1. “Diabetes Days” A Practice Efficiency Strategy
Improving Diabetes Mellitus Patient Care Delivery & Outcomes
<Facilitator name and Credentials>

3. Today’s Objectives
Discuss Application of Care Change Concepts in Primary Care
Review Planned Recall Strategy
Review Batching Strategy: Diabetes Days “101”
Discuss Sample Schedule and Tools
Assess Best Practices for Implementation
Determine Measures for Effectiveness

4. Today’s Agenda INTRODUCTION AND CONTEXT 10 minutes
Introductions and Program Overview
IMPROVING DIABETES CARE DELIVERY AND OUTCOMES
5 minutes
Care Change Concepts
Case Study
Planned Recall and Batching Strategies
20 minutes
Diabetes Days 10 Steps
Monitoring Quality Improvement
WRAP UP AND MEASURE EFFECTIVENESS
FACILITATOR NOTES:

5. Diabetes Care in Family Practice
The Challenge: Diabetes a complicated, growing disease:
Incidence and prevalence of diabetes in Canada continue to increase1
Control is not improving: 50% of Type 2 Diabetes patients in Canada are not meeting their blood glucose targets 2
Implications and burden for primary care practice:
Over 80% of type 2 diabetes patients will be under the care of their Family Physician with an average of 8 visits per year2
What is the solution?
Governments & CDA promoting interdisciplinary team approach & enablers
MD, RN, NP, Diabetes Educators, Pharmacists, Family Health Teams and Primary Care Networks
Flow-sheets, registries, incentives etc….
Informed & empowered patients
Module 1 we learned:
Burden of diabetes in Canada is high
The impact of diabetes on family practice is high
Average practice has between patients with diabetes
Patients with diabetes visit their family physician on average 8 times per year
Implementation of a team-based approach can have significant impact
Teams require practical, implementable approaches to care delivery
1. Canadian Diabetes Association.
2. Harris SB, et al. Diabetes Res Clin Pract 2005; 70:90-7.

6. Therapeutic Goals CDA Guidelines:1 Ontario Ministry of Health:
Goal of treatment is to minimize the risks of the macrovascular and microvascular complications of diabetes by aiming for the following metabolic targets:
Ontario Ministry of Health:
Quality Targets for Primary Care Physicians: Example:2
A1C
≤ 7.0% BP
< 130/80 mm Hg
LDL-C
≤ 2.0 mmol/L
FACILITATOR NOTES:
The gap between goals and outcomes needs addressing i.e. one in two type 2 diabetes patients in Canada are not at target
Health outcomes are linked to continuity of care
Attachment to a primary care practice shows substantial cost savings
A1C
Within 6 months
LDL-C
Within 1 year
Retinal eye exam
Within 2 years
The Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada., Can J Diabetes. 2008;32(suppl 1):S1-S201
Ontario Ministry of Health- Quality Targets for Primary Care Physicians:

7. Systematic Approach to Diabetes Care CDA Guidelines Recommendations
Develop a Diabetes Registry of identified DM Patients
Process required
Systematic Recall Process
Clinical Flow Sheets
Diabetes Focused Visits
Group Visits
Reinforced need for and usage of a Clinic Diabetes Registry.
Focus on Priority patient management and logistics
Module 3
Reinforced the Group Patient Visits
Selected a scheduling method that could be effectively utilized in the clinic.
Teams require practical, implementable approaches to care delivery
CDA Clinical Practice Guidelines for the Prevention and Management of
Diabetes in Canada, Can J Diabetes. 2008;32(suppl 1):S1-S201

8. PROGRAM OVERVIEW TODAY’S TOPIC FACILITATOR NOTES:
The Pathways to Diabetes Management Program will take the Clinic Team through a 5-Step Process from completing Clinic Assessments through to the development of a specific Action Plan aimed at improving the management of patients with diabetes in the clinic practice.

9. Principles of Access Optimize the Care Team
Ensure that all members of the team are full scope of practice
Physicians must educate patients so that patients understand the team approach
Care Delivery Model (Who Does the Work)1
Identify the roles of the healthcare team, as well as the process for providing care and advice to patients using agreed upon guidelines
Identify and Manage the Constraint
Use standardized guidelines and protocols to increase care that can be provided in alternate ways
Care delivery models (Who does the work) pg 7 • Principles of Access • Office Practice Redesign: Access and Efficiency Workbook © 2011 Quality Improvement and Innovation Partnership
1. Office Practice Redesign in Primary Healthcare: Access and Efficiency Workbook, Quality Improvement and Innovation Partnership p. 7

10. Care Change Concepts2 Delivery System Design Health Care Organization
Define roles and delegate tasks among team members
Use planned proactive visits to support evidence-based care
Build “effective” care management functionality into practice
Assure continuity by the primary healthcare team
Ensure regular follow-up
Health Care Organization
Use effective improvement strategies for comprehensive system change
Information Systems
Include clinically useful and timely information on patients in registry
Identify relevant patient subgroups and provide proactive care
38 • Appendix • Office Practice Redesign: Access and Efficiency Workbook© 2011 Quality Improvement and Innovation Partnership
Care Model Change Concepts
A change concept represents a set of practices,
ideas and tools that have demonstrated
effectiveness in other environments and
can be tested in your environment. Please
note: “The change concepts are not specific
enough to be applied directly to making
improvements. Rather, the concept must be
considered within the context of a specific
situation and then turned into an idea.
The idea will need to be specific enough to
describe how the change can be developed,
tested, and implemented in the specific
situation. Sometimes, a new idea seems at first
to be a new change concept; but often, with
further thinking, it is seen to be an application
of one of the more general concepts.” (Ontario
Health Quality Council).
2. Office Practice Redesign in Primary Healthcare: Access and Efficiency Workbook, Quality Improvement and Innovation Partnership Appendix, 38

11. Family Practice: Case Study
Hamilton Family Health Teams – first wave FHT
Aging patient population
Focus on timely access to appropriate care, chronic disease prevention and management
Practice advantage: inter-professional practice team
Physician, 2 RN’s, Part time DNE, medical student
2500 rostered patients
Preventative care, advanced access and after hours care
Balance between acute and preventative care needed
Facilitator Notes:
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
Inter-professional support and incentives existed but process required to manage population of patients with Diabetes… “The How”

12. For Health Professionals
Planned Recall
For Patients
For Health Professionals
Increases likelihood of follow-up for patients who need it
Targets hard-to-reach patients
Prevents complications through proactive treatment
Helps patients self-manage their care
Increases patient satisfaction
Helps providers target care to meet patient needs
Improves clinical outcomes and care processes
Facilitates other practice improvements, such as group visits and patient self-management
Improves professional satisfaction
Facilitates clinical research
Source URL:
URL:

13. “Diabetes Days” Planned recall: patient “batching” strategy
Goal to provide efficient, effective DM focused visits
Leverage expertise of inter-professionals clinic team
Optimize “Work Flow”
Improve practice efficiency, effectiveness, patient health outcomes
Scheduling strategy allows for
Preventative care appointments
Advanced Access appointments
Joint scheduling (Physician, RN, DNE, Dietitian)
Facilitator Notes:
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.

14. The Solution: Diabetes Days 10 Steps
Establish DM registry
Step 2
Seek Staff alignment
Step 3
Adopt a flow sheet to track activity and monitor patient progress
Step 4
If EMR establish visit protocols with EMR stamps
Step 5
Review patient needs and assign team roles and accountabilities
Step 6
Develop a coordinated schedule with “diabetes healthcare team”
Step 7
Communicate diabetes days to patients
Step 8
Initiate diabetes days
Step 9
Monitor practice effectiveness and patient/provider satisfaction
Step 10
PDSA – Adjust and evolve plan for quality improvement
Add page numbers for practice guide for
Facilitator notes: provide overview and ensure participants understand that additional information is documented in the practice guide for each step
Step 1: DM registry
Step 2: Staff alignment
Step 3: Adopt a flow sheet (paper)
Step 4: EMR Stamps, Visit protocols
Step 5: Team roles and responsibilities
Step 6: Coordinated schedule and rooming assignments
Step 7: Patient communication
Step 8: Initiate “Diabetes Days”
Step 9: Monitor effectiveness
Step 10: PDSA
Provide overview of the steps
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.

15. Set up a DM Patient Registry
“DIABETES DAYS” STEP 1
Set up a DM Patient Registry
Paper or Electronic
Screen for patients using e.g. A1C >7%, LDL >mmol/L, BP >130/80 Hg etc
Allows you to know who your patients are and track their visits and progress
Facilitator notes:
See practice guide page _____
One effective way to begin to manage patients with diabetes is to establish a clinic diabetes registry. Patient registries will differ according to your practice model and charting system
See diabetes registry fields pg _____ of practice guide
For development of manual (paper based) registries, see pg _____ of practice guide
Reference:
Practice Guide
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See Practice Guide Page

16. See Practice Guide Page 66
“DIABETES DAYS” STEP 2
Staff Alignment
Team Alignment is critical:
Alignment should anchor to benefits diabetes days approach can make to patients and providers
Ensures each team member’s contribution is leveraged
Coordinate around staff availability (RN, DNE)
Standardize visits supported with agreed upon protocols, roles
Standardized tools and materials agreed upon: EMR, Stamps, Flow Sheet, Diabetes Education Kit and Patient Materials
Discuss objectives, goals and benefits of “Diabetes Days” with staff
Communicate benefits to patient and team (pg. ___ of practice guide)
Set priorities, establish plan, seek alignment
Define success, mechanism for feedback and timelines
Reference:
See Practice Guide
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See Practice Guide Page 66

17. See Practice Guide Page 69
“DIABETES DAYS” STEP 3
Adopt Flow Sheet
Offering: Tool to track activity and monitor patient progress
Sample
Facilitator notes:
Reference:
Practice Guide
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
Use of a flow sheet has been recommended by the CDA as well as through several provincial diabetes programs
Use of a flow sheet will guide care with the aim of ensuring that appropriate guidelines based care is delivered and can be monitored or tracked at appropriate intervals
If EMR, visits aligned to the flow sheet can be embedded through EMR stamps
See Practice Guide Page 69

18. If EMR: Establish visit protocols with EMR Stamps
“DIABETES DAYS” STEP 4
If EMR: Establish visit protocols with EMR Stamps
EMR allows for development of “stamps”, “favorite notes” or templates
Applied to specific health issues
Will guide care delivery by team
Can be a short cut for documentation to ensure consistency
Facilitators note:
Refer to examples in practice guide of diabetes “stamps”
EMR provider can be contacted by individual teams to customize stamps or address issues/questions
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See Practice Guide Page 63-64

19. Diabetes Days – Sample EMR Stamp
Initial Visit
Facilitator notes:
Sample EMR Stamp
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See examples in practice guide
Reference Szarka

20. Diabetes Days – Sample EMR Stamps
Ongoing Management Visit
DDay f/u today. See my DM sheets or flow sheet F1. Bloodwork results and medications reviewed with pt. including compliance. «yes»«no»
Target organ damage - see problem list +PxHx above (MI/stroke/nephropathy/neuropathy/eyes/hypoglycemia/med intolerance)
BP: • HR: • Wt:• Kgs WH: • last K030 - Oct 11, last Q040 - never done
Foot check pt checks feet B. I. D.« yes»« no»
Hypoglycemia no, Lifestyle ?smoking, exercise etc discussed
Mood "Bothered in the past month by feeling down, depressed or hopeless" «n/a» «yes» «no»
"Bothered in the past month by little interest or pleasure in doing things" «n/a» «yes» «no»
Discussed DM pathophysiology, progression of DM, DM complicaitons, basic lifestyle management of blood sugars as appropriate
Target BGs ac and pc meals discussed -
Target (for most) N Range (if possible)
Before Meals
2Hrs. After
A1C ≤ <6
Provided with - «Just the Basics,» «DM Hamilton,» «What is DM?,» «Managing DM,», «Highs and lows of blood sugars,» «Stand Up to Diabetes»
Pt demonstrated a «good»«poor» understanding of discussion with appropriate comments and questions. Expect pt will make some changes.
Issues identified: Not at target - «WT » «BP » «'lytes » «LFT's » «CK» «creat/eGFR » «HDL »«LDL » «ualb/creat » «FBG »«A1C »
Pt may benefit from :
F/u booked for: 3-4/12 with req. given to pt. for lab work and for them to make appt.
Benefits and side effects of medications prescribed by me are discussed in detail with the patient. RBD of above
Facilitator notes:
Sample EMR Stamps
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See examples in practice guide
Reference Szarka
IFG EGT Visit
Patient did 75 fm GTT, FBS, A1C , and micro albumin/creatinine ratio.  Result is (DMI)  (IFG) (IGT)
Discussed with patient and offered, Appointment with hospital pre-diabetic, Appointment with our dietician, Appointment with our DM Nurse Educator, DVD, and Government Stand up to Diabetes number to call.  Pt told to repeat bloodwork in 1 year.   Following appointments made.

21. Team Roles and Accountabilities
“DIABETES DAYS” STEP 5
Team Roles and Accountabilities
Review patient needs based on patient types
Establish team roles
Activate plan to address any learning needs identified
Facilitator Notes:
Reference
Practice Guide
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See Practice Guide Page 35-37

22. Diabetes Days: Schedule & Workflow
“DIABETES DAYS” STEP 6
Diabetes Days: Schedule & Workflow
Establish a coordinated schedule with the DHC team
Involve all DHC Team members
Establish workflow and room assignments
Best Practice – do not book any other long appointments of physicals during this time
Diabetes related visits only. Other issues to rebooked (within reason)
Facilitator notes:
See Practice Guide Page 60-61

23. Sample Joint Schedule (MD, RNx2, DNE)
Monday DIABETES DAYS
Tuesday
Wednesday
Thursday DIABETES DAYS
Friday
Time
rm 1
rm 2
rm 3
rm 4
rm 5 6
8:00
RN1/MD
DNE
RN2/MD **
RN1
RN2
8:15
Annual
report time DM
8:30
Physical
calls
Physicial
annual
8:45
9:00
diabetic
reg appt
9:15
9:30
9:45
10:00
dibetic
10:15
10:30
10:45
Adv Acc
11:00
11:15
11:30
11:45
12:00
lunch
12:15
12:30
12:45
1:00
1:15
1:30
1:45
2:00
2:15
2:30
2:45
3:00
3:15
3:30
3:45
4:00
4:15
4:30
4:45
5:00
after hours advanced access
5:15
5:30
5:45
6:00
Facilitator Notes:
Sample joint schedule
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
Annual Physical
Advanced Access
Diabetes Days (DM)
Report Time/Calls
Diabetes Days
Diabetic Annual Visit

24. Sample Joint Schedule (MD, RNx2, DNE)
RN/DNE
RN/DNE RN
RN/DNE
RN/DNE
Reg
Reg
Reg
Reg
Facilitator Notes: Sample Schedule (screen capture)
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
Reg
Reg
Reg

25. See Practice Guide Page 60-61
Sample Clinic Work Flow: Diabetes Days Patient Type: Ongoing DM Management
MD moves between rooms
Exam Room 1 –DM Patient A: 15 mins
RN:
Examinations
Results of investigations
Discuss Patient Targets/Importance
Develop or discuss goals to reach Targets
Review and discuss patient self management
Review current treatment and medications
Update records
Physician:
Review Results and Plan with Patient and RN
Answer Patient questions
Completes any additional assessment or treatment changes required
Exam Room 2– DM Patient B: 15 mins
RN:
Examinations
Results of investigations
Discuss Patient Targets/Importance
Develop Goals to reach Targets
Review and Discuss Patient Self Management
Review Treatment and Medications
Update records
Physician:
Review Results and Plan with Patient and AHCP
Answer Patient questions
Completes any additional assessment or treatment changes required
Exam Room 3 – DM Patient C: 30 – 60 mins
Dietician/Diabetes Nurse Educator
First appointment for newly diagnosed Patient
or yearly for ongoing patient management
Physician:
Review Results and Plan with Patient and Dietician/Diabetes Nurse Educator
Answer Patient questions
Completes any additional assessment required
Exam Room 4 –Short Visit (if required)
RN :
Examinations as required
Physician:
Short Visit for acute issues only – no long appointments or physicals
See Practice Guide Page 60-61

26. Patient Communication
“DIABETES DAYS” STEP 7
Patient Communication
Critical for patients to understand they are integral part of the Diabetes Care Team
Regular preventative visits essential
Goals will be mutually set, progress tracked
Communicate role of all staff in DHC and value of each team member contribution
Role of Patient: active participation, goal setting, labs completed prior to visits, meds each visit
Facilitator Notes:
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See Practice Guide Page 62

27. Patient Communication: The Basics
Patient centered team based care strategy to improve patient health outcomes
Healthcare team: Patient and Family, Physician, RN, DNE, Dietitian
Importance of regular preventative care and patient self management
Diabetes only issues addressed
Labs completed prior to appointment
Patient to bring medications to Diabetes Day visits
Setting goals, tracking outcomes against targets at each visit
Facilitator notes:
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.

28. Implement Diabetes Days
“DIABETES DAYS” STEP 8
Implement Diabetes Days
Initially may take 3 – 6 months to establish
Start with two appointments per “day”, increase as more patients are enrolled
Initiate process for staff and patient feedback
See Practice Guide Page 91-92

29. Monitor Effectiveness
“DIABETES DAYS” STEP 9
Monitor Effectiveness
Determine criteria to monitor diabetes days effectiveness
Patient health outcomes
Process outcomes
Patient satisfaction
Provider satisfaction
Facilitator notes:
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See Practice Guide Page 93-95

30. Quality Improvement: PDSA
“DIABETES DAYS” STEP 10
Quality Improvement: PDSA
Establish PDSA objectives and timelines
Establish outcome targets, measures and timelines
P PLAN
D DO
S STUDY
A ACT
Facilitator notes:
Reference:
Dr. Steve Szarka, Assistant Clinical Professor, McMaster University, Faculty of Family Medicine, Hamilton Family Health Team, Hamilton, ON.
See Practice Guide Page 90

31. Clinic Diabetes Management Dashboard
Measures
Baseline
Current
Goal
Measures Options
% with A1C <7
% with A1C measure last 6 months
% with BP < 130/80
% with BP measure last 12 months
% with LDL <2mmol
% with LDL < = 2 mmol last 12 months
% on and ACE/ARB
% on a statin
% with self management goal
% with depression screening last 12 months
% with microalbumin screen last 12 months
% with foot exam last 12 months
% with 24 month retinal exam
% with annual flu vaccine
% with pneumococcal vaccine
% currently smoking
Facilitator notes
The purpose of this report is to capture the improvements being made in your practice through the Pathways program. Your facilitator will review this document along with your outcomes data and provide guidance for future improvement.
Complete at pre-determined intervals e.g. 3 months, 6 months, 1 year

32. Pathways Dashboard: Narrative Report
Key Changes
Describe changes made in the way you care for patients with diabetes
PDSAs
List two or three critical PDSAs that helped you achieve the changes above
Impact on Outcomes
Describe how you believe these changes impacted particular outcomes you are monitoring
What next?
Describe what you will be doing regarding future improvements.
The purpose of this report is to capture the improvements being made in your practice through the Pathways program. Your facilitator will review this document along with your outcomes data and provide guidance for future improvement.
Complete at set intervals to assess progress and determine next steps in the PDSA cycle: 3 mos, 6, mos, 9 mos

33. Q and A Clinic Team Regroup FACILITATOR NOTES:
The teams have been working together for the day - The purpose of this final regroup is to have the Clinic Teams discuss their successes and what key building blocks they can take forward to enable successful implementation of their Action Plans.

34. Wrap up
Parking lot
Measure Effectiveness – Complete CHE Evaluation Form and hand in prior to leaving
FACILITATOR NOTES:
The session is wrapped up by ensuring that the items in the parking lot are acknowledged and allow the participants the remainder of the time to complete the CHE Evaluation form.