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CHI Diabetes Toolkit Using Diabetes to introduce Population Based Care

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This PowerPoint Highlights the contents of the CHI Diabetes toolkit. ... EXCEL Diabetes Registry. Keep only the most recent visit's data ... – PowerPoint PPT presentation

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Title: CHI Diabetes Toolkit Using Diabetes to introduce Population Based Care


1
CHI Diabetes Toolkit Using Diabetes to
introduce Population Based Care
  • David Swieskowski, MD, MBA
  • dswieskowski_at_mercydesmoines.org

2
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

3
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

4
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

5
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.

6
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

7
CHI HgA1C Data April 2008
8
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

9
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

10
Communities Knowledge Communities Physician
Practice Leadership PMAC Members CHI Diabetes
Toolkit 2008
11
CHI Diabetes ToolKit File Structure
12
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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15
Also in this section
  • Corporate bylaws establishing the MCI Quality
    Committee
  • Physician VP for Quality Job description
  • MCI Quality Mission Statement

16
MCI Quality Mission Strategies
  • Measurement
  • Information technology
  • Chronic Care Model
  • Standardization
  • Partnering
  • Transparency
  • Communication
  • Self-management support

17
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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20
Diabetes standing lab orders
21
Standing Orders Flowsheet
22
Framingham 10-year CHD Risk Assessment Calculator
23
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

24
Business Case for Data Collection
and Population Management
25
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

26
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

27
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

28
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

29
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

30
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

31
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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33
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

34
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

35
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

36
To Enter Data Sort Alphabetically by Last
Name Duplicates can be removed manually or in
bulk using Excel features
37
To determine A1c values by range Sort by HgA1c
Result
38
To identify patients who are overdue for
care Sort by Date of most recent HgA1c
39
To Create performance reports
Sort by Provider and then value
Dr. A
Dr. A
40
Excel Spreadsheet for Expanded Diabetes Data
Collection
41
Sample Patient LettersOne example
42
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

43
Downloadable at http//www.mercyclinicsdesmoines.
org/Quality/HealthCoachPaperAMGA208.pdf
44
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
45
  • Diabetes Audit form
  • Used for
  • Pre-visit review
  • Order form
  • Data collection

46
Pre-visit Review Audit Form 1
47
Pre-visit Review Audit Form 2
48
Pre-visit Review Audit Form 3
49
CMS PQRI Diabetes Data Collection form
50
Diabetes HTN Standing Orders Flowsheet Done in
Excel
51
Standing Orders Flowsheet
52
Diabetic Foot Exam Documentation Form On the
back of the diabetes flowsheet
53
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55
5. Self-Management Support
  • This section of the Toolkit contains
  • 5As Self-Management support forms
  • Goal Setting form
  • Patient education handouts

56
5As Self Managememt Support Form Specific for
Diabetes
57
5As Self Managememt Support Form Generic for any
condition
58
Diabetes Self Management Goal Setting Form
59
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60
Patient Education Handout
61
Patient Education Handout
62
Patient Education Handout
63
Patient Education Handout
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Patient Education Handout
66
Patient Education Handout
67
6. Reference MaterialCommunity Resources
  • This section of the Toolkit contains
  • PDFs (or links) of publications that may be
    useful

68
Downloadable at http//care.diabetesjournals.org/
cgi/reprint/31/Supplement_1/S5
69
Downloadable at http//www.qualityforum.org/pdf/r
eports/diabetes_update.pdf
70
Downloadable at http//www.iom.edu/Object.File/Ma
ster/27/184/Chasm-8pager.pdf
71
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

72
All of this material is currently available in
the Diabetes Toolkit found athttp//www.mercycl
inicsdesmoines.org/Quality/docs/Toolkits/toolkits.
htm
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