Change in Diabetes Outcomes as a Result of Self-Management 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
ALL Diabetes Data 11/1/06-10/31/07 ALL Diabetes Data 11/1/06-10/31/07
Provider Brown Goal
Total Patients 154
Diabetes Process Goals
HgAlc last 12 mo. 95 94
LDL last 12 mo. 95 94
Microalb last 12 mo. 85 90
Eye Exam last 12 mo. 44 70
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Outcome Goals Attainment Report
Diabetes Outcome Goals 11/1/06-10/31/07 Brown Goal
HgAlc lt 8.0 85 75
HgAlc lt 7.0 67 50
LDL lt 130 66 75
BP lt 140/80 67 75
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Surpassing Goals Since 2003
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Whole Clinic Report
Care Measures Performance Reports Care Measures Performance Reports Care Measures Performance Reports
South Clinic Oct 2007
WELLMARK HTN Data 11/1/06-10/31/07 WELLMARK HTN Data 11/1/06-10/31/07 WELLMARK HTN Data 11/1/06-10/31/07
Whole Clinic Goal
Total Patients 956
Outcome goal BP lt 140/90 76 75

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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
Revenue Comments
EM visit lab differential 76,879
Level 1 visits 45,025
Offset Dr. Nurse work 15,183 probably low estimate
P4P Wellmark - 2006 paid 114,000
CMS PQRI (potential) 14,000
Total Revenue 265,087

Expenses
Coach Salary RN II 36,728 0.7 FTE benefits
Coach Salary LPN 36,434 0.9 FTE benefits
Differential Microalbumin cost 9,932
Differential HgA1c cost 4,763
Total Expenses 87,857

Contribution to Overhead 177,230
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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.