Patient Self-Management: in Primary Care Team SPANK: St Peter Aims for New Knowledge

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Patient Self-Managementin Primary CareTeam
SPANK St Peter Aims for New Knowledge

• March 9, 2004
• Devin Sawyer, MD
• Joseph Wall, MHA
• Shari Gioimo, MA
• Janet Wolfram, CDE

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We are

• A Residency Program- Full Scope FM
• 37,000 patient visits a year
• Residents UW med students- 6 per year
• Aprox. 300 diabetics
• Participated in WSDC II and RWJ grant
• Getting better at a TEAM APPROACH to chronic care
  and patient Self-Management

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What we have done lately

• WA Diabetes Collaborative, 2000-2001
• Focused on Patient Self-Management
• The role of each player providers, medical
  assistants, administrative support, patients, and
  mentors
• RWJ funding for Advancing Diabetes
  Self-Management (300,000)

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What is Self-Management?

• Checking blood sugars
• Taking meds (pills and shots)
• Eating right (CDE, doctor, other diabetics)
• Exercising (30 mins/day, 150 mins/week)
• Checking feet
• Making appointments (PCP, eye doc, CDE)
• What is missing?

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24/7/365

• The patients right and responsibility to make
  decisions that make sense within the context of
  their lives
• Education and support refocused on helping
  patients make achieve goals and outcomes that
  they themselves have selected
• Must acknowledge and support the patients role
  as the key decision maker in self-management
• Patient role? Provider role? Staff role? Others?

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The NPR news report on effective diabetes care
in 2003 N Engl J Med, 2003 348,5383-459
(Steno-2 study in Copenhagen)

• An Experienced TEAM
• Motivated
• Enthusiastic
• With a Gung Ho attitude

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Our program

• MA Planned Visits with goal setting
• Provider Visits with emphasis on patient goal
  setting
• Medical Group Visits
• Registry to support patient care (CDEMS)
• Exercise opportunities
• Patient Mentoring (buddy system)
• Newsletter

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CDEMS Our Run Charts
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CDEMS Our Run Charts
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What it has taken to get us here

• MA training (Boldt Center)
• Provider training (faculty development, and
  resident workshops and precepting - BBSWAR)
• Patient education
• Practical description of self-management an
  SMG cycles (new way of thinking for our clinic)

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How do we teach this to the MAs?

• A new curriculum for the MAs (A new service for
  diabetes educators?)
• Skills in-service foot checks, CDEMS, planned
  visits, phone skills, group visits (Camp SPANK)
• Shadowing
• On the job training

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MA planned visits(see standing orders)

• They follow the standing orders
• Introduce SMG
• Occur 1 week before provider visit
• 90 of our MAs perform planned visits
• This frees up some of the provider time

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How do we do and teach this to the providers?

• Big Bad
• Sugar WAR

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The 15 minute encounter A toolBig Bad Sugar
W.A.R.

• Background
• Barriers
• Successes
• Willingness to change
• Action plan
• Reinforcement

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An Action Plan

• Something the patient comes up with and WANTS
  to do
• Should be REASONABLE
• Behavior specific
• Should answer the questions
• What?
• How much?
• When?
• How often?
• Confidence level (likelihood-of-success) 1-10

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Patient Goal Quality

• Evaluate, record, and track patient SMG quality
• 1 point for activity (what- i.e. briskly walk,
  or stop skipping breakfast)
• 1 point for location (where- i.e around Capital
  Lake, or at home and at the office)
• 1 point for frequency (how often- i.e M,W,F, or
  5 days a week)
• 1 point for time/duration (how long- i.e. for 45
  minutes at 700 am, or 8 am before I leave for
  work)
• 1 point for LOS score (from 1 to 10)

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SMG quality over time
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The Group Visit
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The Group Visit

• Developing patient oriented self-management
  curriculum
• More providers (faculty), more staff being
  trained
• More patients coming
• Now an educational expectation for residents
• High patient satisfaction
• Outcomes in 2001
• HbA1C of our practice 7.7
• HbA1C of those who come to DGV 6.3

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Patient Data Registry(CDEMS)

• Free from the DOH, developed locally
• MAs do data entry and us for patient outreach
• PCPs use patient report with the patient visit
• PCP/MA team can query their data to target care
  (outliers), for patient recall, and for patient
  goal reinforcement

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Exercise Opportunities

• Walking Club
• Pedometer Program
• SPFP Moves With You Video

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Walking Club
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Pedometer Program
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SPFP Moves With You

• The Video

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Patient Mentoring (buddy system)

• Patients are supporting Patients
• One patient calls another about 2 months after
  the provider visit to check-in with their SMG
• Sent a card with a patients information
• Provides additional support and accountability
• Bridges the gap between the planned/provider
  visit and the beginning of the next cycle

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What is next? Spread

• Graduate trained providers
• More grant money- Phase II
• In-service local providers- Elma
• Provide training to local MAs
• A role in the STEPS grant

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Contact Info

• Devin Sawyer, MD- devin.sawyer_at_providence.org
• Joseph Wall, MHA- [phone]
  joseph.wall_at_providence.org
• Shari Gioimo, Medical Assistant-
  shari.gioimo_at_providence.org
• Janet Wolfram, Diabetes Educator
• janet.wolfram_at_providence.org