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NW PA Best Practice Sharing. Practice 1. PA-Spread Patient Centered Medical Home Pilot Project Workflow Redesign to Improve Diabetic Care . Primary Workflow Redesigns. Identified DM patients through an alert in EHR

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practice 1

Practice 1


Patient Centered Medical Home

Pilot Project

Workflow Redesign to Improve Diabetic Care

primary workflow redesigns
Primary Workflow Redesigns
  • Identified DM patients through an alert in EHR
  • Provided patients with a “Scorecard” as a visual aid to educate them on where they are and their goal
  • Proactive documentation of eye and foot exams utilizing fax back forms
  • Comprehensive protocols well established and communicated throughout the entire team
dm alert in ehr
DM Alert in EHR
  • Front office staff enter the alert when they see a DM patient on the schedule
  • Clinical staff enter alert when patient is diagnosed
  • Whenever the patient chart is accessed in the EHR, the alert pops up to remind providers that the patient is diagnosed with DM and they then are prompted to look for the appropriate labs and measures
patient scorecard
Patient Scorecard
  • Implemented to help patients understand where they are relative to where the physician would like them to be for their measurements related to their diabetes.
  • Also helps patients with a sense of accountability, areas that they can affect change to help improve their own outcomes.
eye and foot examinations
Eye and Foot Examinations
  • Practice team took ownership of these parameters, proactively seeking out these results and documentation, rather than the prior attitude of advising they be done, but not necessarily a concerted effort to follow up.
  • Whole team involved in making sure these get done, documented and appropriately charted for capture in the EHR.
comprehensive protocols
Comprehensive Protocols
  • Since participation in the project, providers and staff are communicating better
  • Patients are being seen more frequently when needed to adjust medications
  • With the tighter control of the parameters, seeing earlier medication changes and nephrology referrals
  • Overall increased awareness of the goals
  • Most significant improvement measured:
  • Focused on the “ABCs” of diabetic care (HA1C, Blood Pressure, LDL Cholesterol)
    • Increased number of pts with HA1c<8%
    • Pts with HA1C>9% were <10% entire study
    • Reached and stayed above goal with BPs <140/90 since January!
    • Pt LDLs <100mg% moving steadily upwards!
  • Revised methods of coordinating with eye doctors to better capture eye exam results
  • Steady improvement performing/documenting foot exams
challenges changes made
Challenges/Changes Made
  • Now have a better understanding of what we don’t know!—pulling data from EHR challenging!
    • Team effort between IT, Admin, & Clinicians to determine where data was ‘going’ once entered, where best to enter it, and how retrieve it;
    • Reviewed/removed inactive patients from registry
    • IT embedded a foot diagram that has been stolen by shared with our project partners who use the same EHR;
    • Stole Adopted the self management EHR documentation/capture methods of project partner to measure our efforts. Previously done, but not captured
  • Once clinical staff joined the team, all ran smoother—better understanding in both arenas
  • Anticipate slow continuous efforts to educate remaining staff to change culture/transform practice
future needs
Future Needs
  • Transformation support in the form of

technical assistance—

    • practice facilitation,
    • experts to call on with questions/issues related to data interpretation, process improvement, resources available
  • Financial incentives such as the federal EHR program
  • Reimbursement model that reflects new responsibilities of primary care/pcmh
diabetic score cards
Diabetic Score Cards
  • Snapshot review of diabetes management
  • Provides most recent results for A1C, LDL, urine microalbumin, foot exam, eye exam, and smoking cessation status
  • Easy and concise
  • Included in Clinical Visit Summaries to help with self management goals
eye exam referral sheets
Eye Exam Referral Sheets
  • Inter-office fax forms
  • Communication about appt. time and dates
  • Good for annual recalls
  • Ensures appointments are actually made
  • Easy way to get report back from eye doctor
team approach
Team Approach
  • It’s a Group Effort!
  • Get front office staff and nursing involved in patient care goals
  • Gather information (have A1C ready, make eye exam referral, obtain urine, get shoes off, and complete diabetic score cards)
  • Stream-lines the visit for the provider
  • Rewarding for staff and patients
remaining challenges
Remaining Challenges
  • Improve LDL scores
    • Titrate statins
    • Relieve patient fears concerning statins
  • Continue to work on reducing A1Cs > 9.0
    • System to address our high risk patients / patient non-compliance
  • Continue to stress a high standard of patient centered care!
transformation support needs
Transformation Support Needs
  • Has been a great tool to improve our care of diabetic patients
  • Goal to extend this model to other patient groups
  • Diabetic educators
    • Consider certifying one or more of our current staff members
the good
The Good
  • Learning how to develop chronic disease registries in our EMR
  • Meeting with Optho docs to make sure they were using the right codes for our patients to get credit for their exams
  • Carrying a monofilament in my pocket and making sure every room has one in a drawer
  • Being more aggressive with starting insulin
  • Being more aggressive in the initial titrations of meds
    • Lisinopril 10 mg instead of 5mg
    • Atorvastatin 20 mg instead of 10 mg
the bad
The Bad
  • Unable to get our EMR vendor to have a high alert label/button on the opening screen to identify high risk populations
  • Changing office culture (allowing for different tasks by different people)
  • Changing patients’ behaviors’
    • Many did not want to take additional classes on diabetes self management
    • Many patients gained weight while having their medications titrated
    • Could not convince more than half of my patients to have an eye exam in the last 1 year
the ugly
The Ugly
  • Predicted cost to my practice for NCQA recognition using model from our recent webinar.
    • 2 new MAs—one per physician
    • 1 clinical care coordinator
    • Cost of NCQA recognition
  • Estimate of above is $75,000
Estimate of diabetics in full practice = 600
  • With 3 visits per year (every 4 months) = 1800 visits
  • Additional payments from having NCQA recognition = 1800*$27 = $48,600 if every patient had commercial insurance
  • OVIM is 25% commercial = $12,150 in reimbursement
  • Net annual loss = ($62,850)