Instructions

1
Instructions

• A few of the slides you created for your previous
  storyboard might remain consistent, (i.e. Aim
  Statement, list of key measures, list of team
  members.) The exception would be if the
  directors provided comments/edits to any of these
  areas on your monthly report. You need to
  remain consistent and have the AIM statement,
  list of key measures, etc as they appear on your
  monthly report.
• You will have submitted two monthly reports by
  learning session two. You are either TESTING
  ideas under each component of the Chronic Care
  Model and/or have already IMPLEMENTED changes
  under the components of the Care Model.
  (remember, that means that the change would not
  go away in your organization if you ended
  participation in the Collaborative process
  today!!) The tests of change and changes
  implemented is the new information you will be
  sharing at learning session two. Most of the
  information youll need is already in your
  monthly report. Keep the description short and
  to the point but with enough description that the
  reader can get the major points from your
  storyboard.
• Update your data and insert the graphs from your
  excel file on slides as demonstrated on slide 13
  and 14. Make the graphs large enough so that
  they are easy to readno more than 2 to a page,
  if possible. Therefore, you will need more than
  2 slides to display your progress for all
  measures that you are tracking. DO NOT SUFFER
  IN SILENCE ! Please post a ticket to the Help
  Desk on SharePoint as soon as possible if you
  need help accomplishing this step.

2
Learning Session 2May 12-14, 2005Atlanta,
Georgia
Cluster
SouthEast Lancaster Health Services
3
SouthEast Lancaster Health Serivces

• Lancaster, PA 17602
• 13 Providers
• Population Served 73 of our patients are
  Hispanic
• Number of patients diagnosed with Diabetes are
  623.
• Currently 109 are in our patient of focus group.

4
Team Members

• Dr. Efrain Torres Physician Champion
• Dr. Chad Harris Dentist Champion
• Jane Marlin Medical Provider Leader
• Leslie Aikens Team Leader
• Mirna Guzman Clinical Support
• Teresa Durden Data Entry Support
• Jim Kelly Executive Director

Leslie Aikens 717-299-6371, ext.
104 Laikens_at_selhs.org
5
AIM Statement

• The SouthEast Lancaster Health Services wants to
  create a system to optimize the medical standard
  of care and the dental care. We will accomplish
  this by using the Care Model and Model for
  improvement for our patients living with
  diabetes.

6
Selected Measures

• At least 90 of our patients receiving at least 2
  HgbA1cs 3 months apart within one year
• An average HgbA1c less than 7.0
• At least 70 of our patients will have documented
  self-management goals
• At least 70 of our patients will have BPlt130/80
• At least 70 of our patients will have LDLlt100
• At least 70 of our patients will be on statins
  age 40 or older
• At least 70 of our patients with diabetes will
  have a dental exam
• At least 70 of our patients will have a dilated
  eye exam in the past year
• At least 70 of our patients will have a foot
  exam at each visit

7
Self-management

• Currently Testing
• Review of patients chart to determine education
  focus
• An Open House for our Diabetic Patients
• Implemented into our Delivery System
• Created a packet in English and Spanish of
  resources and information for the diabetic
  patient
• Referral to Harrisburg Area Community College
  Nursing Care Program

8
Community

• Currently Testing
• We are currently looking for places to have our
  patients go for exercise and develop an exercise
  sheet with options
• Implemented into our Delivery System
• The relationship with Harrisburg Area Community
  College

9
Healthcare Organization

• Currently Testing
• We are evaluating the advantage of purchasing
  equipment to perform HgbA1c and lipid panels in
  the office
• Implemented into our Delivery System
• Every Board of Directors meeting an update is
  given on the Diabetes Collaborative Care Model

10
Decision Support

• Currently testing
• Diabetes patient appointment times are being
  evaluated to determine the length of time needed
  for each appointment
• Implemented into Delivery System
• Diabetes Goal Sheet for chart documentation
• Standing order form for the diabetic patient
• Dental appointment routing form

11
Clinical Information System

• Currently Testing
• We are testing the information in the PECS system
  for accuracy
• Implemented into Delivery System
• A system to identify the Diabetic patients in our
  computer system ( Centricity) so the scheduler is
  alerted to this information when the patient
  calls in for an appointment

12
Delivery System Design

• Currently Testing
• We are testing two different time frames for
  appointments.
• We are testing the review of charts by a Medical
  Assistant ahead of time and anticipating what is
  needed during the medical visit
• Implemented into Delivery System

13
Functional and Clinical Outcomes

• Measures Goal as of 4/05
• 2 HbA1cs in last yr gt90 4.5
• Average HbA1c lt7.0 16.7
• Documented self gt70 0
• management goal setting
• BP lt 130/80 gt70 26.9
• Statins (age gt40) gt75 61.2
• Dental exam in past year gt70 16.4
• REGISTRY SIZE 110 100

14
National Key Measures
15
Additional Center Key Measures
16
Senior LeadershipMaking the Case for Change

• What information did you share with your ED/CEO
  and/or Board of Directors to encourage them to
  make improvements in the management of
  Diabetes/Depression? i.e., graphs, data, patient
  stories, articles, etc.
• How did you promote the work? i.e., speak at
  meetings, talk with particular people, write
  articles, produce a video, etc

17
Communication Plan (How are you communicating
your progress at the center level and within your
community)

• At the center level
• On February 16, 2005 we had a staff meeting from
  noon - 1pm and described the impact of the Care
  Model with a visualization process. Each team
  member introduced themselves and describe their
  role on the team
• Casual conversations with peers
• Teaching in areas on a need to know basis
• At the Community level
• A representative from the Harrisburg Area
  Community College joined one of our meetings to
  describe their nursing care program approach to
  the Diabetic patient
• A dietician from the Penn State Extension
  Services came to one of our meeting to describe
  their program and look for ways to collaborate.

18
Anticipating Barriers and Issues
Those that the team can resolve
Those that leadership needs to address

• Staff responsibilities
• Education for additional staff

• Resources for time and equipment
• The amount of time allocated for scheduled
  visits- should it vary on the type of visit.

19
A story to share.the patient

• A 55 year old Hispanic male with a 15 year
  history of Diabetes was meeting with me to learn
  about self-management goal setting. His HgbA1c
  was 9.1. As we reviewed diabetic education, diet
  and exercise, his comment to me was I was never
  told not to consume regular sugar?! Starchy
  hispanic vegetables are a daily food for him as
  well.
• I have found the one on one relationship with the
  patient allows the patient to be more open and
  establishes a better working relationship. I gave
  him samples of Equal and Splenda and he agreed to
  try them. The client expressed enthusiasm and a
  readiness to make needed changes in his
  lifestyle.
• He wants to live a healthier life. His goal is
  to gradually decrease the HgbA1c, and have better
  control of his diabetes. He will follow-up with
  me in three months.
• -Submitted by Mirna Guzman, Clinical Support

20
A story to share.our staff

• Our Provider Champion is a very busy internist
  who does not feel very supported. So when we
  asked him to join us on our journey to create a
  new care model and it would involve more
  paperwork, lets say he was not excited. As a
  team we listened to his concerns, documented them
  and decided that if these are the concerns that
  one physician has, then these will be the
  concerns the others will have as well.
• So, instead of looking for a new provider
  champion we decided to meet his challenge and try
  to create a more supportive system for our
  providers so they may better serve our patients.

21
A story to share.the organization

• Employees not involved on the team are asking
  questions of team members concerning the Care
  Model for Diabetes. They want to know what we
  are doing and if we like what we are doing.
• Using the Chart Abstraction tool showed us the
  importance of documentation. We struggled to
  find some information in some of the charts.
  This was a good lesson.
• The information we evaluate on the Registry is
  very useful to planning and measuring
  improvement. We were surprised by the number of
  uninsured out of the 110 patients. We expected a
  higher number. When requesting services for our
  uninsured it is so helpful to be working with a
  specific number who may need the service.