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East Carolina University/Bertie Memorial Hospital

Delivery Design “ an improvement model of diabetes care” a project funded by the Robert Wood Johnson Foundation. East Carolina University/Bertie Memorial Hospital East Carolina Health-Bertie All-County Health Services Paul Bray, MA., Skip Cummings, Pharm.D., Jolynn Harrell, RN.

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East Carolina University/Bertie Memorial Hospital

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  1. Delivery Design“an improvement model of diabetes care”a project funded by the Robert Wood Johnson Foundation East Carolina University/Bertie Memorial Hospital East Carolina Health-Bertie All-County Health Services Paul Bray, MA., Skip Cummings, Pharm.D., Jolynn Harrell, RN

  2. KeystoDeliveryDesign • Education with coaching (E-C) is the primary tool used to achieve patient self-management • E-C is delivered by an advanced skilled non-physician clinical staff • E-C is delivered at the time of the (primary care provider) PCP visit • The physician’s and (Educator/coach) EC form a care team • The physician’s leadership is very important to the team’s success • Nurses and front desk support staff play important and expanded roles • There are 6 Steps to the delivery design; 4 steps PCP visit redesigned and 2 steps education-coaching

  3. Step 1: Monthly QI (Quality Improvement) Team Meetings • Team reviews 3-5 evidence-based clinic panel outcome indicators including A1C & BP, • Team initiates corrective PDSA (Plan, Do, Study, Act) cycles • Team reports outcomes quarterly to board of directors, or governing body

  4. Clinical Measures Reviewed in QI Meetings Phase I

  5. Step 2: Nurse schedules all patients through standing orders for E-C & Labs • Standing Orders • E-C with initial Dx of DM • E-C at minimum every 12 months • E-C visit asap for A1c >8 • A1c q 3 months • Eye exam report every12 months • Lipid panel q 12 months • Shoes off every provider visit

  6. Nurse scheduling of education based on clinic calendar • Same day if EC is on-site • Schedule EC for same day if follow-up PC visit is within 30 days • If follow-up is not within 30 days, schedule a brief PC visit and EC same day • Empowerment of nurse to expedite urgent EC visits (A1c>8.0, TRG >300, BP> 150/90, BS>200, open wound, or combination) • Nurse linking EC, PCP & Doctor • Coordinates PCP introduction of EC to patient • Coordinates PCP brief visit to E-C session • Coordinates E-C during exam room waiting times

  7. Step 3: Support staff scheduling follow up and tracking • Follow-up appointments scheduled as directed by PCP or EC • New diagnosis, 3-4 visits focused on key self-management objectives • Follow-up visit scheduled for key learning objectives (i.e. glucose testing, insulin management and bs goals) • New start insulin/medication or changes in insulin/medication dose follow up within 2 weeks • Visits follow-up <30 days apart with a1c > 8

  8. Support Staff ( front desk, etc.) calls and reminds all patients one day before visits • Support staff calls and re-schedules all no-shows • EC calls patient after two no-shows • Educator-coach empowered to re-schedule

  9. Step 4: Team consultations for most patients • Hall-way brief case conferences • Brief visit by PCP in education • Brief visit by EC in exam rooms • Physician will ask “what is the clinical goal & SM goal?” • Any team member is encouraged to schedule case conference for difficult or puzzling patient at monthly QI meeting • Educator-coach empowered to recommend medication-insulin (depending on skill)

  10. Step 5: Focused 1st E-C Visit • Use short intake summary questionnaire form • Chart consulted: confirm diagnosis, medications, labs, A1C, consult progress notes • Seek quick understanding of issues & barriers; clarify why a medication may not be working, determine patient’s knowledge base, literacy, length of diabetes, ability to test blood sugars • Clarify blood sugar goals, basic nutrition knowledge, basic survival skill knowledge • Key inquiry: what did you eat in last 24 hours, how did it affect blood sugars? • Check office meter against patient’s meter: Do they have a glucometer and are they competent in its use, are supplies affordable, do they understand how to use results?

  11. Step 5: 1st Visit (con’t) 7. Standard 1st visit self-management goal: • Check blood sugars as prescribed, return to next scheduled DM visit with log and meter; • Begin to understand how portions of carbohydrates and activity impact bs results. • Always have return visit in mind. Proceed to check-out, for scheduling of next appointment --or add E-C visit to next physician appointment. 8. Encourage next visit to be with care-partner • At end of first visit: Patient should believe they can have control over their diabetes and they should have some definition of blood glucose – and how numbers impact health • Final words to patient ALWAYS, “what is your diabetes goal today?”

  12. Step 5: 1st visit (con’t) 11. Seek out physician for 2 minute hall-way consultation 12. Provide “introduction to diabetes” hand-out, provide score sheet to record bs Information gathered in the 1st visit is entered into EMR forms. These forms can then report the progress a patient is making in diabetes management both to the patient and the health care team. The following two screen shot slides are reproductions of the clinic’s EMR diabetes forms (in Centricity EMR).

  13. Step 6: Follow-up 2nd to 4th to ongoing visits • At least monthly visit until blood sugars stable • Prioritize key ADA (American Diabetes Association) curriculum issues that are preventing diabetes management • Order of modules – based on intake assessment – most problematic or crucial to least problematic.

  14. Step 6: 2nd visit and on (con’t) • Work towards education in each ADA curriculum module • Disease of DM, A1C, BS goals, Basic meal planning • Nutrition and Carbohydrate Counting • Nutrition and Heart Disease • Weight loss • Exercise • Dealing with diabetes, living with life style changes, psychological impact • Self management and complications of diabetes • Medications and monitoring • Problem Solving

  15. Step 6: 2nd visit and on (con’t) • End each session with self-management goal (SMG), begin each session with review of SMG, review of blood sugars, challenges faced in self management. • Implement Motivational Interviewing model to enable self-confidence in ability to make healthy change. • Screen for Depression • Problem solve Eye Exam

  16. Step 6: 2nd visit and on (con’t) The following PDF files detail the diabetes curriculum used by the EC http://nc-e-care.com/Teaching_points_Overview_Class.pdf http://nc-e-care.com/Teaching_points_Intro_class_1-4.pdf http://nc-e-care.com/Teaching_points_Nutrition_Class.pdf http://nc-e-care.com/Teaching_points_Nutrition_and_Cholesterol.pdf http://nc-e-care.com/Teaching_points_Medication_Class.pdf

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