CHI Diabetes Toolkit Using Diabetes to introduce Population Based Care

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CHI Diabetes Toolkit Using Diabetes to
introduce Population Based Care

• David Swieskowski, MD, MBA
• dswieskowski_at_mercydesmoines.org

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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

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4 Ps 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 dont need to schedule an appointment
  for the care system to reach out to them
• Planned
• Designed to be effective, complete, consistent,
  and sustainable

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Rationale for Population Based Care The 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. 2003348(26)2635-2645)
• Blood sugar is controlled in only 37 of patients
  with diabetes
• (JAMA. 2004291(3)335-342)
• Blood Pressure is controlled in only 35 of
  patients with hypertension
• (Ann Intern Med. 2006145(3)165-175)
• Every system is perfectly designed
• to get the results it gets

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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.

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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

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CHI HgA1C Data April 2008
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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

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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

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Communities Knowledge Communities Physician
Practice Leadership PMAC Members CHI Diabetes
Toolkit 2008
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CHI Diabetes ToolKit File Structure
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1. Organization of Health CareChronic 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

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Also in this section

• Corporate bylaws establishing the MCI Quality
  Committee
• Physician VP for Quality Job description
• MCI Quality Mission Statement

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MCI Quality Mission Strategies

• Measurement
• Information technology
• Chronic Care Model
• Standardization
• Partnering
• Transparency
• Communication
• Self-management support

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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

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Diabetes standing lab orders
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Standing Orders Flowsheet
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Framingham 10-year CHD Risk Assessment Calculator
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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

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Business Case for Data Collection
and Population Management
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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

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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

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EXCEL Diabetes Registry

• Keep only the most recent visits 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

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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

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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

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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

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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

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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

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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

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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
• 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

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To Enter Data Sort Alphabetically by Last
Name Duplicates can be removed manually or in
bulk using Excel features
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To determine A1c values by range Sort by HgA1c
Result
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To identify patients who are overdue for
care Sort by Date of most recent HgA1c
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To Create performance reports
Sort by Provider and then value
Dr. A
Dr. A
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Excel Spreadsheet for Expanded Diabetes Data
Collection
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Sample Patient LettersOne example
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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

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Downloadable at http//www.mercyclinicsdesmoines.
org/Quality/HealthCoachPaperAMGA208.pdf
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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
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• Diabetes Audit form
• Used for
• Pre-visit review
• Order form
• Data collection

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Pre-visit Review Audit Form 1
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Pre-visit Review Audit Form 2
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Pre-visit Review Audit Form 3
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CMS PQRI Diabetes Data Collection form
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Diabetes HTN Standing Orders Flowsheet Done in
Excel
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Standing Orders Flowsheet
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Diabetic Foot Exam Documentation Form On the
back of the diabetes flowsheet
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5. Self-Management Support

• This section of the Toolkit contains
• 5As Self-Management support forms
• Goal Setting form
• Patient education handouts

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5As Self Managememt Support Form Specific for
Diabetes
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5As Self Managememt Support Form Generic for any
condition
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Diabetes Self Management Goal Setting Form
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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6. Reference MaterialCommunity Resources

• This section of the Toolkit contains
• PDFs (or links) of publications that may be
  useful

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Downloadable at http//care.diabetesjournals.org/
cgi/reprint/31/Supplement_1/S5
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Downloadable at http//www.qualityforum.org/pdf/r
eports/diabetes_update.pdf
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Downloadable at http//www.iom.edu/Object.File/Ma
ster/27/184/Chasm-8pager.pdf
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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 teams efforts

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All of this material is currently available in
the Diabetes Toolkit found athttp//www.mercycl
inicsdesmoines.org/Quality/docs/Toolkits/toolkits.
htm