Change in Diabetes Outcomes as a Result of SelfManagement Support by Health Coaches in Mercy Clinics

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Change in Diabetes Outcomes as a Result of
Self-Management Support by Health Coaches in
Mercy Clinics

• American Nurses Association
• National Database of Nursing Quality Indicators
  (NDNQI) Conference
• February 1, 2008, Orlando, FLA
• Del Konopka, RN, MS, Clinics Education
  Coordinator
• Kelly Taylor, RN, MSN, CCM, Clinics
  Director for Quality Improvement
• Sharon
  Phillips, RN, Chief Operating Officer
• www.mercyclinicsdesmoines.org

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Mercy Clinics, Inc. (MCI)

• Des Moines, IA suburbs
• 40 Clinics
• 145 Physicians
• 70 Primary Care
• 877,808 Patient visits in FY07
• 100 Fee-for-service

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Learning Objectives

• Recognize the Health Coaches role in patient
  self-management support in primary care clinics.
• Identify data capabilities of a disease registry
  in improving chronic disease management outcomes.

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Purpose

• We set out to improve the health status of our
  clinic patients with diabetes by providing
  consistent and proactive treatment using the
  standards of care recommended by the ADA.
• To do this, we redesigned the clinic system and
  added a measurement tool.

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How This is Relevant

• We are able to show how we
• Quantified nursing care to change chronic disease
  outcomes.
• Built a business case.
• Used data to have a voice within the health care
  and insurance community.

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Triggers

• The book by the Institute of Medicine Crossing
  the Quality Chasm.
• Problems to explore
• How to measure our performance on diabetes care
  at the clinic level. We knew we gave good care,
  but measures had not been in place to quantify
  this.
• How to improve the level of care, based on the
  data, the following year.

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Health Coaches

• Nursing Staff
• Key in making delivery system redesign work
• Decision Support for the Staff
• Practice Guidelines for Diabetes
• Standing Orders
• Disease Registry

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Health Coaches

• Mercy Clinics have 16 full time Health
  Coaches
• Four clinics have 2 Health Coaches
• New clinic staff role
• Started as RN, CMA, LPN, receptionist
• Were mostly data oriented
• Now new Health Coaches must be RNs
• Now more clinically oriented

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Health Coaches Job Description

• Facilitate planned care visits for patients.
• Maintain the disease registry.
• Conduct pre-visit chart reviews to evaluate
  ensure patients are current within standards of
  care.
• Work with patients families on Self- Management
  Support using a behavioral change approach.

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Coaches Plan the Visit

• Review the charts of patients before they
  are seen for
• Chronic disease standards of care
• Preventive health care
• Immunizations
• More effective than doctor reviewing chart

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Process

• Labs and referrals are done before the patients
  are seen (based on standing orders)
• Frees up doctors time
• Health Coaches enter data in the registry to
  track
• Diagnoses
• Appointments
• Lab Tests
• Process and Outcome Goals

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Coaches Oversee the Registry

• Contact patients overdue for visits or not
  meeting goals (opportunities list)
• 90 of patients respond positively
• In the past, only 70 of patients with diabetes
  came in for a visit within one year, now 95 come
  in yearly
• Review performance reports

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Self-Management Support

• Health Behavior Change
• 5As Assess, Advise, Agree, Assist, Arrange
• Medication Adherence
• Only 40 of MCI patients are highly adherent
• Major area for health behavior change
• Didactic Patient Education
• Provided or arranged by Health Coaches

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Measurement

• Measures chosen to quantify care for
  9054 patients with diabetes
• Hemoglobin A1c
• Blood pressure
• Lipids
• Urine microalbumin results
• Descriptive statistical analyses were used.

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Process Outcome Measures 10/05 12/07

• Compared to National Quality Forum
• National benchmark for performance, created by
  leaders in quality. Focus is on outcomes as well
  as processes How to get there.
• We passed the 90th percentile benchmarks
  for diabetes performance.

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National Quality Forum Diabetes Measures
Jan.- Dec. 2007
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Process Performance Report
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Outcome Goals Attainment Report
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Surpassing Goals Since 2003
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Whole Clinic Report
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What the Data Showed

• Monthly, transparent reporting of processes
  outcomes to physicians clinics revealed the
  status of their own diabetic patient population.
• This allowed Mercy Clinics to
• Compare results for the clinics
• Identify trends
• Identify progress in disease management.

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Implications for Practice

• We were concerned patients might resist more
  frequent office visits lab tests, but they
  appreciated the extra support in meeting their
  self-identified goals.
• Easy point of contact for patients.
• A gallon of milk in a day story of a patient
  new to diabetes.

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Significance

• The system redesign involved coordination of all
  the team members to ensure efficient, thorough,
  patient-centered care.
• When processes were retooled, diabetes outcome
  measures significantly surpassed the NQF measures
  for quality of care over one year.

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Benefits from Having Coaches

• Improved quality and patient outcomes
• Patient satisfaction
• Moved practices from reactive to proactive
• Increased ancillary revenue
• DEXA, lipids, Pap tests, mammograms,
  immunizations
• Supported the business case.
• They partner with patients to optimally manage
  diabetes.

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Business Case Mercy North Coaches
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Coaches are Change Agents

• Trained to use Plan-Do-Study-Act cycles
• Time dedicated to proactive QI
• Leading their clinics in improvement
  collaboratives
• Iowa Academy of Family Practice
• Wellmark
• American Medical Group Association

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Next Steps

• AEHR process standardization
• Expansion to all chronic diseases
  preventive health care
• Mine the registry data on our 20,000 patients
• Expanded Self-Management Support
• Improvements in patient satisfaction
• Never ending improvement processes

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Recognition

• Wellmark grant awarded to provide
  depression screening in the clinics.
• Recognition by NCQA AMGA
• Thanks to our physician champion,
• David Swieskowski, MD, MBA,
  Vice President for Quality.
• Our gratitude to
• The Health Coaches for all their great
  work. Our patients for the
  privilege of serving them.