PROGRAM FACULTY

2. PROGRAM FACULTY Stewart B. Harris MD, MPH, FCFP, FACPM Canadian Diabetes Association -Chair in Diabetes Management Ian McWhinney Chair of Family Medicine Studies Professor-Schulich School of Medicine & Dentistry, The University of Western Ontario Rick Ward MD, CCFP, FCFP Calgary Foothills Primary Care Network Patsy Smith MN, RN PLS Consulting Inc. Canadian Nurses Association CONTRIBUTORS Steve Szarka, B. Eng, M. Eng, MD, CCFP Assistant Clinical Professor, McMaster University, Faculty of Family Medicine Hamilton Family Health Team, Hamilton ON John McDonald MD CCFP – Lead Physician - PrimCare Family Health Team President and Chair – Association of Family Health Teams of Ontario Durhane Wong-Reiger  BA, MA, PhD Institute for Optimizing Health Outcomes, Canada Maureen Clement  MD CCFP Medical Director, Diabetes Education Centre Vernon Jubilee Hospital Assistant Clinical Professor, University of British Columbia Alice Y.Y. Cheng, MD, FRCPC Endocrinologist Credit Valley Hospital and St. Michael's Hospital Assistant Professor, Dept of Medicine University of Toronto This program and enduring materials are aligned with Consensus Guidelines and have been developed by the Program Faculty with input from Inter-Disciplinary Practice Teams, other diabetes experts and healthcare professionals including Physicians & Allied Health Practitioners involved in Family Health Teams (Ontario) and Primary Care Networks (AB). as well as Associations e.g. CDA,, MoHLTC, Ontario FHT’s, Professional Associations etc.

3. Disclaimer: The following information may refer to drugs or indications that have not been approved by Health Canada. While AstraZeneca has provided financial support for the program, this presentation was created by an independent steering committee and accredited by an independent accrediting body. AstraZeneca does not endorse any use of its products other than in accordance with the current version of the Health Canada approved labeling.

4. Facilitators • Provide names and credentials of the facilitators for this specific clinic session

5. Disclosure of Potential for Conflict of Interest • Financial Disclosure • Grants/Research Support- XYZ Pharma Co • Speakers Bureau/Honoraria • Consulting Fees: XYZ Company • Other: Employee of XXY Hospital Group

6. Clinic Team Introductions • Clinic “Champion” and Clinic Team Members • What does your Clinic Team hope to achieve today?

7. Learning Objectives Primary Objectives: • Following this program, participants will be able to: • Apply principles of chronic disease management to their panel • Manage Diabetes Mellitus (DM) patients as a team based on the agreed upon Pathway • Establish outcomes to assess changes made as a result of this process • Develop and implement an action plan utilizing strategies and tools that will optimize type 2 diabetes patient management in their clinic Secondary Objectives: • Following this program, participants will be able to: • Maximize interdisciplinary team based care using available resources • Increase trust within team • Provide new models and options for managing DM within a primary care team using Chronic Disease Management (CDM) principles

8. Pathways to Diabetes ManagementProgram Goals: • Provide interdisciplinary diabetes health care (DHC) teams with a structured, step-wise approach to develop individualized, practical Diabetes Action Plans using guidelines-based strategies and tools to: • Improve Patient Health outcomes • Promote team effectiveness • Optimize practice efficiency • Increase patient access to treatment Teams require practical, implementable approaches to care delivery

9. PROGRAM OVERVIEW Step 1 Step 2 Step 3 Step 4 Step 5

10. Diabetes Practice Management Practice Guide Participant Workbook Practical Strategies, Tools & Materials Canadian Nurses Association Patient Education Toolkit

11. Today’s Agenda [to be customized based on event’s start and end time]

12. The Clinical Challenge • Diabetes Care in Family Practice • CDA Guidelines: Therapeutic Goals and Organization of Care

13. Diabetes Care in Family Practice • The challenge: Diabetes is a complicated, growing disease: • More than 9 million Canadians live with diabetes or prediabetes1 • Risk of CV death is 2-4 times greater than in the general population2 • 25% of patients with diabetes suffer from depression2 • 11% of patients with diabetes have 3 or more co-morbidities2 “Despite increasing evidence about the benefits of effective management, little progress has been made in providing effective care” —CDA Guidelines Committee Canadian Diabetes Association. http://www.diabetes.ca/diabetes-and-you/what/prevalence. Canadian Diabetes Association – 2008 Clinical Practice Guidelines. http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf

14. Primary Care Challenge • Average practice has between 100-200 patients with diabetes1 • Patients with diabetes visit their family physician on average 8 times per year2 • Thus, the burden on the clinic is significant (this does not even include the burden of those with cardiometabolic risk)1 DICE: Diabetes in Canada Evaluation study2 Most recent A1C test results (n = 2,337) One in two type 2 diabetes patients in Canada are not at target (< 7%)Mean A1C = 7.3% Uncontrolled A1C 49% Controlled A1C 51% Steering Group Communications. Harris SB, et al. Diabetes Res Clin Pract 2005; 70:90-7.

15. Chronic disease management for diabetes and vascular disease could result in the avoidance of annually……1 • 8,000 heart attacks • 4,000 strokes • 8,000 unnecessary deaths • 1,200 cardiac bypass and balloon angioplasties • 369 amputations Few mechanisms exist to implement practical solutions Q Monitor, Ontario Health Quality Council 2008 Report On Ontario’s Health System.

16. Therapeutic Goals CDA Guidelines:1 • Goal of treatment is to minimize the risks of the macrovascularand microvascularcomplications of diabetes by aiming for the following metabolic targets Ontario Ministry of Health: Quality Targets for Primary Care Physicians2 • Example: Baseline Diabetes Dataset Initiative Targets The Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada., Can J Diabetes. 2008;32(suppl 1):S1-S201 Ontario Ministry of Health- Quality Targets for Primary Care Physicians: http://health.gov.on.ca/en/ms/diabetes/en/about_diabetes_care_rep.html

17. CDA Recommended Diabetes Surveillance Timely screening for complications and aggressive management of risk factors are integral parts of diabetes management. Harris S., Lank C. eds. Elsevier 2008.

18. CDA Organization of Care Guidelines Good Outcomes for people living with diabetes depend on: The “System”….. A Team Based Approach Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines.2008. http://www.diabetes.ca/documents/for-professionals/Fact_Sheet_FINAL_FOR_WEBSITE.pdf.

19. Team Approach • Impact on Patient Outcomes: What does the data show us? • Team Effectiveness

20. Hollander Report:Primary Care Practices Are the Cornerstone of Effective Chronic Disease Management • Health outcomes are a function of continuity of care by the same family physician1 • Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs1 • Group Patient Visits may facilitate attachment by enhancing patient access, time with the medical team, and supportive services provided 2,3 Hollander MJ, et al. Healthcare Quarterly 2009;12(4): 32-44. Steering Group Communications. Noffsinger EB. The Permanente Journal 1999 ; 3 (3): 58-67.

21. Increasing Value for Money in the Canadian Health- care System: New Findings on the Contribution of Primary Care Services Diabetes and CHF – RUB 5 (2007-2008) Cost Reduction Attributable to Attachment Congestive Heart Failure (CHF) Diabetes $ (CDN) $13,250 $16,114 Proportion of Total Cost Attributable to Hospital Costs 65% Percentage of Attachment Hollander MJ, et al. Healthcare Quarterly 2009;12(4): 32-44.

22. Primary Care is Essential for Optimal Chronic Disease Management • Individuals with a primary care practitioner that they saw on a regular basis had lower rates of hospital use, specialist use and costs1 Attachment to a practice was the best predictor of a patient’s overall healthcare costs – more so than other variables such as patient age, gender, income or physician gender and practice span.1 Hollander MJ. et al. Healthcare Quarterly 2009;12(4): 32-44.

23. Shared Medical Appointments Based on the Chronic Care Model A Quality Improvement Project to Address the Challenges of Patients with Diabetes with High CV Risk1 • Setting: Primary care clinic • High CV risk defined as one or more of the following: • A1C levels >9% • Systolic Blood Pressure (SBP) > 160 mm Hg • Low Density Lipoprotein cholesterol (LDL-C) >3.53 mmol/L • Patient characteristics for each group were similar AIM: Improve outcomes for patients with diabetes at high cardiovascular risk via Group Patient Visit (GPV) implementation Kirsh S, et al. Qual Saf Health Care 2007;16:349-353.

24. Better Cardiovascular Risk Reduction was Observed in Patients Attending Group Patient Visits (GPV)1 HbA1c P= 0.002 LDL-c P= 0.29 SBP P= 0.04 2.9 = 2.54 = 0.14 = 0.41 = 1.44 = -0.30 = 14.83 2.8 11 155 2.7 Mean mmol/L % Mean mm Hg 2.6 Mean % 10.5 150 2.5 10 145 9.5 2.4 140 2.3 9 135 2.2 8.5 2.1 130 8 Control GVP Control GVP Control GVP Baseline Follow-up Control n= 35 GPV n=44 Patients participating in GPV experienced greater benefits in HbA1c, LDL-c and SBP levels compared to usual core patients. Kirsh s, et al. Qual Saf Health Care 2007;16:349-353.

25. Team Effectiveness in Diabetes Treatment • Why a team? • What are the attributes of an effective team? • Why is this important?

26. Team Efficiency1-5 Features of high performing teams • The delegation of key roles to non-physicians • Coordinated patient flow strategies: Triaging, multiple access points, advanced access, EMR registry recall, case management • Group visits/shared medical appointments • Disease-specific targeted “Mini” Clinics • Integration of specialist care when appropriate Common challenges • Time • Pressure to provide both acute and preventive care • Volume pressure • Fee-for-service • After hour access • Long wait times • Focus on task substitution vs. teamwork • Underutilization of interprofessional health team EICP - Enhancing Interdisciplinary Collaboration in Primary Health Care. April 2005. McMurchy D. CIHR, 2009; retrieved from: www.chsrf.ca Barrett et al. CHSRF. 2007 Kirsh S, et al. QualSaf Health Care 2007;16:349-353. Steering Group Communications.

27. Team Effectiveness results in…1-5 Improvement in: • Practice efficiency • Professional satisfaction • Patient access– reduced wait time • Care coordination • Comprehensiveness of care • Preventative care • Achievement of metabolic targets • Self-care capacity • System navigation/health literacy • Quality of life • Follow-up (less falling through the cracks) • Patient satisfaction Reduction in: • Hospital admissions • ER use • Outpatient visits • Blood pressure • Cholesterol • Risk of complications Aschner P, et al. Int J Clin Pract Suppl. 2007; 157:22-30. Sperl-Hillen et al. JT Comm J Qual Saf. 2004;30(6):303-309 Vargas RB et al. J Gen Intern Med . 2007;22(2);215-222 McMurcahy D. CIHR, 2009;. Barrett et al. CHSRF. 2007. Steering Group Communications.

28. Diabetes Care Teams….A System Change Points to consider:

29. Diabetes Care Teams….A System Change Working together as a team includes…

30. Protocol Setting — what does the data tell us? CHAMP Results Increase in use of therapies in post MI treatment 100% 92% 86% 80% The UCLA Medical Center’s Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) increased guideline intervention 78% 61% 60% 56% 40% 20% 12% 6% 4% 0% Pre-CHAMP Post-CHAMP Aspirin Beta-blocker ACE Inhibitor Statin Fonarow GC, et al. Am J Cardiol 2001;87:819–822.

31. Protocol Setting — what does the data tell us? CHAMP Results Death or Recurrent MI% 20% 14.8% 15% CHAMP protocol reduced death or recurrent myocardial infarction 10% 6.4% 5% 0% Pre-CHAMP Post-CHAMP Fonarow GC, et al. Am J Cardiol 2001;87:819–822.

32. Summary

33. Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION

34. WORKSHOP OUTLINE • Step 1A - Priority Patient Population • Step 1B - Patient Management Needs • Step 1C - Team Readiness • Step 1D – Diabetes Resource Inventory • ACTIVITIES: • Review results of Clinic Assessments • Validate/align the direction and outcomes of the assessments with the team • Fine-tune the direction (if required) • MATERIALS: • Summary of Clinic Assessment Results • Diabetes Resource Inventory Note MBC on 15 July that not directional enough and Mike to advise - CHECK Materials are provided in the Participant Workbook

35. Summary of YOUR Clinic Assessment Do you agree?

36. Diabetes Resource Inventory What resources did you identify?

37. Team Reflection and Alignment Exercise • What did you learn about your patients? Your team? Clinic efficiency gaps and opportunities? • Do any of the results surprise you? • Do you agree that, by focusing on the areas highlighted in the Clinic Assessment Summary, your team can make a difference in the treatment of DM patients? • Priority Patient Type – goals and outcomes • Build a Registry (if required) or assess • Improved team care • Scheduling Methods • Is your team READY to develop and implement a team-based diabetes management program? MAKE ACTION PLAN NOTES

38. Clinic Team Regroup • Share key learnings from Team Reflection and Alignment Exercise • Learnings about your patients, your team and clinic efficiency gaps and opportunities • Highlight any areas in which your Clinic Team would benefit from feedback/input from the larger group MAKE ACTION PLAN NOTES

39. Workshop Outline Develop or Access Clinic Diabetes Registry ACTIVITIES • Do you have a Clinic Diabetes Registry? • Why is it important? • Review EMR and Manual registry options MATERIALS • Diabetes Practice Guide Materials available in Diabetes Practice Guide

40. The Role of the Clinic Diabetes Registry Does your clinic have a Diabetes Clinic Patient Registry? As indicated by the CDA’s Organization of Care Guidelines, a Diabetes Patient Registry is a very important step in patient management. Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines.2008. http://www.diabetes.ca/documents/for-professionals/Fact_Sheet_FINAL_FOR_WEBSITE.pdf.

41. EMR Patient Registry Track patients using appropriate “data searches” • Identify and categorize “specific” patients by category or billing information • Identify patients who require intervention by conducting a data search based on disease-specific clinical outcomes or problems list • Examples: A1C > 7%; BP >130/80 mm Hg; Elevated cholesterol levels • Facilitate outcomes measurement ** Is your EMR an effective/optimal Registry tool? If not, contact your EMR provider for assistance Diabetes Registry Fields

42. Manual Patient Registry EXCEL Diabetes Patient Registry • Track patients via commercially available spreadsheets • Registry could be populated… • at diagnosis • when reviewing charts or at patient’s next appointment • when lab results or consultation reports are received • Notes: • Registry management should be assigned to one team member to ensure it is updated • Although a registry is a key element, some “patient practice” changes can be made while the registry is being developed (e.g. scheduling patients more efficiently) Ortiz D. Family Practice Management, Fam Pract Manag. 2006 Apr;13(4):47-52. retrieved from: www.aafp.org.

43. Diabetes Registry Next Steps • If no Clinic Diabetes Registry: • PRIORITY FOR THE CLINIC ACTION PLAN SHOULD BE SETTING UP AN EMR OR MANUAL REGISTRY • If Clinic Diabetes Registry is in place: • THINK ABOUT OPPORTUNITIES TO IMPROVEEFFICIENCY • FOCUS ON PRIORITY PATIENT TYPE DIABETES TEAM ACTIVITY CHECKLIST IMPLEMENTATION MAKE ACTION PLAN NOTES

44. Clinic Team Regroup • Share key learnings • Clinic diabetes registry development or assessment • Overall input/collaboration with other Clinic Teams MAKE ACTION PLAN NOTES

45. Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION

46. Workshop Outline Priority Patient Type, Diabetes Team Activity Checklist, Scheduling Methods ACTIVITIES: • Validate your Clinic’s Priority Patient Type • Review your Diabetes Resource Inventory • Complete the Diabetes Team Activity Checklist and Assign Team Roles • Review and Select Scheduling Method MATERIALS: • Clinic Needs Assessment Summary • Diabetes Resource Inventory • Priority Patient Type - Diabetes Team Activity Checklist: (one of the following: Prediabetes, New Diagnosis, Ongoing Management, Insulin Starts, Complex Patient) ACTIVITIES: • Validate your Clinic’s Priority Patient Type • Review your Diabetes Resource Inventory • Complete the Diabetes Team Activity Checklist and Assign Team Roles • Review and Select Scheduling Method MATERIALS: • Clinic Needs Assessment Summary • Diabetes Resource Inventory • Priority Patient Type - Diabetes Team Activity Checklist: (one of the following: Prediabetes, New Diagnosis, Ongoing Management, Insulin Starts, Complex Patient) All materials can be found in the Participant Workbook. Descriptions of scheduling options are located in the Practice Guide.

47. Step 3A: Validation of Priority Patient Type • Using the criteria below for your Priority Patient type, describe a patient in your clinic practice that would fit this profile • What are the major challenges faced when dealing with this patient? MAKE ACTION PLAN NOTES

48. Step 3A: Review of Diabetes Resource Inventory • What resources can we utilize to help manage this patient type? • What resources are we missing? MAKE ACTION PLAN NOTES

49. Step 3B: Complete the Diabetes Team Activity Checklist Diabetes Team Activity Checklists: Lists of CDA recommended activities for each patient type • Utilize the Diabetes Team Activity Checklist for your identified priority patient type • Assign roles to each task – think about the resources on the Diabetes Resource Inventory Considerations: • Delegation of key tasks to non-physicians • Coordinated patient flow strategies • Integration of specialist care • Utilization of interprofessional resources Diabetes Team Activity Checklists are provided in the Participant Workbook

50. Clinic Team Regroup • Share • Priority Patient Type and rationale • Potential patient management changes based upon the Priority Patient Checklist Review • Highlight any areas in which your Clinic Team would benefit from feedback/input from the larger group MAKE ACTION PLAN NOTES