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CHI Diabetes Toolkit Using Diabetes to introduce Population Based Care . David Swieskowski, MD, MBA dswieskowski@mercydesmoines.org. CHI Ambulatory Quality Goal. Starting with HgA1c data collection, CHI physicians and ambulatory care administrators will:

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chi diabetes toolkit using diabetes to introduce population based care

CHI Diabetes ToolkitUsing Diabetes to introduce Population Based Care

David Swieskowski, MD, MBA

dswieskowski@mercydesmoines.org

chi ambulatory quality goal
CHI Ambulatory Quality Goal

Starting with HgA1c data collection,

CHI physicians and ambulatory care administrators will:

  • Make population based care a core competency of CHI primary care practices
  • Create a culture of measurement and continuous improvement in CHI ambulatory care practices
4 p s of the population based care
4 P’s of the Population Based Care
  • Population based
    • Success is measured by the percent of the entire population that is meeting goals
  • Patient centered
    • Patient needs motivate care delivery
  • Proactive
    • Patients don’t need to schedule an appointment for the care system to reach out to them
  • Planned
    • Designed to be effective, complete, consistent, and sustainable
slide4

Rationale for Population Based CareThe current care delivery system was design for acute episodic care and does a poor job for chronic and preventive care. Until there is fundamental system change we will not do much better than the following:

  • Evidence based care given only 55% of time
    • (NEJM. 2003;348(26):2635-2645)
  • Blood sugar is controlled in only 37% of patients with diabetes
    • (JAMA. 2004:291(3):335-342)
  • Blood Pressure is controlled in only 35% of patients with hypertension
    • (Ann Intern Med. 2006;145(3):165-175)

“Every system is perfectly designed

to get the results it gets”

pmac hga1c quality recommendation
PMAC HgA1c QualityRecommendation

All MBOs with FP or IM employed physicians should track HgA1c electronically for all patients with diabetes and report aggregate HgA1c data at least quarterly

  • Goal is to improve glycemic control in the diabetes population and to introduce population based disease management to the MBOs.
initial metrics
Initial Metrics
  • % of HgA1c tests ≤ 7.0

and

  • % of HgA1c tests ≤ 8.0

Defined by: NQF Measure # 14

    • Most recent HgA1c value by range
      • ≤6.0, 6.1-7.0, 7.1-8.0, 8.1-9.0, 9.1-10.0, >10.0
      • Denominator includes only patients seen in the last year
      • Remove upper age limit
why not wait until the aehr
Why not wait until the AEHR?
  • Most AEHRs do not function as registries that support population based care
    • It will take 5 years for system wide HgA1c reporting
  • The HgA1c data collection process is relatively easy, inexpensive, has a positive ROI immediately, and produces better health outcomes now
  • It is important to learn population based care prior to implementing an AEHR
    • Then design AEHR processes support it
chi diabetes toolkit

CHI Diabetes Toolkit

  • The Toolkit is designed to help MBOs comply with the PMAC HgA1c quality recommendations
  • This PowerPoint Highlights the contents of the CHI Diabetes toolkit.
    • Scrolling through the slides is an easy way to learn what is available
  • All the documents on this powerpoint (and more) are available in the folders on the CHI web site
    • Communities » Knowledge Communities » Physician Practice Leadership » PMAC Members » CHI Diabetes Toolkit 2008
slide10
Communities » Knowledge Communities » Physician Practice Leadership » PMAC Members » CHI Diabetes Toolkit 2008
1 organization of health care chronic care model
1. Organization of Health Care“Chronic Care Model”
  • The Chronic Care Model provides the theoretical framework for redesign of care delivery
  • The Model has six domains that are all important to improve chronic and preventive care
  • The CHI Diabetes Toolkit is organized according to the six domains
also in this section
Also in this section
  • Corporate bylaws establishing the MCI Quality Committee
  • Physician VP for Quality Job description
  • MCI Quality Mission Statement
mci quality mission strategies
MCI Quality Mission Strategies
  • Measurement
  • Information technology
  • Chronic Care Model
  • Standardization
  • Partnering
  • Transparency
  • Communication
  • Self-management support
2 decision support
2. Decision Support
  • Guidelines are to set the goals and to help in the design of your QI program not for physician use during care of the patient
  • Standing Orders standardize care
3 information systems registry the single most important step to improve chronic care
3. Information Systems – Registry “The single most important step to improve chronic care”
  • This section of the Toolkit contains:
    • A sample HgA1c Excel spreadsheet with practice data
    • A powerpoint describing how and why to create a HgA1c database in Excel
properties of a registry
Properties of a registry
  • Create lists of patients:
    • With a defined condition
    • Overdue for care
    • Not meeting outcome goals
  • Create performance reports – that give the % of population meeting goals
    • By provider, clinic, or system
  • Create patient summary reports
how to get started with and excel registry
How to Get started with and Excel Registry
  • Pick one provider to be the program champion and start the registry with his/her patients
  • Identify patients with diabetes
    • From billing or lab systems (HgA1c done)
  • Set up the registry in Excel
    • Back load one year of HgA1c data
  • Enter new data as patients come for visits
    • Write over any pre-existing data (save only the last value)
  • Create lists of patients overdue for care or not meeting goals and send them a letter to come in.
  • Prepare quarterly reports
  • Spread to a second provider when it is working well for the first provider
  • Finally add microalbumin to the registry to make the economic case
slide27

EXCEL Diabetes Registry

  • Keep only the most recent visit’s data
  • Sort alphabetically to enter data
  • Sort by date to find Pts. overdue for testing
  • Sort by value to find poorly controlled Pts.
  • Registry PowerPoint is in the toolkit
data needed for hga1c registry
Data Needed for HgA1c Registry
  • Patient ID
    • Lastname, first name, birthdate
  • Provider Who ordered the test
    • May not be the patient primary care provider, but it is the easiest way to assign a provider
  • HgA1c data
    • Date of test, result
where to find hga1c data
Where to find HgA1c Data
  • In office
    • Is there a log of all tests (CLIA requires this)
      • Use the log for your source of data
  • Reference lab
    • Can you get aggregated electronic reports
      • Enter them electronically or manually into the registry
    • If no electronic report then create a paper or electronic log as reports come in
on going data collection test done in office
On-going Data CollectionTest done in office
  • Keep a log of HgA1c tests in the lab
    • Columns in the log are:
      • Name, birthdate, provider, date done, result
    • Once a day or once a week add the newly done tests to the Excel spreadsheet
    • If there is already a result in Excel erase it and put the new one in
on going data collection test done in reference lab
On-going Data CollectionTest done in reference lab
  • Log all HgA1c tests sent out
    • Name, birthdate, provider, date sent out, result
  • Log all HgA1c tests when they return
    • Add the result (this also confirms none are lost)
  • Once a day or once a week add the newly done tests to the Excel spreadsheet
  • If there is already a result in Excel erase it and put the new one in
resources needed for a1c data collection
Resources needed for A1C Data Collection
  • Average FP has 100 patients with diabetes
  • Average patient comes in 3 times a year
  • 300 diabetes visits and 200 working days
    • 1-2 diabetes visits per doctor per day
    • 7-8 diabetes visits per doctor per week
  • At 3 minutes of data entry time per visit
    • 5 minutes per doctor per day
resources needed for diabetes population management
Resources Needed for Diabetes Population Management

Monthly

  • Sort Excel by Provider then A1c results
    • Give list of patients not at goal to provider
  • Sort Excel by Provider then Date of A1c
    • Give list of patients overdue for A1c to provider
  • Send letters to patients needing care
    • 5 letters per provider / month
  • Staff time required for sorting and sending letters
    • 1 hour per provider per month
    • Cost of letters $1.00 each
resources needed for national data reporting
Resources needed for National Data Reporting

Reported Quarterly

  • Local staff Collect the Excel spreadsheets for each clinic in the MBO
    • Paste into one spread sheet
    • Sort Excel by date and delete all rows with results greater than 1 year old
    • Sort remaining rows by value and calculate the percent < 7.1 and < 8.1
    • E-mail the aggregate MBO result to CHI
    • Time: 1.5 hours a Quarter
  • CHI Central staff
    • Take results and create a national report by MBO
    • Time: 2 hours a Quarter
slide36

To Enter Data:

Sort Alphabetically by Last Name

Duplicates can be removed manually or in bulk using Excel features

slide38

To identify patients who are overdue for care:

Sort by Date of most recent HgA1c

slide39

To Create performance reports:

Sort by Provider and then value

Dr. A % < 7.0

= 3/7 = 42.9%

Dr. A % < 8.0

= 5/7 = 71.4%

slide40

Excel Spreadsheet

for Expanded Diabetes Data Collection

4 delivery system redesign
4. Delivery System Redesign

This section of the Toolkit contains:

  • Health Coach Position
    • Paper about office based health coaches
    • Job Descriptions
      • Three descriptions for different skill levels
  • Pre-visit chart review forms
  • Diabetes Flowsheets
  • Office visit charting forms
slide43

Downloadable at:

http://www.mercyclinicsdesmoines.org/Quality/HealthCoachPaperAMGA208.pdf

health coach job description
Health Coach Job Description

Essential Functions:

  • Oversees the disease registry database…
  • Conducts pre-visit chart review…
  • Works with patients and families on Self-Management Support…
  • Coordination of Care across the care continuum…
  • Involvement in QI activities

Three job descriptions are available from the Inside CHI web site

slide45

Diabetes Audit form

  • Used for:
  • Pre-visit review
  • Order form
  • Data collection
slide52

Diabetic Foot Exam Documentation Form

On the back of the diabetes flowsheet

5 self management support
5. Self-Management Support

This section of the Toolkit contains:

  • 5A’s Self-Management support forms
  • Goal Setting form
  • Patient education handouts
slide57

5A’s Self Managememt Support Form

Generic for any condition

slide58

Diabetes

Self Management

Goal Setting Form

6 reference material community resources
6. Reference MaterialCommunity Resources

This section of the Toolkit contains:

  • PDFs (or links) of publications that may be useful
slide68

Downloadable at:

http://care.diabetesjournals.org/cgi/reprint/31/Supplement_1/S5

slide69

Downloadable at:

http://www.qualityforum.org/pdf/reports/diabetes_update.pdf

slide70

Downloadable at:

http://www.iom.edu/Object.File/Master/27/184/Chasm-8pager.pdf

steps to population based care
Steps to Population Based Care
  • Set up a registry
    • To identify and track the population
  • Organize a team
    • To manage the project
    • Include a physician champion
  • Create a Diabetes Guideline
    • To direct the team’s efforts
slide72

All of this material is currently available in the Diabetes Toolkit found at:http://www.mercyclinicsdesmoines.org/Quality/docs/Toolkits/toolkits.htm