Spread and Sustainability

1
Spread and Sustainability

• Lessons learned from
• the Diabetes Collaborative
• Presented by
• Dr. A. David Attwell

2
So what have we learned?

• We have heard so many new ideas and innovations
  from the teams
• like

3
What has worked for some teams

• Teamwork
• Patient Registries
• Recall Systems
• Practice Self-evaluation
• Planned Patient Care
• Planned Visits
• Group Visits
• Patient Self-management

4
What has worked for some teams

• PDSAs
• Cascading blood glucose records
• BP tables
• Separating DM from depression visits
• Self-management goal setting visits
• Involving MOAs
• Giving flowsheets to patients
• Small/incremental changes

5
What has worked for some teams

• Target 1 or 2 patients a day
• Outreach from the HAs
• Sharing experiences
• Improving patient access
• Culturally sensitive interventions
• .etc. etc.

6
Future directions

• We will compile the lessons learned from the
  Collaborative to support further work.
• What has worked and what hasnt will also help us
  to make decisions to support you to provide
  better patient care.

7
Diabetes Collaborative

• Our focus has been on processes
• to support the care of patients with diabetes
• Can we take the lessons learned and
• translate them into something more?

8
Diabetes Collaborative

• The first steps in change involved
• how we approach care of patient with chronic
  disease, and
• how we organize our practices to provide that
  care
• Now we need to look at what worked
• (and what didnt)
• and apply it to other areas of care.

9
Why?

• All patients (including those with diabetes) can
  get
• Hypertension
• Vascular Disease
• Breast Cancer
• Prostate Cancer
• Colon Cancer
• Many other medical conditions
• that should be monitored

10
Care of the Complex Patientin The Complex
Practice
11
Who are our complex patients?

• Multiple medical problems
• Chronic diseases / conditions
• Co-morbidities
• Elderly
• Unstable psycho-social situations
• Patients with lists
• Worried well
• etc.

12
What does a complex patient look like?
13
Meet ROZ
14
Medical Hx

• 53 year old lady
• Type 2 Diabetes ( X 5 years)
• Dyslipidemia (treated with a statin)
• Osteoporosis (treated with a bisphosphonate)
• Strong family history of colon cancer.

15
What needs to be done?

• Pap and bimanual pelvic exam every 1 to 2 years,
• Clinical breast exam every year,
• Mammogram every 1 to 2 years,

16
What else needs to be done?

• Annual complete physical exam,
• HgbA1c every 3 to 6 months,
• Albumin/Creatinine Ratio every 6 to 12 months,
• Lipid profile at least every 2 years,
• ALT every 6 months to monitor statin
  side-effects,
• Ophthalmologic examination every 1 to 2 years to
  monitor for diabetic retinopathy,

17
.and ?

• BMD every 1 to 2 years,
• Colon cancer surveillance
• Annual DRE and Occult Blood test
• Colonoscopy every 5 to 8 years.

18
What am I going to do?
19

• You cannot get to the top
• by sitting on your bottom.
• Anon.

20
One problem with complex patients

• Things dont get done that need to be done
• Oversights
• The Care Gap

21
The Care Gap

• The difference between
• the care that patients should optimally receive
• as indicated by medical evidence
• and
• the care that patients actually receive.

22
Provincial diabetes careBC Stats 2000/01

• HgbA1c 39 61
• Urine microalbumin 30 70
• Eye exam 47 53
• Lipid test 72 28

23
Provincial renal statsBC Stats 2002/03

• Patients at risk for renal disease
• DM
• HTN
• CAD
• CHF
• Only 27 had a Creatinine done
• within the previous 5 years

24
Who or what is to blame?

• We are..
• knowledgeable,
• honorable,
• ethical,
• and
• we act in the best interests of our patients.

25
The medical education system has failed patients
and physicians/providers
Contributing factors

• by failing to provide some of the
• most basic tools needed to care for patients
  proactively
• and support physicians in practice.

26
The regulatory system has failed patients and
physicians
Contributing factors

• by decreeing that physicians cannot
• solicit business from their patients,
• which has deterred physicians from
• practicing proactively.

27
The payment system has failed patients and
physicians
Contributing factors

• by not paying for preventive care and
• time needed to provide care,
• which has prevented physicians from
• practicing proactively.

28
Consequently Care tends to be Reactive

• Patient comes in
• We deal with the problem
• The patient leaves
• Some follow-up may be arranged to deal with the
  problem at hand
• But usually patients are followed-up as needed.

29
Reactive care is a problem because

• We are always putting out fires and have to deal
  with the unexpected, so
• Office runs late
• We all become frustrated
• Appointments are rushed
• Important things get missed
• Disease specific
• General
• We are often playing catch-up
• Quality of care suffers so patients suffer!

30
Why do we need to be more Proactive?

• Ethical / moral obligation
• The population is ageing
• Patients are becoming more
• informed
• demanding
• complicated
• litigious
• Our jobs are not getting any easier,
• ..so we need systems to deliver care
• more efficiently and effectively.

31
What needs to be done for ROZ?

• Annual complete physical exam to monitor her
  health, especially diabetes and associated
  complications,
• Pap and bimanual pelvic exam every 1 to 2 years,
• Clinical breast exam every year
• a mammogram every 1 to 2 years,
• HgbA1c every 3 to 6 months,
• Albumin/Creatinine Ratio every 6 to 12 months,
• Lipid profile at least every 2 years,
• ALT and CK every 6 months to monitor Statin
  side-effects,
• Ophthalmologic examination every 1 to 2 years to
  monitor for diabetic retinopathy,
• BMD every 1 to 2 years,
• Colon cancer surveillance
• an annual DRE and Occult Blood test
• a colonoscopy every 5 to 8 years.

32
How can you deal with complex patients?

• Proactively
• Divide and conquer
• and get organized

33
How can we use the tools to help to care for ROZ?

• Patient Registries
• Recall Systems
• Practice Self-evaluation
• Planned Patient Care
• Planned Visits
• Group Visits
• Patient Self-management
• .

34
A different way of looking at practices

• Practices are complex organizations
• We need to implement tools that will help us deal
  with the complexity of practice,
• not just the complexity of individual patients.

35

• Consider that
• Practices are made up of
• collections of individual patients
• that can be grouped by
• certain criteria
• (like age, gender, disease or condition)

36
A typical General Practice of 1600 patients

• Is a complex organization!

37
A typical General Practice of 1600 patients

• 835 females
• 765 males
• 475 patients over age 65
• 225 minors
• 250 patients with hypertension
• 85 patients with diabetes
• 65 patients with asthma
• 30 patients with cancer
• 25 patients with chronic renal failure
• 10 patients with heart failure

38
How can you manage all of these patients?

• Divide and conquer
• and get organized
• in your practice

39
How can you conquer your practice using the
following tools?

• Patient Registries
• Recall Systems
• Practice Self-evaluation
• Planned Patient Care
• Planned Visits
• Group Visits
• Patient Self-management
• ..

40
Lets ask some interesting questions

• Can we now use these tools to
• find those patients at risk of CKD?
• Id bet you can!

41
Lets ask some interesting questions

• Can we now use these tools to
• evaluate what percent of your practice had Pap
  tests, mammograms, DREs, etc ?
• Id bet you can!

42
Lets ask some interesting questions

• Can we now use these tools to
• target a large group of patients at risk of
  osteoporosis?
• Id bet you can!

43
Lets ask some interesting questions

• Can we now use these tools to
• improve your practice income?
• Id bet you can!

44
Lets ask some interesting questions

• Can we now use these tools to
• find those patients eligible for flu-shots?
• Id bet you can!

45
Patients eligible for flu shot

• 835 females
• 765 males
• 300 patients over age 65
• 225 minors 35 under the age of 2
• 250 patients with hypertension
• 85 patients with diabetes
• 40 patients with asthma
• 30 patients with cancer 7 getting ChemoRx
• 25 patients with chronic renal failure
• 10 patients with heart failure
• 450 eligible patients

46
How do you ensure that they get flu shots next
year?

• Use a recall system
• Use ICD-9 coding in future
• so that the registry
• is accurate next year

47
Is there a case for change?

• Is the investment worth it?
• Can it pay for itself?
• Is it better for practices?
• Does it improve your work environment?
• Is it better for patient care?

48

• When one door closes another door opens but we
  so often look so long and so regretfully upon the
  closed door, that we do not see the ones which
  open for us.
• Alexander Graham Bell

49
Is there a case for change?

• I believe there is a case for change
• Improve income
• Improve efficiency
• Improve professional satisfaction
• Reduce Medicolegal risks
• Improve patient confidence and satisfaction
• Improve patient care

50
Another Great philosopher

• You miss 100 of the shots
• you never take
• Wayne Gretzky

51
How do you bring change into practice?

• Do it gradually (Over a year or two)
• One patient at a time
• One chart at a time
• One condition at a time
• One piece of evidence or guideline at a time
• Use or expand your Registry (ICD-9 codes are key)
• Gradually implement or expand your Recall System
• Plan care for patients (Complex patients first)
• Self-management and Group Visits
• Evaluate how you are doing

52
Consider this

• What are the potential legal implications of not
  providing comprehensive care and follow-up?

53
Litigation for errors of OMISSION

• Mainly involve a failure to treat acutely
• But the looming medicolegal threat is
• Failure to treat chronically
• Failure to follow-up
• Failure to monitor
• Failure to manage appropriately

54
Can we implement tools to reduce medicolegal
risks?

• Patient Registries
• Recall Systems
• Practice Self-evaluation
• Planned Patient Care
• Planned Visits
• Group Visits
• Patient Self-management
• ..

55

• Delivering optimal patient care
• Involves a mix of
• patient specific interventions
• combined with
• population based management.

56

• but
• it must make sense for you to do it
• Organizationally and Financially
• if not, it cannot be sustained.

57

• We occupy such a critical role in patient health
• We save lives
• not just today,
• but 5, 10, 20, and 30 years from now!
• We must act now
• in order to have the greatest impact!!

58

• Only those who dare to fail greatly
• can ever achieve greatly.
• Robert F. Kennedy
• Congratulations on completing the collaborative
• and for the courage
• to look at how you practice and to change.

59

• So you thought it was all over?

60

• To keep the momentum going
• We are exploring the use of some of the unspent
  money from the Collaborative to support the work
  that has been started here.
• We intend to have another
• learning session in September
• (at the time of the Self-Management Conference)

61
Thank you

• Co-Directors
• Support personnel
• MOH
• BCMA
• Sponsors
• and to you!

62

• This is not the end,
• nor is it the beginning of the end,
• but it may be the end of the beginning.
• Sir Winston Churchill
• Thank you