2PROGRAM FACULTY CONTRIBUTORS Stewart B. Harris MD, MPH, FCFP, FACPMCanadian Diabetes Association -Chair in Diabetes ManagementIan McWhinney Chair of Family Medicine StudiesProfessor-Schulich School of Medicine & Dentistry, The University of Western OntarioRick Ward MD, CCFP, FCFPCalgary Foothills Primary Care NetworkPatsy Smith MN, RNPLS Consulting Inc.Canadian Nurses AssociationCONTRIBUTORSSteve Szarka, B. Eng, M. Eng, MD, CCFPAssistant Clinical Professor, McMaster University, Faculty of Family MedicineHamilton Family Health Team, Hamilton ONJohn McDonald MD CCFP –Lead Physician - PrimCare Family Health TeamPresident and Chair – Association of Family Health Teams of OntarioDurhane Wong-Reiger BA, MA, PhDInstitute for Optimizing Health Outcomes, CanadaMaureen Clement MD CCFPMedical Director, Diabetes Education Centre Vernon Jubilee HospitalAssistant Clinical Professor, University of British ColumbiaAlice Y.Y. Cheng, MD, FRCPCEndocrinologistCredit Valley Hospital and St. Michael's HospitalAssistant Professor, Dept of MedicineUniversity of TorontoFACULTY NOTES:The Program Faculty should introduce themselves to the group. Give a brief overview as to why the faculty members felt this program was so needed and so important to develop. Acknowledge additional contributors to the content.This program and enduring materials are aligned with Consensus Guidelines and have been developed by the Program Faculty with input from Inter-Disciplinary Practice Teams, other diabetes experts and healthcare professionals including Physicians & Allied Health Practitioners involved in Family Health Teams (Ontario) and Primary Care Networks (AB). as well as Associations e.g. CDA,, MoHLTC, Ontario FHT’s, Professional Associations etc.
3Disclaimer:The following information may refer to drugs or indications that have not been approved by Health Canada. While AstraZeneca has provided financial support for the program, this presentation was created by an independent steering committee and accredited by an independent accrediting body. AstraZeneca does not endorse any use of its products other than in accordance with the current version of the Health Canada approved labeling.3
4FacilitatorsProvide names and credentials of the facilitators for this specific clinic sessionFACILITATOR NOTES:Facilitators introduce themselves (or have the Clinic ‘Champion’ introduce them) to the clinic team participating in the program. It may be beneficial to give some background as to why this program is an important tool for the improvement of diabetes management in a team setting.Have the participants introduce themselves, their roles and what they are interested in getting out of this program (record on flipchart).
5Disclosure of Potential for Conflict of Interest Financial DisclosureGrants/Research Support- XYZ Pharma CoSpeakers Bureau/HonorariaConsulting Fees: XYZ CompanyOther: Employee of XXY Hospital GroupFACILITATOR NOTES:Please disclose to the audience any financial disclosures (before commencing the CHE program) related to the following:Names of companies from which you have received consulting fees or advisory board honorariaNames of companies from which you have received funding for clinical trials or studiesNames of companies from which you have received speaker bureau funding or speaker honorariaNames of companies from which you have received grants/financial supportOther (please specify)
6Clinic Team Introductions Clinic “Champion” and Clinic Team MembersWhat does your Clinic Team hope to achieve today?FACILITATOR NOTES:Have each Clinic “Champion” introduce themselves, the location of their clinic, size of clinic and what their Clinic Team hopes to achieve during this workshop. Then, have each Clinic Team member introduce themselves and their current role.
7Learning Objectives Primary Objectives: Following this program, participants will be able to:Apply principles of chronic disease management to their panelManage Diabetes Mellitus (DM) patients as a team based on the agreed upon PathwayEstablish outcomes to assess changes made as a result of this processDevelop and implement an action plan utilizing strategies and tools that will optimize type 2 diabetes patient management in their clinicSecondary Objectives:Maximize interdisciplinary team based care using available resourcesIncrease trust within teamProvide new models and options for managing DM within a primary care team using Chronic Disease Management (CDM) principlesFACILITATOR NOTES:These are the Learning Objectives for this program.
8Pathways to Diabetes Management Program Goals: Provide interdisciplinary diabetes health care (DHC) teams with a structured, step-wise approach to develop individualized, practical Diabetes Action Plans using guidelines-based strategies and tools to:Improve Patient Health outcomesPromote team effectivenessOptimize practice efficiencyIncrease patient access to treatmentFACILITATOR NOTES:The Pathways to Diabetes Practice Management Program is a guidelines implementation strategy for Interprofessional Practice Teams. Its aim is to provide the framework for Clinic Teams to understand their practice needs and develop an action plan focused on improving health outcomes, team effectiveness, team efficiency and patient access. This program will provide strategies, tools and most importantly the opportunity for team discussion.Teams require practical, implementable approaches to care delivery
9PROGRAM OVERVIEW Step 1 Step 2 Step 3 Step 4 Step 5 FACILITATOR NOTES: The Pathways to Diabetes Management Program will take Clinic Teams 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.Step 4Step 5
10Practical Strategies, Tools & Materials Participant WorkbookCanadian Nurses AssociationPatient Education ToolkitFACILITATOR NOTES:Throughout this workshop, the participants will be provided with strategies to improve DM Patient care in their clinics. They will also be provided with valuable tools and resources to support those strategies:Diabetes Practice Guide – comprehensive reference manual which organizes DM Care Strategies for interprofessional teamsParticipant Workbook– participants will all receive a workbook with the results of their clinic’s assessments completed prior to this workshop, worksheets to be used during this session and copies of information presented today.CNA Patient Education ToolkitDiabetes Practice Management Practice Guide
11Today’s Agenda [to be customized based on event’s start and end time] INTRODUCTION AND CONTEXT75 minutesIntroductions and Program OverviewThe Clinical ChallengeTeam EffectivenessCLINIC WORKSHOP55 minutesStep 1: Clinic Assessment Results and Alignment15 minutesStep 2: Clinic Diabetes Registry60 minutesStep 3A & 3B: Priority Patient Type Review and Diabetes Team Activity Checklist Completion45 minutesStep 3C: Scheduling OptionsACTION PLAN DEVELOPMENT105 minutesStep 4: Action Plan CompletionStep 5: Action Plan Implementation and Measurement30 minutesWRAP UP AND EVALUATIONFACILITATOR NOTES:The majority of time will be spent participating in clinic team activities directed at improving the effectiveness and efficiency of the clinic teams in managing DM patients. The agenda is structured so that your teams can work together to develop your individualized plans while time is also allotted to the sharing of learnings and best practices developed across all of the Clinic Teams participating today.
12The Clinical Challenge Diabetes Care in Family PracticeCDA Guidelines: Therapeutic Goals and Organization of CareFACILITATOR NOTES:The next section provides the clinic team with a reminder of:-Burden of diabetes in CanadaImpact of diabetes on family practiceThe gap between goals and outcomes in the management of DMCDA guidelines including surveillance guidelines and the inclusion of the Organization of Care section which, for the first time, includes the Family Practice role and the need for a team-based approach to diabetes care.
13Diabetes Care in Family Practice The challenge: Diabetes is a complicated, growing disease:More than 9 million Canadians live with diabetes or prediabetes1Risk of CV death is 2-4 times greater than in the general population225% of patients with diabetes suffer from depression211% of patients with diabetes have 3 or more co-morbidities2“Despite increasing evidence about the benefits of effective management, little progress has been made in providing effective care” —CDA Guidelines CommitteeFACILITATOR NOTES:This slide reminds us of the impact that type 2 diabetes has on patients and the fact that much more needs to be done to improve care.References:Canadian Diabetes Association.Canadian Diabetes Association – 2008 Clinical Practice Guidelines. (S2)Canadian Diabetes Association.Canadian Diabetes Association – 2008 Clinical Practice Guidelines.
14Primary Care Challenge Average practice has between patients with diabetes1Patients with diabetes visit their family physician on average 8 times per year2Thus, the burden on the clinic is significant (this does not even include the burden of those with cardiometabolic risk)1DICE: Diabetes in Canada Evaluation study2Most recent A1C test results (n = 2,337)One in two type 2 diabetes patients in Canada are not at target (< 7%) Mean A1C = 7.3%FACILITATOR NOTES:The management of patients with DM can create a significant burden on the average family practice, with many patients still not at target.Harris S., Ekoe J-M., Zdanowicz Y., Webster-Bogaert S. Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada evaluation study). Diabetes Research and Clinical Practice 2005 (70): 90–97.Uncontrolled A1C 49%Controlled A1C 51%Steering Group Communications.Harris SB, et al. Diabetes Res Clin Pract 2005; 70:90-7.
15Few mechanisms exist to implement practical solutions Chronic disease management for diabetes and vascular disease could result in the avoidance of annually……18,000 heart attacks4,000 strokes8,000 unnecessary deaths1,200 cardiac bypass and balloon angioplasties369 amputationsFACILITATOR NOTES:Implementation of a chronic disease management program can have significant impact.Reference: Ontario Health Quality Council, May 2008.Few mechanisms exist to implement practical solutionsQ Monitor, Ontario Health Quality Council Report On Ontario’s Health System.
16Therapeutic Goals CDA Guidelines:1 Goal of treatment is to minimize the risks of the macrovascular and microvascular complications of diabetes by aiming for the following metabolic targetsOntario Ministry of Health: Quality Targets for Primary Care Physicians2Example: Baseline Diabetes Dataset Initiative TargetsA1C≤ 7.0%BP< 130/80 mm HgLDL-C≤ 2.0 mmol/LFACILITATOR NOTES:The first step in minimizing macro and microvascular complications in DM is to focus on the attainment of specific treatment targets.References:Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 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.A1CWithin 6 monthsLDL-CWithin 1 yearRetinal eye examWithin 2 yearsThe Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada., Can J Diabetes. 2008;32(suppl 1):S1-S201Ontario Ministry of Health- Quality Targets for Primary Care Physicians:
17CDA Recommended Diabetes Surveillance Timely screening for complications and aggressive management of risk factors are integral parts of diabetes management.Diabetes Surveillance Schedule1Clinical parameterScreening test(s) and intervalsIntervalGlycemiaA1CEvery 3-6 months, depending on controlBlood PressureBPAt every diabetes-related visit and at least once a yearCholesterolFull fasting lipid profile (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], and calculated LDL-CEvery 1-3 years (more frequently if treatment for dyslipidemia is initiated)CV riskBaseline resting electrocardiogram (ECG) or exercise stress testingAt age 40. Repeat testing every 2 years in people at high riskChronic kidney disease (CKD)Random urine albumin-to-creatinine ratio (ACR) and a serum creatinine converted to an estimated glomerular filtration rate (eGFR)Annual. Those with CKD should have random ACR and eGFR at least every 6 months.Neuropathy10-g monofilament testingAnnualFoot problemsfoot examinationAnnual( more frequently in those at high risk)RetinopathyExpert funduscopic examination through dilated pupil or digital fundus photographyEvery 1-2 years, depending on whether retinopathy is presentErectile dysfunctionSexual function historyPeriodicallyDepression or anxietyStandardized questionnaire or direct queriesFACILITATOR NOTES:This slide is intended to anchor the participants to the CDA Guidelines and to indicate that this program is based on the CDA Surveillance Schedule.The CDA guidelines include a detailed surveillance schedule for screening and risk factor management. Details can be found in the Diabetes Practice Guide.References:Harris S., Lank C. eds. Prevention and Management of Type 2 Diabetes in Adults: A Clinical Primer based on the Canadian Diabetes Association 2008 Clinical Practice Guidelines. Elsevier 2008.Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 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.Harris S., Lank C. eds. Elsevier 2008.
18CDA Organization of Care Guidelines Good Outcomes for people living with diabetes depend on:The “System”….. A Team Based ApproachIdentify patients with diabetesDevelop a Clinic Diabetes RegistryPaper charts (manual identification) or EMR recordsImplement a Systematic Recall ProcessPaper charts- recall by birth month, 3 month prescriptions to trigger next visit, recall visit booked at current visit, booked lab tests and recall by MD when results receivedEMR- auto recall and search for patients by last appointmentMake use of a Clinical Flow SheetsTracks metabolic parameters - ensures timely assessment and treatment to improve adherence to guidelinesFlow Sheets and EMR: automatically populate lab values and tracks overdue elementsParticipate in Diabetes Focused Visits and/or Group VisitsDiabetes Visits - empower patients and utilize interdisciplinary team members to address issues, discuss lab tests, share ideas with fellow patientsGroup visits - increase capacityFACILITATOR NOTES:The CDA Organization of Care guidelines indicate that the patient and DM team work together to provide good outcomes for patients. Key points are identification of patients with diabetes (preferably with a Clinic Diabetes Registry), systematic recalls, use of clinic flow sheets and the use of diabetes-focused visits.Team will need to set up appropriate templates or stamps and reports and review those reports. As not all systems are capable of automatically inserting of data or recall, teams will need to contact their EMR supplier to confirm EMR capabilityReference:Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 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.Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice GuidelinesClement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines
19Team Approach Impact on Patient Outcomes: What does the data show us? Team EffectivenessFACILITATOR NOTES:The next section reinforces the data supporting a team approach to the management of diabetes and the resulting positive impact on patient outcomes. The effective and efficient work of the clinic teams is the cornerstone to positive patient outcomes.
20Hollander Report: Primary Care Practices Are the Cornerstone of Effective Chronic Disease Management Health outcomes are a function of continuity of care by the same family physician1Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs1Group Patient Visits may facilitate attachment by enhancing patient access, time with the medical team, and supportive services provided 2,3FACILITATOR NOTES:Good primary care is essential to effective chronic disease management. This is supported by several studies aligning positive health outcomes with continuity of care. A recent study conducted in British Columbia (BC) by Victoria-based Hollander Analytical Services Ltd. assessed attachment, or the frequency that a patient seeks services from the same medical practice (vs. physician) and the impact on healthcare utilization. This landmark study highlights the importance and value of chronic disease management delivered by primary care practitioners and their teams.References:Hollander MJ., Kadlec H., Hamdi R., Tessaro A. Increasing value for money in the Canadian Healthcare System: new findings on the contribution of primary care services. Healthcare Quarterly. 2009; 12(4):The Hollander report draws on the following key references (among others):Starfield B. Primary care: Balancing health needs, services and technology. New York: Oxford University Press, 1998.Macinko J, et al. The impact of primary healthcare on population health in low- and middle-income countries. Journal of Ambulatory Care Management 2009;32(2):Hollander MJ, et al. Healthcare Quarterly 2009;12(4):Steering Group Communications.Noffsinger EB. The Permanente Journal 1999 ; 3 (3):
21Congestive Heart Failure (CHF) Increasing Value for Money in the Canadian Health- care System: New Findings on the Contribution of Primary Care Services$ (CDN)Percentage of AttachmentDiabetes and CHF – RUB 5 ( )$13,250DiabetesCongestive Heart Failure (CHF)Proportion of Total Cost Attributable to Hospital Costs65%Cost Reduction Attributable to Attachment$16,114FACILITATOR NOTES:Hollander et al. assessed usage data from more than 98,000 high-care-needs patients in BC for the fiscal year of , with a focus on two common chronic disease conditions: diabetes and congestive heart failure (CHF). Attachment, or the frequency that a patient seeks services from the same medical practice, was examined in relation to direct health care costs. What the authors found was that continuity of care or attachment to a practice tended to keep patients healthier and this is associated with markedly lower annual costs to the healthcare system. The effect of attachment on healthcare costs are shown in the figure for patients considered to be high medical resource users (where RUB 0 is a non-user and RUB 5 is a high resource use).As is evident, attachment to a primary care practice is associated with substantial cost savings. For diabetic patients, attachment is associated with a cost reduction of approximately $13,000 per patient while the cost reduction for CHF is more pronounced at approximately $16,000 per patient.Interpreting the figures:Percentage of attachment - is the percentage of GP services provided by the practice (vs. physician) that provides a patient with the most medical services in one year. For example, if a patient was to see the same physician in a solo practice for 4 services and also went to 2 other practices (e.g. two separate drop-in clinics), then the attachment to the main practice would be 66.6%.RUB (Resource Utilization Band) - a means to classify the resource utilization of clinical groups of patients ranging from non-users (RUB 0) to high resource users (RUB 5).Interpreting the total:65% = hospital costs in lowest attachment group was $16, 988 and that in the highest attachment group was $5,909.Reference:Hollander MJ., Kadlec H., Hamdi R., Tessaro A. Increasing value for money in the Canadian Healthcare System: new findings on the contribution of primary care services. Healthcare Quarterly. 2009; 12(4): 32-44Hollander MJ, et al. Healthcare Quarterly 2009;12(4):
22Primary Care is Essential for Optimal Chronic Disease Management Individuals with a primary care practitioner that they saw on a regular basis had lower rates of hospital use, specialist use and costs1Attachment to a practice was the best predictor of a patient’s overall healthcare costs – more so than other variables such as patient age, gender, income or physician gender and practice span.1FACILITATOR NOTES:Hollander’s results are consistent with two previous Canadian studies (Menec et al. 2006, Ionescu-Ittu et al. 2007) which when assessing the impact of attachment to a primary care practice, found that emergency department use/ hospitalizations were associated with a lack of, or reduced attachment to, a family physician. Other studies have noted that the personal relationship that can develop between a patient and family practitioner, tends to keep patients healthier and out of hospital (Starfield et al. 2005, Guthrie et al. 2008).This was confirmed by the finding that attachment was the best predictor of a patient’s overall health care costs, more so than other variables such as patient age, gender, income, location (rural or urban) or physician gender, practice span or number of hours worked.References:Hollander MJ., Kadlec H., Hamdi R., Tessaro A. Increasing value for money in the Canadian Healthcare System: new findings on the contribution of primary care services. Healthcare Quarterly. 2009; 12(4): 32-44Menec VH, Sirski M, Attawar D, and A. Katz. Does continuity of care with a family physician reduces hospitalizations among older adults? Journal of Health Services Research and Policies 2006;11(4):Ionescu-Ittu R, McCusker J, Ciampi A, Valdeboncoeur A-M, et al. Canadian Medical Association Journal 2007;177(11):Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly 2005;83(3):Guthrie B, Saultz JW, Freeman GK, and JL Haggerty. Continuity of care matters. British Medical Journal 2008;337:a867.Hollander MJ. et al. Healthcare Quarterly 2009;12(4):
23Shared Medical Appointments Based on the Chronic Care Model A Quality Improvement Project to Address the Challenges of Patients with Diabetes with High CV Risk1Setting: Primary care clinicHigh CV risk defined as one or more of the following:A1C levels >9%Systolic Blood Pressure (SBP) > 160 mm HgLow Density Lipoprotein cholesterol (LDL-C) >3.53 mmol/LPatient characteristics for each group were similarFACILITATOR NOTES:A primary care clinic at a tertiary care academic medical centre sought to improve intermediate outcome measures for diabetes in patients at high cardiovascular risk by implementing Group Patient Visits (shared medical appointments). At-risk patients received a letter inviting them to call the clinic and participate in the group visits. At each group visit, patients were made aware of their relevant clinical information (e.g., A1C level, SBP, LDL-C etc.) and engaged in a group discussion/education session reviewing clinical goals, self-management and other topics relevant to diabetes management (e.g. smoking). Patients had the opportunity to participate in up to 7 Group Patient Visits.This was a quasi-experimental study with non-randomized concurrent controls. The intervention group constituted all patients who participated in at least one GPV (n=44). Control subjects included all patients who participated in at least one GPV (n=39) with the control data obtained retrospectively for a period prior to participation in the GPV.Baseline characteristics of the intervention (GPV group) and controls were similar. Of note, all but one patient was male (97.7%). Each GPV group had up to 8 patients. Patients had the opportunity to participate in up to 7 GPVs – 38.6% of patients participated in one visit with the rate declining to 6.8% patients participating in all seven visits.Compound Conventional (US) Unit Factor SI UnitLow-density lipoprotein (LDL)cholesterol mg/dl mmol/lConversion table for chemical compounds from conventional to SI units Conventional unit => SI unit: multiply by factor SI unit => conventional unit: divide by factorReference:Kirsh S., Watts S., Pascuzzi K., O’Day ME., et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care 2007;16:AIM: Improve outcomes for patients with diabetes at high cardiovascular risk via Group Patient Visit (GPV) implementationKirsh S, et al. Qual Saf Health Care 2007;16:
24Better Cardiovascular Risk Reduction was Observed in Patients Attending Group Patient Visits (GPV)1 Patients participating in GPV experienced greater benefits in HbA1c, LDL-c and SBP levels compared to usual core patients.1010.59.58.51198Mean %GVPControl2.2Mean mmol/L %188.8.131.52.184.108.40.206.9Mean mm Hg130135140145150155= -0.30= 1.44= 0.14= 0.41= 2.54= 14.83HbA1cP= 0.002LDL-cP= 0.29SBPP= 0.04BaselineFollow-upControl n= 35GPV n=44FACILITATOR NOTES:Patients with diabetes participating in Group Patient Visits (GPV) experienced greater benefits in terms of cardiovascular risk reduction than the control group.Reductions seen for control and intervention patients, respectively were:A1C (%): vs (p=0.002)LDL-C (mg/dL): 0.14 vs (p=0.29)SBP (mm Hg): 2.54 vs (p=0.04)While the p value for the relative reduction in LDL-C levels for control and GPV patients did not reach statistical significance, it should be noted that the reduction in the LDL-C level experienced by patients participating in GPVs was greater than the control patients and may represent a clinically beneficial decrease.The authors also assessed the proportion of patients prescribed aspirin in the two intervention groups and found that, of those patients eligible to take aspirin, 88.4% had been prescribed it at baseline (i.e. prior to initiation of GPVs) and this rose to 97.7% being prescribed it at the GPV.In addition, participation in GPVs was positively associated with the proportion of patients meeting clinical targets. Numerically a greater proportion of patients met clinical targets for all three measures with significance being achieved for SBP (data below).A1C LDL-C SBPPatients meeting clinical targets:Pre-intervention % 69.4% %Post-intervention % 83.3% %P valueReference:Kirsh S., Watts S., Pascuzzi K., O’Day ME., et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care 2007;16:Kirsh s, et al. Qual Saf Health Care 2007;16:
25Team Effectiveness in Diabetes Treatment Why a team?What are the attributes of an effective team?Why is this important?FACILITATOR NOTES:This section of the program answers the following questions:1. Why a team? How can a team deliver DM care? Discuss the attributes of an effective team 2. Why is this important?Present data illustrating why teams are effective
26Features of high performing teams Team Efficiency1-5Common challengesTimePressure to provide both acute and preventive careVolume pressureFee-for-serviceAfter hour accessLong wait timesFocus on task substitution vs. teamworkUnderutilization of interprofessional health teamFeatures of high performing teamsThe delegation of key roles to non-physiciansCoordinated patient flow strategies: Triaging, multiple access points, advanced access, EMR registry recall, case managementGroup visits/shared medical appointmentsDisease-specific targeted “Mini” ClinicsIntegration of specialist care when appropriateFACILITATOR NOTES:RW to provide speaker notes References:EICP - Enhancing Interdisciplinary Collaboration in Primary Health Care. AprilMcMurchy D. What are the Critical Attributes and Benefits of a High Quality Primary Health-care System? Background paper for the Canadian Working Group on Primary Health-care Improvement. January 2009.Kirsh S., Watts S., Pascuzzi K., O’Day ME., et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care 2007;16:Added: Barrett J, Curran V, Glynn L, Godwin M. CHSRF synthesis. Interprofessional collaboration and quality primary healthcare. Ottawa, ON: Canadian Health Services Research Foundation; 2007.EICP - Enhancing Interdisciplinary Collaboration in Primary Health Care. April 2005.McMurchy D. CIHR, 2009; retrieved from:Barrett et al. CHSRF. 2007Kirsh S, et al. Qual Saf Health Care 2007;16:Steering Group Communications.
27Team Effectiveness results in…1-5 Improvement in:Practice efficiencyProfessional satisfactionPatient access– reduced wait timeCare coordinationComprehensiveness of carePreventative careAchievement of metabolic targetsSelf-care capacitySystem navigation/health literacyQuality of lifeFollow-up (less falling through the cracks)Patient satisfactionReduction in:Hospital admissionsER useOutpatient visitsBlood pressureCholesterolRisk of complicationsFACILITATOR NOTES:RW to provide speaker notes - Discussion regarding the effectiveness of team approach and resultant outcomesReferences:Aschner P, et al. The team approach to diabetes management: partnering with patients. Int J Clin Pract Suppl. 2007; 157:22-30.Sperl-Hillen JM, Solberg LI, Hroscikoski MC, Crain AL, Engebertson KI, O'Connor PJ. Do all components of the chronic care model contribute equally to quality improvement? Jt Comm J Qual Saf. 2004; 30(6):Vargas RB, Mangione CM, Asch S, et al. Can a chronic care model collaborative reduce heart disease risk in patients with diabetes? Journal of General Internal Medicine Feb;22(2):McMurchy D,.What are the Critical Attributes and Benefits of a High Quality Primary Health-care System? Background paper for the Canadian Working Group on Primary Health-care Improvement. January 2009.Barrett J, Curran V, Glynn L, Godwin M. CHSRF synthesis. Interprofessional collaboration and quality primary healthcare. Ottawa, ON: Canadian Health Services Research Foundation; 2007.Aschner P, et al. Int J Clin Pract Suppl. 2007; 157:22-30.Sperl-Hillen et al. JT Comm J Qual Saf. 2004;30(6):Vargas RB et al. J Gen Intern Med ;22(2);McMurcahy D. CIHR, 2009;.Barrett et al. CHSRFSteering Group Communications.
28Diabetes Care Teams….A System Change Points to consider:READINESS TO CHANGEIs your team ready to change the delivery of healthcare to optimize practice efficiency and promote team effectiveness?STRATEGIC AND STRUCTUREDIs the change addressing an important need?Team meets to assess the problem and present optionsSolution selected as a teamDIRECTEDSpecific person is responsible for driving agenda and keeping to timelinesATTRIBUTES OF LEADERSHIPBe presentBe preparedModel interprofessional behaviourProvide the energy!INVOLVE THE ENTIRE TEAMSystem change generally involves all team players“If team members know the “why’s” then they can often help with the “how’s”Who does what? Consider the most optimal use of team resourcesAn activity which brings the team together to improve clinical care increases trust and alignmentFACILITATOR NOTES:Developed by Rick Ward faculty
29Diabetes Care Teams….A System Change Working together as a team includes…PROTOCOL SETTINGDelegation of key tasks to interdisciplinary team membersDelivery of consistent guidelines-based care by the interdisciplinary teamIncreased patient confidenceAPPROPRIATE ROLES AND RESPONSIBILITIES3 R’s: Right provider… Right job… Right time…Maximizes scope of practice and avoids redundancyLeast costly position who is able to competently fulfill the roleAuthority to act – ensure team members are empoweredENSURING CHANGE IS WELL PLANNEDSmall simple attainable changes –e.g. patient handouts regarding BP targets and how to conduct home BP measurementSpecific and measurable, action-oriented changes with tools and goalsRealistic and specific timelines- adequate time for change to occur- not too long or momentum will be lostInvolve and delegate to many team members- the more that are involved, the greater the ownershipFACILITATOR NOTES:Developed by Rick Ward (Faculty)This slide is used to reinforce the characteristics for change within the clinic and clinic team:Small, simple changes that are easily attainable likely have the greatest benefit with the least cost. Example – patient hand-out sheets on how to measure blood pressure and appropriate blood pressure targets may be easier than bringing patients into an office for a nurse to demonstrate home blood pressure assessment and education around targets.Be specific about change goals. Instead of “we are going to find out who our patients are with diabetes”, move to goals like “we are going to develop a spreadsheet of all our patients with diabetes that contains information that allows us to track important variables including BP, A1C, statin use and recall date”.Timelines should be specific (date) and allow adequate time for change to occur. Timelines that are too long result in loss of momentum, timelines that are too short usually result in rescheduling or incomplete work. How long for timelines? When undergoing change cycles, biweekly or monthly meetings are usually required. These can be shorter meetings as things start to evolve and may not include all team members.The more involvement in a change process, the more ownership. One person doing all the work and then trying to ‘sell’ the change to colleagues is less effective than a process which involves team members.Maximize scope of practice and provide team members with the authority to follow through. For example – if it is within scope of practice for nurse educator to adjust insulin dosage, does this patient need to see the physician to confirm dosage adjustment? If you have a nurse educator who can do foot exams, does the physician need to do this? If the community pharmacist who sells blood glucose monitors can demonstrate device use – does the patient need to come back to the DM nurse to be shown how this is done?
30Protocol Setting — what does the data tell us? CHAMP Results Increase in use of therapies in post MI treatment100%92%86%80%The UCLA Medical Center’s Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) increased guideline intervention78%61%60%56%40%FACILITATOR NOTES:The CHAMP study targeted post-MI care. It was established that there was relatively low usage at discharge of evidence-based post MI therapy– specifically beta blockers, ASA, Statins and ACE-inhibitors. The intervention in this study was standard protocol based order sets for these patients which defaulted to these four interventions. The team involved in care of post-MI patients were aware of both the rationale for the treatments AND the uniform requirement for all patients to receive these interventions. The process was built into standard care. Naturally, some patients may not have been appropriate to receive certain therapies. In these cases the protocol would be modified. The default, however, was to follow the protocol.After introduction of the protocol there was significant increase in use of all four therapies.Reference: Fonarow GC, et al. Improved Treatment of Coronary Heart Disease by Implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol 2001;87:819–82220%12%6%4%0%Pre-CHAMPPost-CHAMPAspirinBeta-blockerStatinACE InhibitorFonarow GC, et al. Am J Cardiol 2001;87:819–822.
31Protocol Setting — what does the data tell us? CHAMP Results Death or Recurrent MI%14.8%6.4%Pre-CHAMPPost-CHAMP15%5%10%0%20%CHAMP protocol reduced death or recurrent myocardial infarctionFACILITATOR NOTES:More impressive, was the expected but impressive reduction in recurrent events post-intervention, including death and recurrent MI. The bottom line – protocols work.Reference:Fonarow GC, et al. Improved Treatment of Coronary Heart Disease by Implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol 2001;87:819–822.Fonarow GC, et al. Am J Cardiol 2001;87:819–822.
32Summary FACILITATOR NOTES: The burden of diabetes in Canada is high The impact of diabetes on family practice is highAverage practice has between patients with diabetesPatients with diabetes visit their family physician on average 8 times per yearThe gap between goals and outcomes needs addressing i.e. one in two type 2 diabetes patients in Canada are not at targetHealth outcomes are linked to continuity of careAttachment to a primary care practice shows substantial cost savingsImplementation of a team-based approach can have significant impact
33Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION
34Materials are provided in the Participant Workbook WORKSHOP OUTLINEStep 1A - Priority Patient PopulationStep 1B - Patient Management NeedsStep 1C - Team ReadinessStep 1D – Diabetes Resource InventoryACTIVITIES:Review results of Clinic AssessmentsValidate/align the direction and outcomes of the assessments with the teamFine-tune the direction (if required)MATERIALS:Summary of Clinic Assessment ResultsDiabetes Resource InventoryNote MBC on 15 July that not directional enough and Mike to advise - CHECKWORKSHOP #1:TOTAL TIME ALLOTTED: 40 MINUTESFACILITATOR NOTES:NOTE: Facilitators and clinic “champions” will meet prior to the CHE and discuss the findings of all clinic assessment forms and Clinic Teams will be provided with copies of the Clinic Assessment Summary.This slide will introduce the Workshop for Step #1. Each clinic team has completed 4 Clinic Assessment forms – copies of the forms are included in the Participant Workbook: 1A- Identifying Patient Populations, 1B Patient Management Needs Assessment, 1C Team Readiness and 1D Resource InventoryACTIVITIES:The intent of this session is to review the results of the 4 Assessments for YOUR clinic and,To introduce the direction determined by the champions on the basis of the Clinic Assessments and in discussion with the facilitators prior to the CHEClinic Assessment Summary - 20 minutesDiabetes Resources Inventory – 10 minutesTo validate/align the direction and outcomes of the assessments – 10 minutesTo fine-tune the direction if requiredMATERIALS: The Summary of Clinic Assessments and the Diabetes Resource Inventory can be found in the Participant Workbook.Materials are provided in the Participant Workbook
35Summary of YOUR Clinic Assessment Time allotted: 20 minutesFACILITATOR NOTES:NOTE: Slide will be pre-populated based on the Champion/clinic feedbackPrior to reviewing the Clinic Assessment Results, thank the team for their time that they took to think about their current clinic practice and opportunities for improvement. This slide summarizes the overall input of the team.Review Clinic Assessment Results and ask for agreement after each section:This slide will facilitate discussion and validation of the outcomes of assessment tools:1A Identifying Priority Patient Populations1B Patient Mgmt Needs Assessment1C Team ReadinessDo you agree?
36Diabetes Resource Inventory What resources did you identify?Time allotted: 10 minutesFACILITATOR NOTES:NOTE: Slide will be pre-populated by facilitator based on champion/clinic feedbackReview this slide with the team to provide a snapshot of the clinic and community resources identified during the Clinic Assessment. The completed Diabetes Resource Inventory will be used in the “Diabetes Team Activity Checklist” workshop during Step 3.Is anything missing?Consider ALL staff – MOA’s, interdisciplinary team members, telephone staff etc.Community Resources - consider regional DM programs, community pharmacists, CDA, local health clubs (fitness centers, the ‘Y’ etc.)Internet or web based resources
37Team Reflection and Alignment Exercise What did you learn about your patients? Your team? Clinic efficiency gaps and opportunities?Do any of the results surprise you?Do you agree that, by focusing on the areas highlighted in the Clinic Assessment Summary, your team can make a difference in the treatment of DM patients?Priority Patient Type – goals and outcomesBuild a Registry (if required) or assessImproved team careScheduling MethodsIs your team READY to develop and implement a team-based diabetes management program?Time allotted: 10 minutesFACILITATOR NOTES:Use this slide to generate discussion within the group and to validate alignment regarding Priority Patient Type, Clinic Registry Needs, Gaps/Opportunities for improved patient management and methods for scheduling that may be useful in the clinic.The team should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.Use Parking lot flipchart to record any out of scope comments/issues. Once alignment is obtained, move on to Step #2.MAKE ACTION PLAN NOTES
38Clinic Team RegroupShare key learnings from Team Reflection and Alignment ExerciseLearnings about your patients, your team and clinic efficiency gaps and opportunitiesHighlight any areas in which your Clinic Team would benefit from feedback/input from the larger groupFACILITATOR NOTES:This discussion provides an opportunity for the teams to demonstrate their alignment on the results of the Clinic Assessments and the assumptions each Clinic Team will be utilizing to create their Action Plans. Encourage the Clinic Teams to ask questions of each other and encourage sharing of experiences.The teams should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.MAKE ACTION PLAN NOTES
39Materials available in Diabetes Practice Guide Workshop OutlineDevelop or Access Clinic Diabetes RegistryACTIVITIESDo you have a Clinic Diabetes Registry?Why is it important?Review EMR and Manual registry optionsMATERIALSDiabetes Practice GuideWORKSHOP #2TOTAL TIME ALLOTTED: 15 MINUTESFACILITATOR NOTES:This slide will introduce Step #2 and the discussion around the importance of a Clinic Diabetes Registry. The purpose of the workshop is to explain the important role that a Clinic Diabetes Registry can play in the management of patients with type 2 diabetes. If a clinic doesn’t currently have a registry, setting one up needs to be the priority when developing the Action Plan. For those clinics that do currently have a registry, the discussion should be around how the registry could be used more effectively.MATERIALS: Information regarding Clinic Diabetes Registries is available in the Diabetes Practice Guide.Materials available in Diabetes Practice Guide
40The Role of the Clinic Diabetes Registry Does your clinic have a Diabetes Clinic Patient Registry?As indicated by the CDA’s Organization of Care Guidelines, a Diabetes Patient Registry is a very important step in patient management.Identify patients with diabetesDevelop a Clinic Diabetes RegistryPaper charts (manual identification) or EMR recordsImplement a Systematic Recall ProcessPaper charts- recall by birth month, 3 month prescriptions to trigger next visit, recall visit booked at current visit, booked lab tests and recall by MD when results receivedEMR- auto recall and search for patients by last appointmentMake use of a Clinical Flow SheetTracks metabolic parameters - ensures timely assessment and treatment to improve adherence to guidelinesFlow Sheets and EMR: automatically populate lab values and tracks overdue elementsParticipate in Diabetes Focused Visits and/or Group VisitsDiabetes Visits - empower patients and utilize interdisciplinary team members to address issues, discuss lab tests, share ideas with fellow patientsGroup visits - increase capacityFACILITATOR NOTES:This slide should remind the team of the important role that a Diabetes Patient Registry can play in the management of DM patients.Reference is made to the CDA Organization of Care guidelines which indicate that a Registry (either electronic or manual) is a MUST DO in patient management. Registries aid in systematic recall, tracking metabolic parameters and implementing the scheduling methods that will be effective in the clinic.Team will need to set up appropriate templates or stamps and reports and review those reports. As not all systems are capable of automatically inserting of data or recall, teams will need to contact their EMR supplier to confirm EMR capabilityReference:Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice GuidelinesThe Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. , Can J Diabetes. 2008;32(suppl 1):S1-S201Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines
41EMR Patient Registry Track patients using appropriate “data searches” Identify and categorize “specific” patients by category or billing informationIdentify patients who require intervention by conducting a data search based on disease- specific clinical outcomes or problems listExamples: A1C > 7%; BP >130/80 mm Hg; Elevated cholesterol levelsFacilitate outcomes measurement** Is your EMR an effective/optimal Registry tool? If not, contact your EMR provider for assistanceDiabetes Registry FieldsFundamentalOptionalDiagnosis: prediabetes, type 1, 2 or gestationalDate of diagnosisLast visitLast A1C and dateLast lipid screen date, LDL and ratio valuesLast blood pressure- date and valueLast nephropathy screen- value and dateLast foot exam dateLast eye exam dateInsulin – yes or no? date initiatedLast influenza vaccine datePneumococcal vaccine dateNext appointment (or recall date)ComplicationsDiabetes education- yes/no and last dateLast EKGLast stress testMedicationsBilling codesFACILITATOR NOTES:A short introduction to the EMR registry which is intended to support clinics with an EMR--- and encourage them to ask… “Is my EMR providing optimal info?” If not, they need to discuss these issues with their EMR provider.Facilitator to direct participants to appropriate sections of the Practice Guide regarding EMR, Stamps etcEMR may have data quality issues particularly related to consistent data entry by the users, searching by category, or problem list may be yield an inaccurate list. For example, a diagnosis of diabetes in the chart could be labelled as diabetes, DM, type 2, etc, often a good idea to compare EMR generated list with billing data and then ensure that physicians reviews the list for accuracy. EMR vendors may or may not be helpful, it may be useful to suggest contacting local IT support to maximise the use of their technology by building appropriate templates or stamps or to hire a data management/IT person to be part of the team - someone familiar with medical terminology is an asset or consider sending them for clinical learning session just to become more familiar with the terms and processes that clinician use.It is critical that whatever data is being tracked that a date is associated with the field as opposed to just a value or a yes/no answer. The same applies to demographic information lik.e smoking satus e.g. can't simply use terms like current smoker, non-smoker without an attached date
42Manual Patient Registry EXCEL Diabetes Patient RegistryTrack patients via commercially available spreadsheetsRegistry could be populated…at diagnosiswhen reviewing charts or at patient’s next appointmentwhen lab results or consultation reports are receivedNotes:Registry management should be assigned to one team member to ensure it is updatedAlthough a registry is a key element, some “patient practice” changes can be made while the registry is being developed (e.g. scheduling patients more efficiently)FACILITATOR NOTES:A short introduction to one “manual” registry.Facilitator to direct participants to appropriate sections of the Practice Guide regarding manual registriesRemind the participants that a registry is a key element… however some “patient practice” changes can be made while the registry is being developed… for example:Scheduling patients more efficientlyBatchingGroup patient visitsReference:Ortiz D. Family Practice Management, Using a Simple Patient Registry to Improve Your Chronic Disease Care. Fam Pract Manag. 2006 Apr;13(4): Available from:Ortiz D. Family Practice Management, Fam Pract Manag. 2006 Apr;13(4): retrieved from:
43Diabetes Registry Next Steps If no Clinic Diabetes Registry:PRIORITY FOR THE CLINIC ACTION PLAN SHOULD BE SETTING UP AN EMR OR MANUAL REGISTRYIf Clinic Diabetes Registry is in place:THINK ABOUT OPPORTUNITIES TO IMPROVE EFFICIENCYFOCUS ON PRIORITY PATIENT TYPE DIABETES TEAM ACTIVITY CHECKLIST IMPLEMENTATIONFACILITATOR NOTES:The group should be encouraged to discuss the next steps required within their clinic team regarding a Clinic Diabetes Registry.If the Clinic does not have a registry, the group should discuss1 – whether or not they will pursue an EMR or Manual Strategy2 – start to discuss broad next steps, roles and responsibilities and record in their Action Plan NotesIf the Clinic does have a registry, the group should discuss1- how the registry is currently working – difficulties, barriers and what is working well2 – discuss how the registry and the team’s use of it could be made more efficient and make Action Plan NotesMAKE ACTION PLAN NOTES
44Clinic Team Regroup Share key learnings Clinic diabetes registry development or assessmentOverall input/collaboration with other Clinic TeamsFACILITATOR NOTES:This discussion provides an opportunity for the teams to demonstrate their alignment on the development or assessment of registries and the assumptions each Clinic Team will be utilizing to create their Action Plans. Encourage the Clinic Teams to ask questions of each other and encourage sharing of experiences.MAKE ACTION PLAN NOTES
45Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION
46Workshop OutlineACTIVITIES:Validate your Clinic’s Priority Patient TypeReview your Diabetes Resource InventoryComplete the Diabetes Team Activity Checklist and Assign Team RolesReview and Select Scheduling MethodMATERIALS:Clinic Needs Assessment SummaryDiabetes Resource InventoryPriority Patient Type - Diabetes Team Activity Checklist: (one of the following: Prediabetes, New Diagnosis, Ongoing Management, Insulin Starts, Complex Patient)Priority Patient Type, Diabetes Team Activity Checklist, Scheduling MethodsACTIVITIES:Validate your Clinic’s Priority Patient TypeReview your Diabetes Resource InventoryComplete the Diabetes Team Activity Checklist and Assign Team RolesReview and Select Scheduling MethodMATERIALS:Clinic Needs Assessment SummaryDiabetes Resource InventoryPriority Patient Type - Diabetes Team Activity Checklist: (one of the following: Prediabetes, New Diagnosis, Ongoing Management, Insulin Starts, Complex Patient)WORKSHOPTOTAL TIME ALLOTTED: 45 MINUTESSteps 3A and 3B – 45 minutesFACILITATOR NOTES:NOTE: ALL CLINIC TEAMS will participate in this activity… including the clinics with NO Registry as this anchors these clinics to the next steps after a Registry is developedThe purpose of this workshop is to reinforce the Priority Patient type focus for the team, to introduce need to access resources outside the clinic (to continually update the diabetes inventory), to assign team roles for the management of the priority patient group.ActivitiesValidate the Clinic’s Priority Patient Type – 10 minutesReview the Diabetes Resource Inventory – 10 minutesComplete the Diabetes Team Activity Checklist and Assign Team Roles – 25 minutesMATERIALS: All materials can be found in the Participant Workbook. Descriptions of Scheduling options are located in the Diabetes Practice Guide.All materials can be found in the Participant Workbook.Descriptions of scheduling options are located in the Practice Guide.
47Step 3A: Validation of Priority Patient Type Using the criteria below for your Priority Patient type, describe a patient in your clinic practice that would fit this profileWhat are the major challenges faced when dealing with this patient?Diabetes Management PathwayPriority Patient TypesTriggering Event#1- PrediabetesIFG and/or IGT#2- New DiagnosisDiagnosis of Type 2 diabetes#3- Ongoing ManagementYearly Review#4- Insulin StartsPatients not at target after optimizing oral medications#5- Complex PatientDiabetes complications and/or patients who have not reached glycemic targetsFACILITATOR NOTES:The clinic team should think about a patient in the clinic that fits the profile of the Priority Patient type the team selected during the Step 1: Clinic Assessments. By thinking about the challenges that these patients bring to the clinic practice, the team can begin to think about the potential solutions.The team should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.MAKE ACTION PLAN NOTES
48Step 3A: Review of Diabetes Resource Inventory What resources can we utilize to help manage this patient type?What resources are we missing?FACILITATOR NOTESReview the Diabetes Resource Inventory presented in Step 1.Discuss with the group the resources that will be necessary to manage the Priority Patient Type.Introduce the need to access resources outside the clinic---and to continually update the Diabetes Resource Inventory.The team should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.MAKE ACTION PLAN NOTES
49Step 3B: Complete the Diabetes Team Activity Checklist Diabetes Team Activity Checklists: Lists of CDA recommended activities for each patient typeUtilize the Diabetes Team Activity Checklist for your identified priority patient typeAssign roles to each task – think about the resources on the Diabetes Resource InventoryConsiderations:Delegation of key tasks to non- physiciansCoordinated patient flow strategiesIntegration of specialist careUtilization of interprofessional resourcesFACILITATOR NOTES:Refer the team to their Participant Workbook and to the page with the Diabetes Team Activity Checklist for the selected Priority Patient Type. The team should work together to complete the checklist and determine the most efficient way of managing this patient type by assigning the most appropriate person in the clinic to each task.Diabetes Team Activity Checklists are provided in the Participant Workbook
50Clinic Team Regroup Share Priority Patient Type and rationalePotential patient management changes based upon the Priority Patient Checklist ReviewHighlight any areas in which your Clinic Team would benefit from feedback/input from the larger groupFACILITATOR NOTES:This discussion provides an opportunity for the teams to demonstrate their alignment on Priority Patient Type and Role assignments based upon the Diabetes Team Checklist. Encourage the Clinic Teams to ask questions of each other and encourage sharing of experiences (esp. teams that have employed specific management techniques within their DM patient population).The teams should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.MAKE ACTION PLAN NOTES
51Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION
52Step 3C: Scheduling Options Advanced AccessA structured and systematic method which ensures patients access to primary health care team at a convenient time“Diabetes Days” BatchingOrganized and coordinated team-based care for DM patientsUtilize a “batching” scheduling strategy to manage populations of patientsGroup Patient VisitsAn expanded medical appointment delivering most elements of an individual visitCoordinated Team SchedulingMD and RN collaborative patient visitsInterdisciplinary Patient Visits- Sample Visit ActivitiesThe right clinician at the right timeFACILITATOR NOTES:The next slides provide an OVERVIEW of scheduling and patient visit options. Further information is available in the Diabetes Practice Guide (including links to full resources). Participants should be encouraged to locate the appropriate pages in the Diabetes Practice Guide as each concept is introduced.Note: For those clinics who do NOT have a Registry, it will be important to keep them engaged in this section and remind them that although Registry is a key element, some “patient practice” changes can be made while the registry is being developed. For example:Scheduling patients more efficientlyBatchingGroup patient visitsTeam to inform in advance of program areas of interest…provide greater detail for strategies of interest onlyFor more information see the Diabetes Practice Guide
53For more information see the Diabetes Practice Guide Advanced AccessA structured and systematic method which ensures patients access to primary healthcare team at a convenient timeSame Day Bookings ~80% of all appointments:Patients call and book an appointment “today”Advanced Booking ~20% of all appointmentsPreventative appointments- e.g. quarterly appointments for DMLabs pre-appointmentSelf care and goal settingSix elements/conditions:Understand the supply/capacity and demandBalance supply and demandReduce the number of appointment typesDevelop contingency plans to sustain the systemReduce and shape the demand for visitsIncrease effective supply: transfer physicians’ functions that can be done by someone elseFACILITATOR NOTES:Once a clinic practice understands the capacity of the clinic, as well as the patient demand, the need for managing chronic conditions can be met through advanced access booking while the majority of other patient visits can be handled by same-day bookings. Laboratory testing can be scheduled in advance of the appointmentThe benefit of this scheduling strategy is that more patients can be seen closer to the time they need and/or request to be seen reducing Urgent Care and Emergency Room use.Refer participants to the Diabetes Practice Guide.For more information see the Diabetes Practice Guide
54“Diabetes Days” Batching Organized and coordinated team-based care for patients with DM: “Diabetes Days” apply a “batching” scheduling strategy for patient with DM, improving patient access to care and improving practice efficiency and effectiveness.Logistics:Allows for scheduling preventative care during regular and advanced access appointmentsType 2 diabetes “batching” on specific days weeklyLabs pre-appointmentNo long appointments scheduled on “batching” daysStrong emphasis on patient’s role as team memberTeam:Effective for small or larger teamsMD and team agree on rolesStandardized/consistent team roles and documentationExam rooms for each team member and MD moves between roomsUse of flow sheet or EMR for quick assessment of patient status, outcome tracking and as a teaching toolFACILITATOR NOTES:“Diabetes Days” utilize a “batching” strategy to organize coordinated team-based care for a defined patient group (e.g. prediabetes, ongoing DM management). This approach allows for scheduling preventative care DM appointments, as well as regular and advanced access appointments within a clinic setting. This process can be applied in small teams with 1MD and 1 RN or in larger teams with more healthcare professional resources.Patients are instructed to book an appointment when labs completed and bring medication to every appointment. Strong emphasis should be placed on patient accountability and the importance of their role in the “Team” is key to success.Refer participants to the Diabetes Practice Guide.For more information see the Diabetes Practice Guide
55Group Patient Visits (GPV) Personal ExamEducationGroup InteractionExpanded medical appointment delivering most elements of an individual visit, includingPersonal examinations (e.g. collection of vital signs, history-taking, physical exam)Formal and informal educationSocial and psychological supportPractice effectiveness and efficiency which…Increases capacity to care for more chronically ill patients in less timeIncreases efficiency as a result of staff working in appropriate roles and assuming appropriate responsibilitiesImproves job satisfaction among staffImproves delivery of quality patient carePatient Self-mgmtFACILITATOR NOTES:Group Patient Visits (GPV) are expanded medical appointments where patients’ medical and psychological needs are met by a team of healthcare providers in the familiar and non-threatening setting of their own family practice. Key components include personal examinations, formal and informal education, and social and psychological support. Patient empowerment and self-management are promoted by the team and patients are encouraged and supported to make informed healthcare decisions.GPV are not ideal for all patients. Rather, careful pre-selection of patient groups and of individual patients within the group will ensure optimal success.Refer participants to the Diabetes Practice Guide.For further information, AstraZeneca Canada has developed an accredited CHE on Group Patient Visits.More information on group patient visits can be found at:For more information see the Diabetes Practice Guide
56Coordinated Team Scheduling Coordinated Schedule ExampleRN Role:Focuses on time-consuming diabetes management appointmentsMD has dual role:Urgent care needs and typical family practice visitsJoins the nurse’s visit (if required) to review the plan and sign prescriptionsFACILITATOR NOTES:Coordinated team scheduling is focused on the MD and RN scheduling collaborative patient visits.Using this method, the RN can focus on some of the more time-consuming patient types and appointments, while the physician can focus on shorter family practice visits, while joining the RN with the DM patient if and when required.Refer participants to the Diabetes Practice Guide.For more information see the Diabetes Practice Guide
57For more information see the Diabetes Practice Guide Interdisciplinary Patient Visits: “Right clinician” at the “Right Time”Sample Visit Activities: Detailed interdisciplinary patient visits checklists/plans are provided in the practice guide for the 5 DM patient groups as follows:PrediabetesNew DiagnosisOngoing ManagementInsulin StartsComplex DM PatientsChecklists are aligned to the CDA Clinical Guideline Surveillance ScheduleFACILITATOR NOTES:Participants should be directed to the appropriate pages of the Practice Guide to view these checklists which will be an integral element in the delivery of care. Comments to be included for clarity:NotesInterdisciplinary Patient VisitsDepending on the patient needs and clinic practice model, patient care may be delivered by several Diabetes Healthcare (DHC) team members:Diabetes Educators, Pharmacists, Psychologists and/or Dietitians.You are encouraged to use these examples and modify them to reflect your clinic situation and patient needs.For more information see the Diabetes Practice Guide
58Scheduling Method Selection Which scheduling method/methods do you believe will be most effective and efficient to manage your Priority Patient Type?Do you need more information?How/where will you get more information?FACILITATOR NOTES:Allow the group to discuss which scheduling options piqued their interest and why?Have the group narrow the list down to 1 or 2 options. Part of the Clinic Action Plan should be directed at learning more about the specific option they have chosen and planning how to implement this method in their clinic.The team should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.MAKE ACTION PLAN NOTES
59Clinic Team Regroup Share Scheduling Method(s) selected and rationaleExpected outcomesConcerns/outstanding information needsDiscuss experiences and potential solutions with the groupFACILITATOR NOTES:During the breakout, the Clinic Teams will decide on the scheduling method they believe will be implementable and will ultimately improve patient management. Encourage the Clinic Teams to ask questions of each other and try to eliminate any concerns that the teams may have regarding the adoption of a new scheduling method.The teams should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.MAKE ACTION PLAN NOTES
60Optimizing Practice Efficiency to Promote Team Effectiveness CLINIC WORKSHOP SESSION
61All materials can be found in the Participant Workbook Workshop OutlineSet specific goals, task, roles, timelines and measurementsACTIVITIESOverview of Clinic Action Plan ExpectationsComplete Clinic Action Plan:Determine Action Plan GOALSDefine 2-3 SPECIFIC TASKSDocument ACTIVITIES requiredIdentify the OWNER and the KEY SUPPORT teamDetermine the TIMELINESDetermine MEASUREMENT TargetsMATERIALSSummary of Clinic Assessment ResultsDiabetes Resource InventoryPriority Patient Type Diabetes Team Activity Checklist“Action Plan Notes” taken during the sessionBlank Action Plan TemplateWORKSHOP #4TOTAL TIME ALLOTTED: 105 MINUTESFACILITATOR NOTES:Each clinic will build an Action Plan to meet their needsReview and validate the CLINIC GOALS set by Champions in the Clinic Assessment stepReview next slides as examples and discuss how the Action Plan can come to life for the clinic teamsMATERIALS: All materials can be found in the Participant Workbook.All materials can be found in the Participant Workbook
62Your Clinic Action Plan Action Plan GoalSpecific TasksActivities to accomplish this task Owner & Key Support Team MembersTimeline for Each ActivitySuccess MeasuresProgress Tracking1.2.3.Owner-Key Support Team-TASK COMPLETION DATE:TASK COMPLETION DATETeam Learning NeedsFACILITATOR NOTES:This Clinic Action Plan is a first step to teach the teams how to work as a team and develop common plans/goals and protocolsClinics with NO REGISTRY will focus on setting up a Clinic Diabetes Registry PLUS building additional action steps for patient management as illustrated in Clinic Action Plan Sample #1.Clinics with a Registry will focus on patient treatment by reflecting on the Diabetes Team Activity Checklists and identify 2-3 patient treatment tasks which require additional attention for identified patient priority type as illustrated in Clinic Action Plan Sample #2.Tools:Summary of Clinic Assessment ResultsDiabetes Resource InventoryPriority Patient Type Diabetes Team Activity Checklist“Action Plan Notes” taken during the sessionSample Action PlansPractice Guide
63Clinic Action Plan: Sample #1 Registry Action Plan GoalDevelop a Manual Clinic Diabetes RegistryBegin to monitor patients’ treatment activitiesSpecific TasksActivities toaccomplish taskOwner & Key SupportTeam MembersTask TimelineSuccess Measurement & TrackingExplore use of computer based spreadsheets as a RegistryMOA and Business Manager explore use of Excel and other programsOwner-Julie-Bus MgrSupport: Kim- MOAApr 30/11Adoption of program for testing by April 20/11Add DM patients to Registry at diagnosisDoctors Kim when patients are diagnosedOwner-KimSupport: MD’sStart May1/11Track activity over 3 monthsAdd DM patients to Registry at follow-up apptMOA’s to give names of patients booked for DM follow-up to KimOwner- Kim-MOASupport- all MOA’sCONDUCT DM PATIENT SURVEILLANCE:Review charts of each new patient added to Registry- book appointments/labs according to CDA guidelines as requiredSupport- MD, RNFACILITATOR NOTES:Samples of clinic plans against some common tasks teams may wish to consider or use as examples
64Clinic Action Plan: Sample #2 New DM Diagnosis Action Plan GoalTo utilize the “right clinician at the right time” when counselling newly diagnosed DM patientsSpecific TasksActivities toaccomplish taskOwner & Key SupportTeam MembersTask TimelineSuccess Measurement & TrackingDevelop a plan to ensure newly diagnosed patients are provided full informationand empoweredBook a team meeting to determine roles MD and team members in delivery of diagnosis and educationOwner-Dr. JonesSupport: Sally- RN and Jill - MOAMay 30,2011Adoption of new team roles: Aug 30, 2011Review Group Patient Visits models and consider for newly diagnosed patientsOwner: Sally - RNSupport: Bob - Pharmacist and Jane - DieticianJuly 1st, 20111st GPV- Sept 30, 2011FACILITATOR NOTES:Samples of clinic plans against some common tasks teams may wish to consider or use as examples
65Clinic Action Plan: Sample #3 Ongoing DM Management Action Plan GoalTo ensure patient care is following CDA surveillance guidelinesSpecific TasksActivities toaccomplish taskOwner & Key SupportTeam MembersTask TimelineSuccess Measurement & TrackingDevelop a plan regarding which team member will undertake patient visitsBook a team meeting to determine roles MD and team members in delivery of diagnosis and educationOwner-Dr. JonesSupport: Sally- RN and Jill - MOASept 1st 2011Adoption of new team roles: Nov 1st 2011DM Patient RegistryEnsure all patients have been entered and prompts are up to dateOwner- Sarah-MOASupport: Carmen- RNOngoingIdentify patients with sub-optimal frequency of investigationsRecall – using registry- patients with out of date routine tests: A1C, MAU, ECG etcFACILITATOR NOTES:To be added when sample completed
66Work on Your Clinic Action Plan Action Plan GoalSpecific TasksActivities to accomplish this task Owner & Key Support Team MembersTimeline for Each ActivitySuccess MeasuresProgress Tracking1.2.3.Owner-Key Support Team-TASK COMPLETION DATE:TASK COMPLETION DATETeam Learning NeedsTime allotted: 50 minutesFACILITATOR NOTES:The groups should take time to work on their Clinic Action Plans. Review HINTS with them to help focus efforts.Materials:Summary of Clinic Assessment ResultsDiabetes Resource InventoryPriority Patient Type Diabetes Team Activity Checklist“Action Plan Notes” taken during the sessionSample Action PlansPractice GuideHints:Changes should be easily actionableSimple changes often have the greatest impactMaximize use of interdisciplinary teamMeasurement… start with small steps- don’t try to measure everything
67Action Plan Presentations Each Clinic Team will review their Clinic Action PlanAsk questionsMake suggestionsShare experienceFACILITATOR NOTES:Each Clinic Team will review their Clinic Action Plans with the group. Encourage the group to ask questions regarding areas that are not clear, make suggestions for changes/adaptation or improvements and to share experiences.Most importantly, show encouragement for the Clinic Teams.The teams should make Action Plan Notes in their Participant Workbook for further discussion during Action Plan development.MAKE ACTION PLAN NOTES
68All materials can be found in the Participant Workbook Workshop OutlineImplement, track progress and evaluateACTIVITIESPlan-Do-Study-Act CycleClinic Action Plan Implementation and Measuring EffectivenessReflect upon the solutions generated today and how the team can be successfulMATERIALSClinic Action PlanClinic Diabetes Management DashboardParticipant WorkbookWORKSHOP #5Total Time Allotted: 30 minutesFACILITATOR NOTES:Any changes in the practice can (and should) have an impact on patient care and as such, it is recommended that a process for monitoring implementation and evaluating results be included in the project planning. This final workshop is meant to focus the team on refining measures of effectiveness and thinking about implementation follow-up over the next 6 months.All materials can be found in the Participant Workbook
69Plan-Do-Study-Act Cycle identify and plan ahead for change, analyze and predict the resultsexecute the plan, taking small steps in controlled circumstancescheck and study the resultsFACILITATOR NOTES:The Plan-Do-Study-Act (PDSA) Cycle is a change implementation strategy widely used to adopt practice improvements. The Plan-Do-Study-Act (PDSA) Cycle is an evidence-based trial-and-learning method to test changes quickly. The clinic team selects a small change and implements it quickly, and then uses the PDSA cycle to measure and refine the changes as required. When it is working, the team implements the change on a wide scale. In this way, the process results in effective changes that are implemented rapidly. Since the PDSA cycle involves only a small investment in time and resources, there is less risk to the practice than is associated with trying new methods without such a cycle.take action to improve the processThe process is flexible… Engage in continual planning, study and refinements at all stages
70Model for Improvement Three Questions What are we trying to accomplish?How will we know that a change is an improvement?What changes can we make that will result in improvement?Model for ImprovementWhat are we trying to accomplish?How will we know that a change is an improvement?What change can we make that will result in improvement?PLANDOSTUDYACTThe Model for Improvement was developed by Associates for Process Improvement (http://www.apiweb.org/API_home_page.htm ). The Model for Improvement  focuses on three questions to set the aim, establish measures and select changes, and incorporates Plan-Do-Study-Act (PDSA) cycles  to test changes on a small scale. The model is designed to keep the improvement effort focused and moving at a rapid pace to implement change more quickly that traditional quality improvement planning.Setting Aims: Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected. Establishing Measures: Teams use quantitative measures to determine if a specific change actually leads to an improvement. Selecting Changes: All improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement. References1. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.2. The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study."3.
71The PDSA Cycle for Learning and Improvement ACTPLANWhat changesare to be made?Next cycle?ObjectiveQuestions andpredictions (why)Plan to carry out the cycle(who, what, where, when)STUDYDOTesting Changes: The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned.  This is the scientific method used for action-oriented learning. Testing ideas for change are done quickly with small sample numbers to accelerate learning. The learnings from the previous cycle are incorporated into the next cycle to advance testing to the point where one is confident to implement the change across the system. This process allows the improvement effort to increase belief the change will result in improvement, measure the amount of possible improvement and evaluate the costs and side effects of change before jumping to implementation.ReferenceComplete theanalysis of the dataCompare data topredictionsSummarize whatwas learnedCarry out the planDocument problemsand unexpectedobservationsBegin analysis ofthe data
72Multiple Cycles to Implement a Change in Diabetes Care Improving Diabetic Foot Exam RatesFoot exam protocol in place within one month of initial testLearningCycle 5: Implement process forall patients as a clinic protocolCycle 4: Put foot care stamp in EMR to promptRPN. Test. All patients received foot examCycle 3: RPN rooming patient removes shoes and socks.Test w/ 5 patients next day. 4 of 5 feet examined.RPN forgot to one patientThis is an example of multiple PDSAs leading to implementation of a foot exam protocol. Best practice informs the care team that if the patient’s shoes and socks are off when the physician enters the room, a foot exam will be completed 100% of the time. The practice team begins with ideas to prompt the physician to remember to do the exam. After a single day of testing with a handful of patients it is clear that the physician does not have enough time to remove shoes and socks, conduct the exam and then record the exam results. Some patients required help removing and putting shoes back on making it more difficult for the physician. The subsequent tests focus on delegating work across the team to save physician time. The final tests ensure that the person rooming the patient is prompted to remove shoes and socks. A clinical protocol is in place within a month of initial testing thus demonstrating the power of rapid testing with small numbers to speed learning.Cycle 2: : Post sign to prompt patients to remove shoes and socks.Test with 5 patients next day. Most patients did not understand.How can practice ensure feet are examined?Cycle 1: Monofilament placed on exam table to prompt provider.Test with 5 patients on one day. No exams done. Provider ran out of time.
73Clinic Diabetes Management Dashboard MeasuresBaselineCurrentGoalMeasures 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 smokingFacilitator notesThe 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
74Clinic Diabetes Management Dashboard: Narrative Report Key ChangesDescribe changes made in the way you care for patients with diabetesPDSAsList two or three critical PDSAs that helped you achieve the changes aboveImpact on OutcomesDescribe how you believe these changes impacted particular outcomes you are monitoringWhat 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
75Team ImplementationWe've been working together for 3 hours today; what did we do best as a team?What enabled us to be successful in coming up with an Action Plan?What will enable us to be successful implementing the Action Plan?FACILITATOR NOTES:Discuss what has made the team successful working together during this session. Make note of which characteristics can be maximized to ensure successful implementation of the Clinic Action Plan.
76Clinic Team Regroup Share Clinic Team interactionAction Plan developmentOverall input/collaboration with other Clinic TeamsWhat will enable successful implementation of the Clinic Action Plan?FACILITATOR NOTES:The teams have been working together - The purpose of this 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.MAKE ACTION PLAN NOTES
77Wrap upParking lotMeasuring Effectiveness – Complete CHE Evaluation Form and hand in prior to leavingFACILITATOR 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.