Diabetes Best Practices Symposium Sponsored by AMGA and Merck

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Diabetes Best Practices SymposiumSponsored by
AMGA and Merck Co., Inc..October 21-22,
2009Detroit, MI

• Improving Diabetes Care and Outcomes An
  Integrated Approach to Population Management
• St. Marys/Duluth Clinic Health System

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St. Marys/Duluth Clinic Health System (SMDC)

• Integrated health system Founded in
  1915, one of the countrys first multi-specialty
  practice groups
• 4 hospitals / 17 clinics
• 438 physicians and 450 credentialed practitioners
• 55 specialties/subspecialties
• gt 1M annual patient visits

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• SMDC clinics are located over 25,000 square miles
  and serve a population of nearly half a million
  people
• 18.7 people per square mile
• Incidence of diabetes ranges from 5-10 across
  counties served

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Team-Based Approach

• Effective coordination and collaboration among
  all available personnel within a practice and
  with external resources

• Patient
• Physician
• Mid Level Provider
• RN
• Certified Medical Assistant
• Schedulers
• Patient Educators
• Nurse on Line
• Information Management (Clarity)
• Information Services (Epic)

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Value in Teams

• Patients reap the benefits of more eyes and
  ears, the insights of different bodies of
  knowledge, and a wider range of skills. Thus team
  care has generally been embraced by most as a
  criterion for high quality care.
• -Dr. Edward H. Wagner, BMJ, February 2000

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Improvement Interventions

• Impact of Practice Changes Review of Diabetes
  Care

Shojania, K.G.et al JAMA 2006296427-440
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Goal Transform the delivery of care to patients
with diabetes who receive their care at SMDC

• Change from a system that is reactive to one
  that is proactive
• Patient-centered - high priority given to
  patients participation, confidence skills in
  managing illness
• Evidence-based - care delivered according to
  proven clinical pathways and health services
  interventions.
• Valuing excellence (and evidence) over
  autonomy
• Population-based - focus on assuring needed care
  to all members of a population rather than simply
  individual patients (e.g., use of registries)
• Consistent clinical experience for patients
  across all sites

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Population Identification

• 11,500 patients with diabetes
• 22 gt 75 yrs old
• 77 have co-morbidity of HTN
• EPIC (EMR platform) feeds into data warehouse
  Clarity
• Data updated weekly- can be run more often

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Interventions Key Elements

• Patient registry
• Evidence- based guidelines
• Collaborative team practice model
• Effective patient self-management and education
  tools
• Process and outcome measurement, evaluation and
  management
• Routine reporting and feedback loop to providers

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Registry



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Self-Management Support

• Partnering with patients to help them become
  informed and activated with the motivation,
  information, skills, and confidence necessary to
  effectively make decisions about their health and
  manage it
• ADA Certification of all sites in collaboration
  with Duluth Clinic Diabetes Center
• Motivational Interview training for RN educators
  (multi-day training)

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Reporting and Feedback Loop

• Routine reporting feedback loop
• Data is provided at physician,clinic and system
  level on monthly basis
• Incorporates evidence-based guidelines
• Process and outcome measurement
• Data is transparent within the health system
• Reported on Balanced Scorecard

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Results Reported on System, Clinic and Provider
Level

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Improvement Interventions

• Lean six-sigma
• Value-stream mapping
• Identify waste, gaps and major constraints in
  care delivery
• Cross-functional teams
• Lean design concepts applied to core processes
  and system.

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Improvement Interventions

• Centralization of select patient services
• Pre-visit planning
• Outreach to overdue patients
• Best Practice Alerts (BPA)
• A workflow that attempts to ensure that patient
  schedules next appointment at conclusion of
  current appointment- including lab orders with
  lab done prior to appointment lab first
• Every patient. Every time.

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Improvement Interventions

• Centralization
• Scheduling
• Pre-visit planning
• Refill authorization and
• RN triage services (Hybrid model)
• Supports Health Care Home
• Patient Care Coordination Center
• Nurse On Line

• Every patient. Every time.

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Improvement Interventions

• Monthly Volumes
• Patient Care Coordination Center
• 60,000 calls per month
• 2,900 outbound calls per month
• 34 FTE
• Nurse On Line
• 20,000 refills per month
• 8,500 triage encounters per month
• All documented in Epic
• Staffed 24 hr
• 28 FTE

• Every patient. Every time.

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Improvement Interventions

• Patient Care Coordination Center
• Raise the minimal qualification of schedulers to
  include clinical knowledge
• Centralized scheduling of primary care clinics
  template standards
• Use of health maintenance alerts to support
  evidence-based best practices and lab first.
• Working the list (e.g. registry) and pre-visit
  planning

• Every patient. Every time.

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Improvement Interventions

• Leverage Epic
• Health Maintenance Alert

• Every patient. Every time.

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Improvement Interventions

• Lab First
• BPAs fire by diabetes diagnosis and last test
  result
• A1C
• Lipid Profile
• LDL
• Creatinine
• MicroAlbumin

• Every patient. Every time.

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Improvement Interventions

• Lab First
• Drug Monitoring BPAs fire by medication and
  diagnosis
• Cholesterol ReducingAST
• Cholesterol ReducingLipid Profile
• AntihypertensiveCreatinine
• Diuretic AntihypertensivePotassium
• Diuretic AntihypertensiveSodium
• Other
• Yearly eye exam and mammogram

• Every patient. Every time.

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Improvement Interventions

• Every patient. Every time.

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Improvement Interventions

• Nurse On Line
• 24 Hour Triage and Refill Support
• 50 RNs with dual licensure (28 FTE)
• Support 24 hour patient access required as part
  of Health Care Home Model.
• Triage
• Appointment Scheduling
• Refill Authorization

• Every patient. Every time.

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Improvement Interventions

• SMDC Refill Protocol
• Jointly authored by physicians/pharmacists
• Used for all Primary Care
• Leverages Epic
• Safety net for patients with chronic disease
• Medication management labs
• Appointments needed
• Patient education

• Every patient. Every time.

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Measures Used

• Process Measures
• A1C q 6 months
• LDL q 12 months
• Outcome Measures
• A1C lt 7
• LDL lt 100
• BP lt 130/80
• Daily ASA ( 40 yrs)
• Documented non-tobacco use
• ADA Guidelines
• Institute for Clinical Systems Improvement

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Challenges

• Change Management
• "Change is hard because people overestimate the
  value of what
• they haveand underestimate the value of what
  they may gain
• by giving that up. Belasco/Stayer Flight of
  the Buffalo (1994)
• Physician Engagement
• Clinical Inertia and Unexplained Variance
• Accountability for implementation and results,
  i.e. becoming a culture of consequences
• No Net New
• Ensuring that efficiencies gained allow for value
  added activities without increase in resources
• Defining values by external customer (patients
  and families) rather than internal (staff,
  physician, payers)

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Outcomes and Successes

• Key Elements
• Leadership- senior and local level
• Strong information technology support
• EMR
• Information Management/Data Collection
• Communication

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Process Measures of patients with A1C in last
6 months if patients with LDL in last 12 months


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Outcome Measure of patients with BP lt 130/80


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Public Reporting MNHealth Scores of Patients
Meeting All 5 Treatment Goals n 9,325 (2008
dates of service)


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Lessons Learned

• Communication is essential
• Do not underestimate the response to change in
  status quo
• The vocal, unhappy minority cannot steer the ship
• Senior leadership support is invaluable
• Involve patients in planning process
• Not a quick fix
• Improvement to metrics will take time
• Will require sustained commitment
• Clear definition of roles and responsibilities
  will help project move forward
• You get what you expect and you deserve what you
  tolerate

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Future Steps

• Pursue Health Care Home (Medical Home)
  Certification
• Rework compensation model (RVU linked to outcomes)

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Questions