West Central Cluster Summit

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• West Central Cluster Summit
• Moving Ahead With Spread
• November 8-10, 2004
• Dallas, TX

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Peoples Clinic (PC) Who We AreDiabetes II
Depression II

• Peoples Clinic is located in urban Boulder,
  Colorado
• PC offers comprehensive primary medical care to
  residents of Boulder County
• Our clinic is one site consisting of 6 FTE family
  practitioners, 2 OB/GYNs, 3 CNMs, 1 NP, 2 PAs, 4
  nurses

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Peoples Clinic (PC) Who We ServeDiabetes II
Depression II

• PC serves the medically underserved (50-55
  uninsured or underinsured), including migrant
  workers, 50 Hispanic population, 7 homeless
• PC sees 10,000 patients a year in 44,000 visits
  and performs 400 deliveries per year

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Aim Statement

• Our mission is to Recognizing that health care
  is an essential human need. Peoples Clinic
  improves our community by providing high quality,
  accessible health care for the medically
  underserved.

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Team Members

• Diabetes and Depression Collaborative Members
• Kay Ramachandran, CEO
• Marc Grushan, MD, Provider Champion
• Hilary Helinek, MSPH, Collaborative Coordinator
• Richard Turco, IS Specialist
• Diabetes Team Members
• Thia Gonzales, PA, Diabetes Team Leader
• Michelle Drury, MD
• Holly Mantych, RN, MPH, Diabetes Nurse Support
• Depression Team Members
• Bettina Willhun, PA, Depression Team Leader
• Ciska Moore, RN, Depression Nurse Support
• Bill Monroe, Certified Substance Abuse Counselor
• Carolyn Dahl, RN, Psychiatric Nurse
• Mark Marshall, MD, Psychiatrist
• Deb Getchell, RN, LCSW, Homeless Outreach Nurse

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Some of PCs Current Collaborative Members
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How it all Started.

• Peoples Clinic started in 1970 with 8 doctors
  and 15 nurses aiming to provide health care to
  low-income people who had nowhere else to turn to
  for medical care.
• The Diabetes Collaborative was formed in 1998 by
  former Medical Director, Kathy Reims
• Currently, PC has 697 patients in the Diabetes
  Registry, 363 which have come in for a clinic
  visit in the last year

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Spreading the Collaborative Movement

• In 2000, Peoples Clinic spread to Depression
• Currently, PC has 727 patients in the Depression
  Registry, 210 which have been in for a clinic
  visit in the last year
• PCs has spread the Care Model to form
  collaboratives for Tuberculosis, Hepatitis C, and
  Substance Abuse/Mental Health
• Collaboratives have spread to work in conjunction
  with the Mental Health Center of Boulder County,
  Boulder County Homeless Shelter, Boulder
  Community Hospital, Colorado Department of Public
  Health, as well as many other health care
  institutions

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More Team Members

• Tuberculosis Team Members
• Robert Drickey, MD
• Marc Grushan, MD
• Ciska Moore, RN, Homeless Outreach Nurse
• Boulder Homeless Shelter
• Hepatitis C Team Members
• Michelle Drury, MD
• Marc Grushan, MD
• Nancy Woods, RN
• Bill Monroe, Certified Substance Abuse Counselor
• Substances Abuse/Mental Health Team Member
• Bill Monroe, Certified Substance Abuse Counselor
• Carolyn Dahl, RN
• Collaborative Coordinator Hilary Helinek,
  720-565-4138, hilaryh_at_peoplesclinic.org

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Sustaining Activities

• Job descriptions reflect responsibilities related
  to collaborative
• Orientation for new staff includes collaborative
  education
• Changes in delivery system are shared with staff
  via Collaborative Coordinator and incorporated
  into policies and procedures
• Collaborative activities are incorporated into
  the clinics healthcare plan and quality
  improvement plan
• Chronic illness goals are part of PCs business
  and strategic plan

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Aim and Key MeasuresDiabetes

• Aim
• Our aim is to reduce and/or delay complications
  related to diabetes by redesigning how we deliver
  healthcare to adult patients with diabetes.
• Key Measures
• National
• 90 of pts will have 2 HbA1Cs at least 3 months
  apart in the last 12 months
• 70 of pts will have self-management goals set in
  the last 12 months
• Average HbA1C lt7.0

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Aim and Key MeasuresDiabetes

• National recommended measures
• 80 of pts will have had an influenza vaccine in
  the last 12 months
• gt70 of pts will have had a dilated retinal exam
  in the last 12 months
• gt80 of pts over age 40 will be taking QD aspirin
  unless contraindicated
• lt15 of pts smoke tobacco
• gt90 of pts will have monofilament testing done
  in the last 12 months
• 80 of pts with have had a pneumovax vaccine in
  the last 5 years
• Site-specific key measures
• 90 of pts will have HbA1cs lt9 in last 12
  months
• lt20 of pts will have Hb1Acs gt9 in last 12
  months
• 75 of pts will have a decrease of 1 in HbA1C
  from initial test
• 70 of pts will have a fasting lipid screening in
  the last 12 months
• 80 of pts with BP gt135/85 will be on an ACE
  inhibitor
• 80 of pts will have had a tetanus vaccine within
  the last 10 years
• 80 of pts will have their own glucometers

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Aim and Key MeasuresDepression

• Aim
• The Peoples Clinic practice will be redesigned
  to improve care for our patients with depression
  by implementing the six components of the CCM.
• Key Measures
• National key measures
• gt40 of CSD pts will have a 50 reduction in
  PHQ
• gt70 of pts will have self management goals
  documented
• gt70 of pts will have a documented PHQ score in
  the last 6 months
• Site-specific key measures
• 80 of pts will have a structured assessment
  within 7 days
• gt70 of pts on meds will still be taking their
  meds at 6 months
• 80 of pts with index PHQgt10 will have follow-up
  within 2 wks of initiation of therapy

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National Key Measures-Diabetes
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National Key Measures-Diabetes
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National Key Measures-Depression
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National Key Measures-Depression
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Community Linkages Diabetes Depression

• Currently Testing
• We have hired a FT nurse who will be trained to
  restart The Bayer Free Glucometer Program and
  do some DM education in the near future
• Information re a DM support group at Boulder
  Community Hospital will be posted for our
  patients
• We have a possible volunteer dietitian for a
  half-day every other week to do group sessions
  and provider inservices starting in December
• Other research is also being done on possible
  community resources available for diabetes
  education and nutritional support. The
  collaborative coordinator is trying to locate
  dietitians in the community who may at least take
  Medicaid/Medicare recipients.
• Peoples Clinic is working with KGNU (a local
  radio station) to promote Diabetes awareness
• Working with CU-Boulders General Clinical
  Research Center to get our pre-diabetes patients
  into a study
• Implemented into our Delivery System
• We continue to collaborate with the Mental Health
  Center and the Addiction Recovery Center in
  Boulder and are constantly searching for
  additional community resources that may aide our
  patients
• We continue to receive support from a
  psychiatrist at Mental Health Center of Boulder
  County, who is a valuable member of our
  Depression Collaborative and a great voice in
  helping make clinical decisions
• Challenges to Sustaining and Spreading CL
  Changes
• Mental Health Center of Boulder County has had
  significant budget cuts and will no longer be
  able to see some of our patients and will be
  sending some of their stable patient to PC for
  f/u care
• Difficulty prioritizing contact with outside
  agencies due to pressing needs within the clinic

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Community Linkages Hepatitis C, Tuberculosis
SA/MH

• PC received a grant to start a Hepatitis C
  treatment program from Schering Corp works
  closely with GSK with regards to Hep A and B
  vaccines has applied for a grant from the state
  health department for help with paying for Hep A
  and B vaccines and has developed MOUs with
  Boulder Community Hospital to get our patient
  discounted lab work and liver biopsies while they
  are going through treatment
• PC works with the Boulder County Homeless Shelter
  to help insure all of their clients have PPD
  screenings
• SA/MH counselors works closely with the Mental
  Health Center of Boulder County and PC will now
  be taking on more of MHCBC patients due to their
  funding cuts

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Organization of HealthcareDiabetes Depression

• Currently Testing
• Collaboratives are continuously being emphasized
  at the provider level as well as the executive
  level as needing support and recognition
• Implemented into our Delivery System
• As part of our clinics new organization under
  our new CEO, each collaborative has a designated
  lead provider who will act as the primary source
  of contact for the Collaborative Coordinator
• Collaborative Coordinator is part of each new
  hire orientation
• Collaborative key measure outcomes are shared
  with staff on monthly and quarterly basis
• Providers will be giving regular reports on their
  DM and Depression patients and how their outcomes
  compare to the clinic as a whole.
• Challenges to Sustaining and Spreading OH
  Changes
• Prioritization of collaborative goals within the
  agency

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Organization of HealthcareHepatitis C,
Tuberculosis SA/MH

• Inservices for providers on Hepatitis C and SA/MH
  are becoming a priority
• New policies and procedures for Hepatitis C and
  Tuberculosis have been developed and approved by
  our Area Directors

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Self-ManagementDiabetes Depression

• Currently Testing
• The Bayer Free Glucometer Program will provide
  education regarding diet, exercise, use of
  glucometeres and other information pertinent to
  our patients with diabetes ability to self manage
• New FT nurse will be working on self-management
  goals such as nutrition and diet with our
  patients with diabetes on an individual level
• We hope to have a volunteer dietitian do group
  diabetes education and weight management groups
  starting in December
• Implemented into our Delivery System
• Diabetes and Depression self-management goal
  sheets are now being used with a reminder
  system to providers and their assistants
• Flyers containing PHQ-9 questions are posted in
  exam rooms for patients to look at while waiting
  for their provider. If the patient answers Yes
  to any of the questions, they are prompted to ask
  their provider for help.
• Challenges to Sustaining and Spreading SM
  Changes
• Time per visit to address multiple client issues
• Lack of provider buy-in

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Self-Management Hepatitis C, Tuberculosis SA/MH

• Hepatitis C patients are required to attend an
  informational session in order to start treatment
  and are made responsible for applying for their
  medications through Schering Corp
• Homeless patients staying at the Boulder Shelter
  must initiate getting their PPD screening

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Delivery System DesignDiabetes Depression

• Currently Testing
• New recall system to bring our patients with
  diabetes back for a clinic visit every 4 months
• Implemented into our Delivery System
• The Collaborative Coordinator communicates with
  the clinic staff when changes are made to the
  delivery of care
• Reminder systems for self-management goal
  sheets and Prime MDs
• Patients starting depression med therapy will be
  brought back to the clinic for f/u within 7-10
  days instead of f/u via phone
• Challenges to Sustaining and Spreading DSD
  Changes
• Our referral of patients to the OJO clinic had to
  temporarily be stopped due to internal problems
  with the OJO clinic. Our patients have been
  notified via letter of the situation and have
  been told they will be notified when the clinic
  will resume.

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Delivery System DesignHepatitis C, Tuberculosis
SA/MH

• Providers were given Hepatitis C packets
  containing information regarding What is Hep C,
  PCs course of treatment for patients, progress
  notes, protocols, etc financial costs for
  Hepatitis C patients are outlined for them in a
  patient contract prior to initiating treatment
• The homeless outreach nurse and collaborative
  coordinator do PPD screening on-site at the
  homeless shelter
• Systems are in place for SA/MH allowing for
  regular f/u either via phone or clinic visit

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Decision SupportDiabetes Depression

• Currently Testing
• Educational materials and published articles are
  being sought for physician review, to determine
  if statins will be introduced to our DM patients
  who are over 40 years of age as protocol.
• PCs new FT nurse, who has DM education
  background, will be providing DM sessions and
  will be joining the DM Collaborative
• Implemented into our Delivery System
• A psychiatrist consultant from Mental Health
  Center of Boulder County is a member of the
  Depression Collaborative
• Modified site-specific measures to reflect the
  most current evidence-based guidelines
• National guidelines/standards/resources and
  educational opportunities are shared with staff
• Challenges to Sustaining and Spreading DS
  Changes
• Disseminating information and resources to the
  rest of staff in a timely and effective manner
• Our connection with ophthalmology is currently on
  hold

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Decision SupportHepatitis C, Tuberculosis SA/MH

• Nurse consultants from Schering helped train PCs
  nurse who teaches the Hepatitis C information
  class and is always available for consolation
  consultant from Hepatitis C Connection in Denver
  trained our new Hep C support group counselor
• Continued consultation with Denver Healths TB
  Coordinator on current policies and guidelines
• Our Certified Substance Abuse Counselor and
  Psychiatric Nurse remain in-house consultants for
  our family practitioners and PAs

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Clinical Information SystemsDiabetes
Depression

• Currently Testing
• Continually updating DM and Depression databases,
  queries, and flow sheets to reflect needs for
  more information to improve our measures
• Implemented into our Delivery System
• Collaborative Coordinator enters DM data from
  lab, DM SOAP note, and performs recall
• Built new Reminder systems
• IS Specialist is dedicated to assisting the
  Collaborative Coordinator when changes are needed
• Challenges to Sustaining and Spreading CIS
  Changes
• Multiple separate registries not linked and not
  utilized by all staff
• Measures are only reflective of the accuracy of
  the data collected and entered

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Clinical Information SystemsHepatitis C,
Tuberculosis SA/MH

• Documentation of Hep C patients through their
  treatment course
• SA/MH have new measures and queries that are
  being tracked on a monthly basis changes have
  been made to the database based on needs of the
  counselors

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Best Practices for Diabetes

• Purchasing a HbA1C machine was an incredible
  benchmark that now allows for quick turnover time
  of tests and better care for our patients
• The Bayer Free Glucometer Program started by a
  former nutritionist. This program provides our
  patients with DM free glucometers and discounted
  strips (0.50/strip)

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Best Practices for Depression

• Mental Health Grant that allowed us to hire a
  Collaborative Coordinator, a Certified Substance
  Abuse Counselor, and a Psychiatric Nurse
• Our planned visit, Prime MD and A-J Model used at
  each Depression visit

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Our A-J Model

• A Anxiety are symptoms of anxiety present?
  This would influence medication choice and type
  of therapy needed.
• B Bipolar. Are symptoms of mania present
  when the patient is not depressed?
• C Cycling- Is the patient always down?
  (dysthymic) If not, how long down? How long
  euthymic? Depressed only in the winter? (SAD)
• D Drugs. Is the patient self-medicating? With
  what? This can really cloud the diagnosis.
• E External factors. Abuse? Relationship
  problems? Recent death in the family? These
  questions help decipher if grief, PTSD are
  playing a role.
• F Fears, Phobias, Obsessions. Is there an
  associated OCD?
• G Little Green Men, or in other words,
  hallucinating? Psychotic component?
• H- How long? Lifelong? Since a divorce?
• I - In counseling? Get a consent to speak with
  this person!
• J - Junk Pile, or in other words, any other
  symptoms? Do a thorough review of symptoms.
  Symptoms suggestive of a medical problem?
  Somatization?

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Lessons Learned

• Hard work of the Collaborative Coordinator and
  Collaborative Teams to keep fires lit and
  maintain positive energy
• Provider buy-in is a challenge, as well as
  turnover
• When strong leadership goes, so goes away the
  chronic care model

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Biggest Challenges/Barriers

• Provider buy-in- PC continues to work on this
• Finances- PC continues to find ways to make ends
  meet and maintain quality care of our patients
• Turnover- PC is working on employee retention and
  will be conducting surveys to see what works and
  what is needed to keep employees satisfied and
  willing to stick with their jobs

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Next Steps

• Depression- increase collaboration with the local
  Mental Health Center
• Self-management continues to be a struggle- PC
  has recently introduced new goal sheets for DM
  and Depression and reminder prompts for
  providers and assistants
• Hepatitis C and Homeless care (TB)-implementing
  the collaborative model

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Success Story to share.From our Homeless
Outreach Nurse/Depression Casemanager

• Middle aged, male patient to new to PC was meet
  by our Depression Casemanager/Nurse during a
  triage
• Pt is articulate, intelligent, but just recently
  moved to CO from CA with his wife and had no job,
  no money, and no health insurance
• Pt was having marital problems
• Pt was started on anti-depressants, but PC was
  unaware if pt obtained meds
• Depression Casemanager/Nurse contacts pt for f/u
  and finds pt has not gotten meds

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From our Homeless Outreach Nurse/Depression
Casemanager

• Pt states he does not even have for gas to get
  to clinic
• Casemanager/Nurse convinces pt to come up with
  to get to clinic, where PC can get pt samples of
  a different anti-depressant
• Casemanager/Nurse spoke with pt one month after
  convincing pt to get to clinic to get new meds
  and now pt and his wife have jobs and are working
  out their marital problems pt is on his wifes
  insurance plan and is now able to f/u for
  previous cancer dx and depression pt is
  stabilized on meds and feels his life is turned
  around

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From our Homeless Outreach Nurse/Depression
Casemanager

• Casemanager/Nurse was able to make a personnel
  connection with pt and make a positive and
  invested relationship
• Casemanager/Nurses persistent f/u and calls to
  push pt to come in to PC for meds made a
  difference in this pts life
• Pt went from hopeless to a mobilized and active
  participant in his own life
• The benefits of the Depression System at PC is
  its f/u care and casemanagement