Diabetes Collaborative LS

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Diabetes Collaborative LS 3 Storyboard

• Queen Charlotte Islands
• Masset

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Team Members

• Cindy Talarico, RN, Diabetes Nurse Educator
• Susan Lyster, Masset Clinic Manager
• Vanita Lokanathan, Family Physician

Team Leader Contact Info Vanita Lokanathan
vanita.lokanathan_at_northernhealth.ca 250-626-4702
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Aim Statement

• Redesign office practice using the Chronic Care
  Model to improve the management of chronic
  illness, using Diabetes as a prototype for office
  system redesign.

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Key Measures

• 85 will have an A1C of lt7.0.
• 60 will have a BP of lt130/80 with the BP being
  measured every 3-6 months.
• 70 will have an LDL lt2.5, done annually.
•  70 will have an annual dilated eye exam.
•  85 will have an annual ACR (Results lt2.0M and
  lt2.8F).
•  90 will have an annual lower extremity exam.
•  85 will have a self-management goal documented
  annually.

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Clinical Information Systems

• Status of Registry in Masset
• 124 patients with diabetes
• 121 with Type II, 3 with Type I
• 9 patients with CHF entered in toolkit
• 4 patients with chronic renal failure
• Persons trained to enter data in toolkit include
  Clinic Manager, Office Assistant, DM Nurse,
  Physician

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Profile Report
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Clinical Information Systems

• Status of Registry in QCC
• 120 patients entered into toolkit
• Most of data entry by DM Nurse, some by
  physicians
• Masset Clinic Manager working with counterpart in
  QCC to train in toolkit use

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Use of Toolkit in Planning Care

• Recall system used in planning care
• To capture missing services eg foot exams with
  Podiatrist, eye exams with visiting
  Opthalmologist
• By Diabetes Nurse Educator to recall for
  individual visit
• By team to prioritize those to invite for
  Planned Visit combined clinics, with group
  education component

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Use of Toolkit in Planning Care

• Use of sorting mechanisms to determine patients
  with needs
• Assess individual need for planned visit or other
  delivery system interventions to improve care eg
  outliers on data extremes report, those with
  complications such as nephropathy, those with
  missing services
• Assess population need for delivery system or
  organizational changes ie where are the biggest
  gaps in process of care, access to services (foot
  or eye exams, flu vaccination, availability of
  dietary counselling)

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Use of Toolkit in Planning Care

• Routine data entry and updating system
• Importance of ongoing data entry to keep registry
  updated and useful and avoid having to do
  repeated chart audits
• Locum physicians oriented to use of encounter
  forms by Clinic Manager
• Example next of recent PDSA test to review use of
  encounter form in practice to maintain up-to-date
  info in toolkit

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Example of a recent PDSA Cycle

• - P (Plan) Review use of the registry and
  toolkit in practice, by reviewing recording of
  one measure (BP) in toolkit
• - D (Do)
• Recall list generated from toolkit to determine
  list of patients overdue for BP.
• Chart audit by medical student to determine which
  overdue and which done but not recorded.
• 31/121 overdue for BP as per toolkit. 13 had BP
  done and recorded in chart but not toolkit. 16
  overdue for BP. 2 not found.
• 13 with BP done entered into toolkit

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BP Run Chart Before Audit
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BP Run Chart After Audit
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Study Act

• S (Study) Approximately half of those overdue
  for BP in fact done but not recorded in toolkit
• A (Act) PDSA 1 to ensure all BPs done in clinic
  are recorded in toolkit. PDSA 2 to increase
  access to toolkit to other providers to allow
  input of BP when done by them.

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Use of Toolkit in Planning Care

• Use of outcome data
• Review of runcharts to target areas for
  improvement in process of care eg recall lists
  for Opthalmologist Podiatrist
• Review runcharts to flag potential problems in
  data entry (eg BP, GFR, ACR completion rates that
  are lower than expected)
• Review of runcharts pre and post interventions to
  determine success (eg change in completion of eye
  foot exam rates after visiting specialists,
  rates of SM goals after group clinic)

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PDSA for Flu Vaccination

• Aim Increase rates of vaccination for diabetics
• Problem No record in clinic chart of vaccination
  given by public health
• Plan Registry list given to PHN pre flu season
• Do PHN calling in all registry patients for Flu
  and Pneumovacc as reqd

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Flu Vaccine Runchart
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Decision Support

• Training staff in lab data entry
• Diabetes Nurse Educator training home support
  workers on nutritional issues,
• Review for physicians of guidelines for frequency
  of lab testing and targets for BP, ACR as part of
  orientation to Encounter form
• Review of encounter forms with patients at Group
  Clinics, including photocopies for some
• Recent foot care course completed by several
  nurses
• Turnover of physicians others is major challenge

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Delivery System Design

• 2 planned visit combined RN/MD clinics
• One Diabetes Clinic Day in September with 20
  participants, group educational and individual
  visits
• Plan for maximizing roles of other providers (eg
  clinic LPN) to increase access for patients with
  CDM to foot exams, SM support

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Self-Management

• Just the Basics CDA sheet selected and
  distributed to care providers as the consistent
  basic diabetes information sheet.
• The self management goal sheet from the CHF
  Collaborative is used consistently by the
  Diabetes Outreach Nurse and entered on the
  toolkit.
• A large binder of resources for patients with
  diabetes, CHF and renal disease has been created
  and distributed to care providers in Masset.
• Health Record books are being given to diabetes
  patients as we see them.
• Pedometers distributed to individuals who
  identify exercise as goal
• Plan for selecting group of 20 potential SMP peer
  leaders for info session on SMP programs and
  assess community interest and develop plan for
  implementation

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Community

• Relationships/Partnerships
• Linking with CO-OP Grocery Manager to facilitate
  access to and labelling of healthy food choices
• Linking with Recreation Commission around
  Alternative Fitness Program stable funding is a
  challenge (currently some Healthy Heart money and
  grants in past from Gwaii Trust)

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Community

• System to Coordinate Care
• One page health directory will be distributed
• Dialogue with local complementary practitioners
• Plan for access to toolkit to some community
  providers involved in primary care (eg PHN)
• Involve larger team in planning process and to
  support integration of services by having
  dedicated weekly PDSA meetings

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Functional and Clinical Outcomes
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85 will have an A1C of lt7.0.
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60 will have a BP of lt130/80 with the BP being
measured every 3-6 months.
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70 will have an LDL lt2.5, done annually.
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70 will have an annual dilated eye exam.
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85 will have an annual ACR (Results lt2.0 M and
lt2.8 F).
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90 will have an annual lower extremity exam.
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85 will have a self-management goal documented
annually.
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ACTION PERIOD I

• Established registry of all known diabetic
  patients and entered baseline data in toolkit
• Implemented use of encounter forms generated
  thru toolkit into daily practice to enable
  ongoing data acquisition, support clinical
  decision-making
• Reviewed toolkit reports to assess target areas
  for improvement (eg linking with public health to
  update immunization records, recall for podiatry
  and opthalmology clinics)
• Trial of 2 planned visit clinics with combined
  RN/MD

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ACTION PERIOD II

• QCC physicians registered and started using
  toolkit
• Planned clinic with group education component in
  June September
• Self-management support dissemination of info
  re goal setting, pedometers
• Targetting missing services toolkit recall
  report used to get eye and foot exams done during
  recent specialists visits
• Locum physicians oriented to encounter forms and
  use in clinical practice to provide decision
  support and maintain up-to-date registry

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Challenges/Barriers

• Involvement of larger team in planning process
• Delegating administrative CDM tasks to support
  staff to free up clinician time
• Funding and resource issues
• Limited number and type of providers, with
  frequent turnover
• Lack of provider continuity underlines need to
  develop a system to spread and embed change to
  all clinicians and staff to ensure sustainability

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Future PDSA Cycles?

• Plan for embedding CDM related tasks into
  physician workflow, including locums
• Plan for maximizing clinic nurse role, care
  coordination with diabetes nurse
• Plan for increasing access to toolkit to
  community providers
• Continue to refine Planned Visit Clinics
• Develop self-management support plans
• Expand team beyond clinic and diabetes program
• Use PDSA templates more consistently

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The End