Anne Barber RN(EC) MScN Michele MacDonald Werstuck, RD MSc CDE Lisa McCarthy, RPh BScPhm Pharm D Inge Schabort, MB ChB CCFP A Diabetes Program in Family Practice: How to Do It!
Disclosure • The presenters perceive no conflict of interest with this presentation. • Slides will be available at: www.stonechurchclinic.ca
Session Objectives • At the end of the session, participants will be able to: • Discuss strategies to identify patients with diabetes including screening approaches, disease registries. • Describe options for maximizing your capacity for providing care including flowsheets, templates, connecting with an interprofessional team. • Access a library of vetted patient and provider resources.
Objectives • To help you... • Identify your patients with diabetes • Start a diabetes clinic /diabetes day • Build a diabetes team • Experiment with group medical visits • Access resources to get you started
Who are we? • Provide primary care for nearly 30 000 patients in Hamilton and surrounding area • 2 clinical teaching units affiliated with McMaster University and Hamilton Health Sciences
Who are we? Stonechurch MFP Physicians 16 (12.7 FTE) 13 (7.5 FTE) Family Medicine Residents 32 (10-12 full-time at any one time) 34 (12-13 at any one time) RN(EC)s 4 (3.5 FTE ) 4 (4.0 FTE) Dietitians 2 (1.0 FTE) 1 (0.8 FTE) Mental Health Therapists 3 (2.6 FTE) 3 (2.4 FTE) Clinical Pharmacists 2 (0.8 FTE) 2 (0.8 FTE) Consultants Palliative Care, Psychiatry, Geriatrics, Internal Medicine
Caring for Patients with Diabetes • Step 1: Identify your patients with diabetes • Do you do this in your practice? • If yes, what has been your experience? • If no, how might you approach it?
Step 1: Identifying Patients with Diabetes • Do you currently track your patients with diabetes (paper, EMR)? • Is your registry accurate? • What criteria did you use to create your registry?
Step 1: Identifying Patients with Diabetes • Lessons Learned: • Tidy up data • Team meetings to reinforce consistent data entry (EMR), documentation • Those with confirmed diabetes enter into your registry
How do you screen for patients with diabetes? • Periodic health exam • Other chronic disease visits • Maximize screening during opportunistic encounters • Whatever your strategy, think sustainability
Step 2: Maximize Your Interprofessional Team • What practitioners do you have available? • What are the essential components for patient care? • How can you maximize scopes of practice for each professional?
Bottom Line “The vast majority of people don’t need glitzy miracles; we need sound, evidence-based, timely, respectful and well communicated primary health care from a team dedicated to getting it right.” Steven Lewis, a Saskatoon-based health policy consultant and part-time academic
The Need for Teamwork • Consider: • Number of patients with diabetes • Number of visits per patient per year • Can be overwhelming to manage alone
MYTH:Stress has no effect on diabetes.FACT:Stress can increase your blood sugar and throw your diabetes out of control. Ask for help with stress management.
Step 3: A Diabetes Clinic (Day) Should your practice have one? • What resources are available to your patients with diabetes right now? • What Diabetes Education Clinic (DEC) services exist? • Do you have providers with a keen interest in diabetes management?
Diabetes Clinic Cont`d • Who will you service? • Determined by: • Patient needs • Skills of your team (e.g., comfort with managing insulin) • What resources already exist within the community
Preparing for Your Diabetes Clinic • Referral system • Triaging system • Team meetings • e.g., case review, team building • Debriefing
Offering a Diabetes Clinic • Let’s brainstorm... • What equipment will you need? • What patient and provider resources do you have available? • Which will you need to locate or create?
Offering a Diabetes Clinic: Equipment • Insuiln (consider in-house supply) • Equipment • Glucometers, one-time use lancets, ketone tests (blood and urine) • Hypoglycemic Emergency Kit • Glucose tablets, juice boxes, injectable glucagon, instructions about how to use kit
Offering a Diabetes Clinic: Resources • If it exists, use it (with permission, of course)! • Don`t forget team education, training with resources • HHS patient education library • www.stonechurchclinic.ca • Goal setting sheet • Diabetes Clinic Follow-Up Visit (list of expectations, what to bring) • Starting with Bedtime Insulin • Diabetes Passport
Step 4: Using a Diabetes Flowsheet • A management MUST! • Try using different flowsheets to find your favourite • If using EMR • Link flowsheet with disease registry and incoming labs
Step 5: Maximize Use of Templates • For example: • Stamps for documentation (electronic or paper) • Frequently used patient education materials • Goal setting, action planning sheets • Hypoglycemia • Starting insulin therapy
Diabetes Group Medical Visits • What is the difference between the group education and group medical visit? • What are the benefits of the group medical visit? • What are the challenges of the group medical visit?
Sharing our Experience: What It Looked Like • Introductory Session • (planned 20 minutes, really 60 min!) • Evolved into discussion with patients • Patient sharing of experiences • (planned 20-30 minutes, could have been longer)
What It Looked Like Cont’d • ‘The Circuit’ • Planned 30 min, Really 45-60 min • Stations for: vitals, foot exam, doctor check-in • Floating IHPs to do goal setting while awaiting the circuit • Group Wrap-Up • Planned 10 minutes, Really cut short!
How We Did It… Find and prepare patients Determine roles, logistics Preparation!!! Deliver Document and Debrief 6) Plan for the next one
Finding Patients • Identified potential patients through EMR • Assumes disease registry or some other mechanisms to identify • Physician vetted list • RPN reached out to recruit • Reminder calls day before
Preparing Patients • Persuasive RPN • Do labs week before, bring all medications, supplements etc., blood glucose records, 3 day food diary, glucometer, told vitals and feet would be examined, consent and confidentiality required • Biggest Draw: extended visit with THEIR family doc!
Preparing Ourselves • Define roles • IMPACT BC Guide (http://www.impactbc.ca/practicesupport/pspmodules/groupvisits) • Logistics • room set up, finding time (evening?), booking space and equipment
Preparing Ourselves Cont`d • Planning the Visit (many team meetings) • Presentation • Intro, what to expect from group visit and for future care, patient sharing of experiences, goal setting • Detailed chart review, • Prepare labs, flowsheet for physician • (most time consuming)
What We Learned • Minimum 15-20 patients registered • Patient packages helped to speed up process • Factor in preparation and documentation time • Patients Loved this Experience!
Group Introductory Visits • Building on prepared patient concept • Initial session offered to patients referred to DM clinic • Introductory diabetes education • How to prepare for follow-up visits • What to expect • What to bring
Resources • Visit our website • www.stonechurchclinic.ca • Canadian Diabetes Association • www.diabetes.ca • Dietitians of Canada • www.dietitians.ca • Hamilton Health Sciences Patient Education Library • www.hamiltonhealthsciences.ca • The Diabetes Food Guide • www.centretown.chc.org
Slides will be available at: www.stonechurchclinic.ca Contact Information: firstname.lastname@example.org email@example.com firstname.lastname@example.org Thank you!