• Exit Workspace leaving the encounter open.

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Mrs. Cs PCP Visit

• The following week, Mrs. C arrives for her
  appointment with her PCP. As her provider enters
  the room s/he is able to review the labs drawn
  last week and review the Nurse Only visit for
  history, medication issues and any other issues
  documented during the nurse only visit.
• The PCP uses the Diabetic Visit template which
  prompts standards of care to address needed
  medication adjustments and follow up on any care
  deficiencies.
• The PCP is able to spend time discussing
  self-management goals, importance of diet, and
  follow-up.
• As Mrs. C is ready to leave, the provider also
  encourages her to attend the Diabetic Group
  visits offered monthly and to please schedule an
  appointment for 3 months to again have a check
  with the nurse and himself.

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TFM WAC Diabetic Back Office Work Flow Provider
Visit

• STEPS
• Open the Office Visit
• Open the MMA Endo DM smart set
• Select a Chief Complaint, Progress Notes, Orders,
  Immunizations, DM HM Orders, Counseling,
  Diagnosis, Follow-up, and LOS. (Some may be
  defaulted with red check)
• Accept/Sign the Order
• Complete the standard Office Visit Navigator.
  (See below)

Notes This visit uses the standard Office Visit
Navigator with the MMA Endo DM smart set.
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What Have We Been Doing Lately?PDSAS

• Division of patient lists based on
• Lab alert! Most recent A1c value gt8
• Past Due Patient not seen for Diabetic check in
  past year
• Next Due Patient due for 3 month check-up
• Front Office Staff Training
• Workflow Scripts
• All Nurse Training
• In Office Telephone Nurse Onlys
• Standing Orders
• Staff messages
• Competency for Diabetic Foot Exam

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Diabetic Nurse Telephone Encounter

• Epic based telephone encounter reason for call
  Diabetes. In comment DM nurse phone contact
• Use smart phrase to document
• Phone Visit Script Hello this is ____ from
  (clinic name) Dr. (PCP) has asked me to call you
  to review some information so he can have that
  information available at your next diabetes appt.
  Do you have 10-15 minutes to spend over the phone
  to discuss your current medications and labs
  needed before your scheduled appt.?
• If patient refuses, schedule a time to call back
• If patient agrees
• Review all current medications document any
  discrepancies
• Review labs with patient if labs due inform the
  patient to come in 2-3 days prior to appt. so
  that lab results will be available at time of PCP
  visit. Enter order as future order
• Review immunizations if due document specific
  immunization needed
• Review with patient date of last eye exam, if
  none for past 12 months generate a referral
• Review last time met with Diabetic
  Educator/Nutritionist if none for past 12
  months ask patient if they would like referral
  placed.
• Review list of self management goals and
  encourage patient to pick one, inform patient
  that material on the goal will be mailed to them
• Thank patient for spending time, remind them of
  up coming appointment and required lab work. Also
  ask them to bring all their meds (or list of meds
  and doses) and their blood sugar log book to the
  appointment.

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MultiCare Health SystemsTacoma Family
MedicineDiabetic Foot Check Competency

• 1. RN/LPN/MA verbalizes understanding of
  rationale for foot check.
• 2. RN/LPN/MA inspects all areas of the foot and
  nails
• 3. RN/LPN/MA accurately palpates pedal pulses.
• 4. RN/LPN/MA can utilize monofilament correctly
• 5. RN/LPN/MA can identify and document presence
  of foot or toe deformity
• 6. RN/LPN/MA can list 3 reason to notify a
  physician immediately following foot exam
• 7. RN/LPN/MA can follow and complete all areas of
  foot exam appropriately
• Competency is achieved when 100 is met

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Diabetic Foot Exam Educational Packet

• This educational packet is designed to be used
  for nursing staff when working with patients that
  may have a disease process that results in
  insensitivity such as diabetes. This packet will
  help to identify current foot problems or a foot
  at risk of developing problems.
• Diabetic neuropathy is a degenerative disease of
  the peripheral nerves and a common complication
  of diabetes. Autonomic, sensory and motor
  functions may be affected individually or in a
  combination with varying degrees of severity.
  This nerve damage can create conditions in the
  foot that produce secondary problems such as
  deformity and foot ulceration, which may lead to
  more severe problems. By using these tools
  included, one can hope to minimize or eliminate
  the devastating effects of peripheral neuropathy
  through careful monitoring of the feet with the
  foot exam, patient education and appropriate
  referral to a foot care specialist when needed.

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The Foot Exam

• 1. Inspect the foot between the toes and from
  toe to heel. Examine the skin for injury,
  calluses, blisters, fissures, ulcers or any
  unusual condition.
• 2. Look for thin, fragile, shiny and hairless
  skin all signs of decreased vascular supply.
• 3. Feel the feet for excessive warmth and dryness
• 4. Remove any nail polish. Inspect nails for
  thickening, ingrown corners, length, and fungal
  infection.
• 5. Inspect socks or hose for blood or other
  discharge.
• 6. Examine footwear for torn linings, foreign
  objects, breathable materials, abnormal wear
  patterns and proper fit.

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• Y or N to indicate findings R L
• Is there a foot ulcer now or a history
• of foot ulcer? __ __
• Is there a toe deformity? __ __
• Is there abnormal shape? __ __
• Are toenails thick or ingrown? __ __
• Are pedal pulses present?
• Can patient see bottoms of his/her feet? __ __
• Is patient wearing improperly fitting shoes?__ __
• How often does patient check feet?______
• Monofilament exam

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PDSAs continured

• MD Template for Diabetic Visit
• Smart Set Developed
• Template sent to Faculty for feedback
• Signs posted on all computers to remind
  physicians how to access
• Resident didactics updated to teach most current
  ADA standards of care
• Brochures Developed
• Diabetic Nurse Only
• Diabetic Group Visits

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Neuro Foot Exam
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What Happened?
Reasons given for declined Nurse Only Visits 1.
Transportation 2. My doctor already does
that 3. I am seen in Podiatry 4. Insurance
issues
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Barriers

• That Cant Be Done!
• Theres not enough time for that
• Thats not the way I would do it
• Why cant we get this out to the entire system?
  (by tomorrow)
• Just release it! (today)
• ALL CULTURAL ISSUES

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What We Have Learned

• BE PERSISTENT!
• DONT GIVE UP!
• OUR PATIENTS ARE WORTH IT!
• REVISE,REVISE, REVISE
• You can never advertise or include others too
  much
• KEEP IT ON OTHERS RADAR!