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PROGRAM FACULTY CONTRIBUTORS

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Presentation on theme: "PROGRAM FACULTY CONTRIBUTORS"— Presentation transcript:

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2 PROGRAM FACULTY CONTRIBUTORS
Stewart B. Harris MD, MPH, FCFP, FACPM Canadian Diabetes Association -Chair in Diabetes Management Ian McWhinney Chair of Family Medicine Studies Professor-Schulich School of Medicine & Dentistry, The University of Western Ontario Rick Ward MD, CCFP, FCFP Calgary Foothills Primary Care Network Patsy Smith MN, RN PLS Consulting Inc. Canadian Nurses Association CONTRIBUTORS Steve Szarka, B. Eng, M. Eng, MD, CCFP Assistant Clinical Professor, McMaster University, Faculty of Family Medicine Hamilton Family Health Team, Hamilton ON John McDonald MD CCFP – Lead Physician - PrimCare Family Health Team President and Chair – Association of Family Health Teams of Ontario Durhane Wong-Reiger  BA, MA, PhD Institute for Optimizing Health Outcomes, Canada Maureen Clement  MD CCFP Medical Director, Diabetes Education Centre Vernon Jubilee Hospital Assistant Clinical Professor, University of British Columbia Alice Y.Y. Cheng, MD, FRCPC Endocrinologist Credit Valley Hospital and St. Michael's Hospital Assistant Professor, Dept of Medicine University of Toronto FACULTY 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.

3 Disclaimer: 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

4 Facilitators Provide names and credentials of the facilitators for this specific clinic session FACILITATOR 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).

5 Disclosure of Potential for Conflict of Interest
Financial Disclosure Grants/Research Support- XYZ Pharma Co Speakers Bureau/Honoraria Consulting Fees: XYZ Company Other: Employee of XXY Hospital Group FACILITATOR 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 honoraria Names of companies from which you have received funding for clinical trials or studies Names of companies from which you have received speaker bureau funding or speaker honoraria Names of companies from which you have received grants/financial support Other (please specify)

6 Clinic Team Introductions
Clinic “Champion” and Clinic Team Members What 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.

7 Learning Objectives Primary Objectives:
Following this program, participants will be able to: Apply principles of chronic disease management to their panel Manage Diabetes Mellitus (DM) patients as a team based on the agreed upon Pathway Establish outcomes to assess changes made as a result of this process Develop and implement an action plan utilizing strategies and tools that will optimize type 2 diabetes patient management in their clinic Secondary Objectives: Maximize interdisciplinary team based care using available resources Increase trust within team Provide new models and options for managing DM within a primary care team using Chronic Disease Management (CDM) principles FACILITATOR NOTES: These are the Learning Objectives for this program.

8 Pathways 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 outcomes Promote team effectiveness Optimize practice efficiency Increase patient access to treatment FACILITATOR 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

9 PROGRAM 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 4 Step 5

10 Practical Strategies, Tools & Materials
Participant Workbook Canadian Nurses Association Patient Education Toolkit FACILITATOR 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 teams Participant 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 Toolkit Diabetes Practice Management Practice Guide

11 Today’s Agenda [to be customized based on event’s start and end time]
INTRODUCTION AND CONTEXT 75 minutes Introductions and Program Overview The Clinical Challenge Team Effectiveness CLINIC WORKSHOP 55 minutes Step 1: Clinic Assessment Results and Alignment 15 minutes Step 2: Clinic Diabetes Registry 60 minutes Step 3A & 3B: Priority Patient Type Review and Diabetes Team Activity Checklist Completion 45 minutes Step 3C: Scheduling Options ACTION PLAN DEVELOPMENT 105 minutes Step 4: Action Plan Completion Step 5: Action Plan Implementation and Measurement 30 minutes WRAP UP AND EVALUATION FACILITATOR 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.

12 The Clinical Challenge
Diabetes Care in Family Practice CDA Guidelines: Therapeutic Goals and Organization of Care FACILITATOR NOTES: The next section provides the clinic team with a reminder of: -Burden of diabetes in Canada Impact of diabetes on family practice The gap between goals and outcomes in the management of DM CDA 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.

13 Diabetes Care in Family Practice
The challenge: Diabetes is a complicated, growing disease: More than 9 million Canadians live with diabetes or prediabetes1 Risk of CV death is 2-4 times greater than in the general population2 25% of patients with diabetes suffer from depression2 11% 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 Committee FACILITATOR 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.

14 Primary Care Challenge
Average practice has between patients with diabetes1 Patients with diabetes visit their family physician on average 8 times per year2 Thus, the burden on the clinic is significant (this does not even include the burden of those with cardiometabolic risk)1 DICE: Diabetes in Canada Evaluation study2 Most 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.

15 Few mechanisms exist to implement practical solutions
Chronic disease management for diabetes and vascular disease could result in the avoidance of annually……1 8,000 heart attacks 4,000 strokes 8,000 unnecessary deaths 1,200 cardiac bypass and balloon angioplasties 369 amputations FACILITATOR 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 solutions Q Monitor, Ontario Health Quality Council Report On Ontario’s Health System.

16 Therapeutic 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 targets Ontario Ministry of Health: Quality Targets for Primary Care Physicians2 Example: Baseline Diabetes Dataset Initiative Targets A1C ≤ 7.0% BP < 130/80 mm Hg LDL-C ≤ 2.0 mmol/L FACILITATOR 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. 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:

17 CDA Recommended Diabetes Surveillance
Timely screening for complications and aggressive management of risk factors are integral parts of diabetes management. Diabetes Surveillance Schedule1 Clinical parameter Screening test(s) and intervals Interval Glycemia A1C Every 3-6 months, depending on control Blood Pressure BP At every diabetes-related visit and at least once a year Cholesterol Full fasting lipid profile (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], and calculated LDL-C Every 1-3 years (more frequently if treatment for dyslipidemia is initiated) CV risk Baseline resting electrocardiogram (ECG) or exercise stress testing At age 40. Repeat testing every 2 years in people at high risk Chronic 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. Neuropathy 10-g monofilament testing Annual Foot problems foot examination Annual( more frequently in those at high risk) Retinopathy Expert funduscopic examination through dilated pupil or digital fundus photography Every 1-2 years, depending on whether retinopathy is present Erectile dysfunction Sexual function history Periodically Depression or anxiety Standardized questionnaire or direct queries FACILITATOR 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.

18 CDA Organization of Care Guidelines
Good Outcomes for people living with diabetes depend on: The “System”….. A Team Based Approach Identify patients with diabetes Develop a Clinic Diabetes Registry Paper charts (manual identification) or EMR records Implement a Systematic Recall Process Paper 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 received EMR- auto recall and search for patients by last appointment Make use of a Clinical Flow Sheets Tracks metabolic parameters - ensures timely assessment and treatment to improve adherence to guidelines Flow Sheets and EMR: automatically populate lab values and tracks overdue elements Participate in Diabetes Focused Visits and/or Group Visits Diabetes Visits - empower patients and utilize interdisciplinary team members to address issues, discuss lab tests, share ideas with fellow patients Group visits - increase capacity FACILITATOR 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 capability Reference: 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 Guidelines Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines

19 Team Approach Impact on Patient Outcomes: What does the data show us?
Team Effectiveness FACILITATOR 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.

20 Hollander 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 physician1 Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs1 Group Patient Visits may facilitate attachment by enhancing patient access, time with the medical team, and supportive services provided 2,3 FACILITATOR 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):

21 Congestive 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 Attachment Diabetes and CHF – RUB 5 ( ) $13,250 Diabetes Congestive Heart Failure (CHF) Proportion of Total Cost Attributable to Hospital Costs 65% Cost Reduction Attributable to Attachment $16,114 FACILITATOR 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): 32-44 Hollander MJ, et al. Healthcare Quarterly 2009;12(4):

22 Primary 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 costs1 Attachment 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.1 FACILITATOR 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): 32-44 Menec 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):

23 Shared Medical Appointments Based on the Chronic Care Model
A Quality Improvement Project to Address the Challenges of Patients with Diabetes with High CV Risk1 Setting: Primary care clinic High CV risk defined as one or more of the following: A1C levels >9% Systolic Blood Pressure (SBP) > 160 mm Hg Low Density Lipoprotein cholesterol (LDL-C) >3.53 mmol/L Patient characteristics for each group were similar FACILITATOR 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 Unit Low-density lipoprotein (LDL) cholesterol mg/dl mmol/l Conversion table for chemical compounds from conventional to SI units Conventional unit => SI unit: multiply by factor SI unit => conventional unit: divide by factor Reference: 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) implementation Kirsh S, et al. Qual Saf Health Care 2007;16:

24 Better 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. 10 10.5 9.5 8.5 11 9 8 Mean % GVP Control 2.2 Mean mmol/L % 2.1 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Mean mm Hg 130 135 140 145 150 155 = -0.30 = 1.44 = 0.14 = 0.41 = 2.54 = 14.83 HbA1c P= 0.002 LDL-c P= 0.29 SBP P= 0.04 Baseline Follow-up Control n= 35 GPV n=44 FACILITATOR 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 SBP Patients meeting clinical targets: Pre-intervention % 69.4% % Post-intervention % 83.3% % P value Reference: 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:

25 Team 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

26 Features of high performing teams
Team Efficiency1-5 Common challenges Time Pressure to provide both acute and preventive care Volume pressure Fee-for-service After hour access Long wait times Focus on task substitution vs. teamwork Underutilization of interprofessional health team Features of high performing teams The delegation of key roles to non-physicians Coordinated patient flow strategies: Triaging, multiple access points, advanced access, EMR registry recall, case management Group visits/shared medical appointments Disease-specific targeted “Mini” Clinics Integration of specialist care when appropriate FACILITATOR NOTES: RW to provide speaker notes References: EICP - Enhancing Interdisciplinary Collaboration in Primary Health Care. April 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. 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. 2007 Kirsh S, et al. Qual Saf Health Care 2007;16: Steering Group Communications.

27 Team Effectiveness results in…1-5
Improvement in: Practice efficiency Professional satisfaction Patient access– reduced wait time Care coordination Comprehensiveness of care Preventative care Achievement of metabolic targets Self-care capacity System navigation/health literacy Quality of life Follow-up (less falling through the cracks) Patient satisfaction Reduction in: Hospital admissions ER use Outpatient visits Blood pressure Cholesterol Risk of complications FACILITATOR NOTES: RW to provide speaker notes - Discussion regarding the effectiveness of team approach and resultant outcomes References: 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. CHSRF Steering Group Communications.

28 Diabetes Care Teams….A System Change
Points to consider: READINESS TO CHANGE Is your team ready to change the delivery of healthcare to optimize practice efficiency and promote team effectiveness? STRATEGIC AND STRUCTURED Is the change addressing an important need? Team meets to assess the problem and present options Solution selected as a team DIRECTED Specific person is responsible for driving agenda and keeping to timelines ATTRIBUTES OF LEADERSHIP Be present Be prepared Model interprofessional behaviour Provide the energy! INVOLVE THE ENTIRE TEAM System 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 resources An activity which brings the team together to improve clinical care increases trust and alignment FACILITATOR NOTES: Developed by Rick Ward faculty

29 Diabetes Care Teams….A System Change
Working together as a team includes… PROTOCOL SETTING Delegation of key tasks to interdisciplinary team members Delivery of consistent guidelines-based care by the interdisciplinary team Increased patient confidence APPROPRIATE ROLES AND RESPONSIBILITIES 3 R’s: Right provider… Right job… Right time… Maximizes scope of practice and avoids redundancy Least costly position who is able to competently fulfill the role Authority to act – ensure team members are empowered ENSURING CHANGE IS WELL PLANNED Small simple attainable changes –e.g. patient handouts regarding BP targets and how to conduct home BP measurement Specific and measurable, action-oriented changes with tools and goals Realistic and specific timelines- adequate time for change to occur- not too long or momentum will be lost Involve and delegate to many team members- the more that are involved, the greater the ownership FACILITATOR 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?

30 Protocol Setting — what does the data tell us? CHAMP Results
Increase in use of therapies in post MI treatment 100% 92% 86% 80% The UCLA Medical Center’s Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) increased guideline intervention 78% 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;87:819–822 20% 12% 6% 4% 0% Pre-CHAMP Post-CHAMP Aspirin Beta-blocker Statin ACE Inhibitor Fonarow GC, et al. Am J Cardiol 2001;87:819–822.

31 Protocol Setting — what does the data tell us? CHAMP Results
Death or Recurrent MI% 14.8% 6.4% Pre-CHAMP Post-CHAMP 15% 5% 10% 0% 20% CHAMP protocol reduced death or recurrent myocardial infarction FACILITATOR 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.

32 Summary FACILITATOR NOTES: The 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 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 Implementation of a team-based approach can have significant impact

33 Optimizing Practice Efficiency to Promote Team Effectiveness
CLINIC WORKSHOP SESSION

34 Materials are provided in the Participant Workbook
WORKSHOP OUTLINE Step 1A - Priority Patient Population Step 1B - Patient Management Needs Step 1C - Team Readiness Step 1D – Diabetes Resource Inventory ACTIVITIES: Review results of Clinic Assessments Validate/align the direction and outcomes of the assessments with the team Fine-tune the direction (if required) MATERIALS: Summary of Clinic Assessment Results Diabetes Resource Inventory Note MBC on 15 July that not directional enough and Mike to advise - CHECK WORKSHOP #1: TOTAL TIME ALLOTTED: 40 MINUTES FACILITATOR 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 Inventory ACTIVITIES: 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 CHE Clinic Assessment Summary - 20 minutes Diabetes Resources Inventory – 10 minutes To validate/align the direction and outcomes of the assessments – 10 minutes To fine-tune the direction if required MATERIALS: The Summary of Clinic Assessments and the Diabetes Resource Inventory can be found in the Participant Workbook. Materials are provided in the Participant Workbook

35 Summary of YOUR Clinic Assessment
Time allotted: 20 minutes FACILITATOR NOTES: NOTE: Slide will be pre-populated based on the Champion/clinic feedback Prior 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 Populations 1B Patient Mgmt Needs Assessment 1C Team Readiness Do you agree?

36 Diabetes Resource Inventory
What resources did you identify? Time allotted: 10 minutes FACILITATOR NOTES: NOTE: Slide will be pre-populated by facilitator based on champion/clinic feedback Review 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

37 Team 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 outcomes Build a Registry (if required) or assess Improved team care Scheduling Methods Is your team READY to develop and implement a team-based diabetes management program? Time allotted: 10 minutes FACILITATOR 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

38 Clinic Team Regroup Share key learnings from Team Reflection and Alignment Exercise Learnings about your patients, your team and clinic efficiency gaps and opportunities Highlight any areas in which your Clinic Team would benefit from feedback/input from the larger group FACILITATOR 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

39 Materials available in Diabetes Practice Guide
Workshop Outline Develop or Access Clinic Diabetes Registry ACTIVITIES Do you have a Clinic Diabetes Registry? Why is it important? Review EMR and Manual registry options MATERIALS Diabetes Practice Guide WORKSHOP #2 TOTAL TIME ALLOTTED: 15 MINUTES FACILITATOR 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

40 The 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 diabetes Develop a Clinic Diabetes Registry Paper charts (manual identification) or EMR records Implement a Systematic Recall Process Paper 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 received EMR- auto recall and search for patients by last appointment Make use of a Clinical Flow Sheet Tracks metabolic parameters - ensures timely assessment and treatment to improve adherence to guidelines Flow Sheets and EMR: automatically populate lab values and tracks overdue elements Participate in Diabetes Focused Visits and/or Group Visits Diabetes Visits - empower patients and utilize interdisciplinary team members to address issues, discuss lab tests, share ideas with fellow patients Group visits - increase capacity FACILITATOR 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 capability Reference: Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines 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 Clement M. Organization of Care: Key elements from the CDA 2008 Clinical Practice Guidelines

41 EMR Patient Registry Track patients using appropriate “data searches”
Identify and categorize “specific” patients by category or billing information Identify patients who require intervention by conducting a data search based on disease- specific clinical outcomes or problems list Examples: A1C > 7%; BP >130/80 mm Hg; Elevated cholesterol levels Facilitate outcomes measurement ** Is your EMR an effective/optimal Registry tool? If not, contact your EMR provider for assistance Diabetes Registry Fields Fundamental Optional Diagnosis: prediabetes, type 1, 2 or gestational Date of diagnosis Last visit Last A1C and date Last lipid screen date, LDL and ratio values Last blood pressure- date and value Last nephropathy screen- value and date Last foot exam date Last eye exam date Insulin – yes or no? date initiated Last influenza vaccine date Pneumococcal vaccine date Next appointment (or recall date) Complications Diabetes education- yes/no and last date Last EKG Last stress test Medications Billing codes FACILITATOR 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 etc EMR 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

42 Manual Patient Registry
EXCEL Diabetes Patient Registry Track patients via commercially available spreadsheets Registry could be populated… at diagnosis when reviewing charts or at patient’s next appointment when lab results or consultation reports are received Notes: Registry management should be assigned to one team member to ensure it is updated Although 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 registries Remind 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 efficiently Batching Group patient visits Reference: 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:

43 Diabetes Registry Next Steps
If no Clinic Diabetes Registry: PRIORITY FOR THE CLINIC ACTION PLAN SHOULD BE SETTING UP AN EMR OR MANUAL REGISTRY If Clinic Diabetes Registry is in place: THINK ABOUT OPPORTUNITIES TO IMPROVE EFFICIENCY FOCUS ON PRIORITY PATIENT TYPE DIABETES TEAM ACTIVITY CHECKLIST IMPLEMENTATION FACILITATOR 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 discuss 1 – whether or not they will pursue an EMR or Manual Strategy 2 – start to discuss broad next steps, roles and responsibilities and record in their Action Plan Notes If the Clinic does have a registry, the group should discuss 1- how the registry is currently working – difficulties, barriers and what is working well 2 – discuss how the registry and the team’s use of it could be made more efficient and make Action Plan Notes MAKE ACTION PLAN NOTES

44 Clinic Team Regroup Share key learnings
Clinic diabetes registry development or assessment Overall input/collaboration with other Clinic Teams FACILITATOR 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

45 Optimizing Practice Efficiency to Promote Team Effectiveness
CLINIC WORKSHOP SESSION

46 Workshop Outline ACTIVITIES: Validate your Clinic’s Priority Patient Type Review your Diabetes Resource Inventory Complete the Diabetes Team Activity Checklist and Assign Team Roles Review and Select Scheduling Method MATERIALS: Clinic Needs Assessment Summary Diabetes Resource Inventory Priority 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 Methods ACTIVITIES: Validate your Clinic’s Priority Patient Type Review your Diabetes Resource Inventory Complete the Diabetes Team Activity Checklist and Assign Team Roles Review and Select Scheduling Method MATERIALS: Clinic Needs Assessment Summary Diabetes Resource Inventory Priority Patient Type - Diabetes Team Activity Checklist: (one of the following: Prediabetes, New Diagnosis, Ongoing Management, Insulin Starts, Complex Patient) WORKSHOP TOTAL TIME ALLOTTED: 45 MINUTES Steps 3A and 3B – 45 minutes FACILITATOR 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 developed The 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. Activities Validate the Clinic’s Priority Patient Type – 10 minutes Review the Diabetes Resource Inventory – 10 minutes Complete the Diabetes Team Activity Checklist and Assign Team Roles – 25 minutes MATERIALS: 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.

47 Step 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 profile What are the major challenges faced when dealing with this patient? Diabetes Management Pathway Priority Patient Types Triggering Event #1- Prediabetes IFG and/or IGT #2- New Diagnosis Diagnosis of Type 2 diabetes #3- Ongoing Management Yearly Review #4- Insulin Starts Patients not at target after optimizing oral medications #5- Complex Patient Diabetes complications and/or patients who have not reached glycemic targets FACILITATOR 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

48 Step 3A: Review of Diabetes Resource Inventory
What resources can we utilize to help manage this patient type? What resources are we missing? FACILITATOR NOTES Review 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

49 Step 3B: Complete the Diabetes Team Activity Checklist
Diabetes Team Activity Checklists: Lists of CDA recommended activities for each patient type Utilize the Diabetes Team Activity Checklist for your identified priority patient type Assign roles to each task – think about the resources on the Diabetes Resource Inventory Considerations: Delegation of key tasks to non- physicians Coordinated patient flow strategies Integration of specialist care Utilization of interprofessional resources FACILITATOR 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

50 Clinic Team Regroup Share
Priority Patient Type and rationale Potential patient management changes based upon the Priority Patient Checklist Review Highlight any areas in which your Clinic Team would benefit from feedback/input from the larger group FACILITATOR 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

51 Optimizing Practice Efficiency to Promote Team Effectiveness
CLINIC WORKSHOP SESSION

52 Step 3C: Scheduling Options
Advanced Access A structured and systematic method which ensures patients access to primary health care team at a convenient time “Diabetes Days” Batching Organized and coordinated team-based care for DM patients Utilize a “batching” scheduling strategy to manage populations of patients Group Patient Visits An expanded medical appointment delivering most elements of an individual visit Coordinated Team Scheduling MD and RN collaborative patient visits Interdisciplinary Patient Visits- Sample Visit Activities The right clinician at the right time FACILITATOR 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 efficiently Batching Group patient visits Team to inform in advance of program areas of interest…provide greater detail for strategies of interest only For more information see the Diabetes Practice Guide

53 For more information see the Diabetes Practice Guide
Advanced Access A structured and systematic method which ensures patients access to primary healthcare team at a convenient time Same Day Bookings ~80% of all appointments: Patients call and book an appointment “today” Advanced Booking ~20% of all appointments Preventative appointments- e.g. quarterly appointments for DM Labs pre-appointment Self care and goal setting Six elements/conditions: Understand the supply/capacity and demand Balance supply and demand Reduce the number of appointment types Develop contingency plans to sustain the system Reduce and shape the demand for visits Increase effective supply: transfer physicians’ functions that can be done by someone else FACILITATOR 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 appointment The 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 appointments Type 2 diabetes “batching” on specific days weekly Labs pre-appointment No long appointments scheduled on “batching” days Strong emphasis on patient’s role as team member Team: Effective for small or larger teams MD and team agree on roles Standardized/consistent team roles and documentation Exam rooms for each team member and MD moves between rooms Use of flow sheet or EMR for quick assessment of patient status, outcome tracking and as a teaching tool FACILITATOR 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

55 Group Patient Visits (GPV)
Personal Exam Education Group Interaction Expanded medical appointment delivering most elements of an individual visit, including Personal examinations (e.g. collection of vital signs, history-taking, physical exam) Formal and informal education Social and psychological support Practice effectiveness and efficiency which… Increases capacity to care for more chronically ill patients in less time Increases efficiency as a result of staff working in appropriate roles and assuming appropriate responsibilities Improves job satisfaction among staff Improves delivery of quality patient care Patient Self-mgmt FACILITATOR 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

56 Coordinated Team Scheduling
Coordinated Schedule Example RN Role: Focuses on time-consuming diabetes management appointments MD has dual role: Urgent care needs and typical family practice visits Joins the nurse’s visit (if required) to review the plan and sign prescriptions FACILITATOR 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

57 For 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: Prediabetes New Diagnosis Ongoing Management Insulin Starts Complex DM Patients Checklists are aligned to the CDA Clinical Guideline Surveillance Schedule FACILITATOR 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: Notes Interdisciplinary Patient Visits Depending 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

58 Scheduling 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

59 Clinic Team Regroup Share
Scheduling Method(s) selected and rationale Expected outcomes Concerns/outstanding information needs Discuss experiences and potential solutions with the group FACILITATOR 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

60 Optimizing Practice Efficiency to Promote Team Effectiveness
CLINIC WORKSHOP SESSION

61 All materials can be found in the Participant Workbook
Workshop Outline Set specific goals, task, roles, timelines and measurements ACTIVITIES Overview of Clinic Action Plan Expectations Complete Clinic Action Plan: Determine Action Plan GOALS Define 2-3 SPECIFIC TASKS Document ACTIVITIES required Identify the OWNER and the KEY SUPPORT team Determine the TIMELINES Determine MEASUREMENT Targets MATERIALS Summary of Clinic Assessment Results Diabetes Resource Inventory Priority Patient Type Diabetes Team Activity Checklist “Action Plan Notes” taken during the session Blank Action Plan Template WORKSHOP #4 TOTAL TIME ALLOTTED: 105 MINUTES FACILITATOR NOTES: Each clinic will build an Action Plan to meet their needs Review and validate the CLINIC GOALS set by Champions in the Clinic Assessment step Review next slides as examples and discuss how the Action Plan can come to life for the clinic teams MATERIALS: All materials can be found in the Participant Workbook. All materials can be found in the Participant Workbook

62 Your Clinic Action Plan
Action Plan Goal Specific Tasks Activities to accomplish this task  Owner & Key Support Team Members Timeline for Each Activity Success Measures Progress Tracking 1. 2. 3. Owner- Key Support Team- TASK COMPLETION DATE: TASK COMPLETION DATE Team Learning Needs FACILITATOR 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 protocols Clinics 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 Results Diabetes Resource Inventory Priority Patient Type Diabetes Team Activity Checklist “Action Plan Notes” taken during the session Sample Action Plans Practice Guide

63 Clinic Action Plan: Sample #1 Registry
Action Plan Goal Develop a Manual Clinic Diabetes Registry Begin to monitor patients’ treatment activities Specific Tasks Activities to accomplish task Owner & Key Support Team Members Task Timeline Success Measurement & Tracking Explore use of computer based spreadsheets as a Registry MOA and Business Manager explore use of Excel and other programs Owner-Julie-Bus Mgr Support: Kim- MOA Apr 30/11 Adoption of program for testing by April 20/11 Add DM patients to Registry at diagnosis Doctors Kim when patients are diagnosed Owner-Kim Support: MD’s Start May1/11 Track activity over 3 months Add DM patients to Registry at follow-up appt MOA’s to give names of patients booked for DM follow-up to Kim Owner- Kim-MOA Support- all MOA’s CONDUCT DM PATIENT SURVEILLANCE: Review charts of each new patient added to Registry- book appointments/labs according to CDA guidelines as required Support- MD, RN FACILITATOR NOTES: Samples of clinic plans against some common tasks teams may wish to consider or use as examples

64 Clinic Action Plan: Sample #2 New DM Diagnosis
Action Plan Goal To utilize the “right clinician at the right time” when counselling newly diagnosed DM patients Specific Tasks Activities to accomplish task Owner & Key Support Team Members Task Timeline Success Measurement & Tracking Develop a plan to ensure newly diagnosed patients are provided full information and empowered Book a team meeting to determine roles MD and team members in delivery of diagnosis and education Owner-Dr. Jones Support: Sally- RN and Jill - MOA May 30,2011 Adoption of new team roles: Aug 30, 2011 Review Group Patient Visits models and consider for newly diagnosed patients Owner: Sally - RN Support: Bob - Pharmacist and Jane - Dietician July 1st, 2011 1st GPV- Sept 30, 2011 FACILITATOR NOTES: Samples of clinic plans against some common tasks teams may wish to consider or use as examples

65 Clinic Action Plan: Sample #3 Ongoing DM Management
Action Plan Goal To ensure patient care is following CDA surveillance guidelines Specific Tasks Activities to accomplish task Owner & Key Support Team Members Task Timeline Success Measurement & Tracking Develop a plan regarding which team member will undertake patient visits Book a team meeting to determine roles MD and team members in delivery of diagnosis and education Owner-Dr. Jones Support: Sally- RN and Jill - MOA Sept 1st 2011 Adoption of new team roles: Nov 1st 2011 DM Patient Registry Ensure all patients have been entered and prompts are up to date Owner- Sarah-MOA Support: Carmen- RN Ongoing Identify patients with sub-optimal frequency of investigations Recall – using registry- patients with out of date routine tests: A1C, MAU, ECG etc FACILITATOR NOTES: To be added when sample completed

66 Work on Your Clinic Action Plan
Action Plan Goal Specific Tasks Activities to accomplish this task  Owner & Key Support Team Members Timeline for Each Activity Success Measures Progress Tracking 1. 2. 3. Owner- Key Support Team- TASK COMPLETION DATE: TASK COMPLETION DATE Team Learning Needs Time allotted: 50 minutes FACILITATOR 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 Results Diabetes Resource Inventory Priority Patient Type Diabetes Team Activity Checklist “Action Plan Notes” taken during the session Sample Action Plans Practice Guide Hints: Changes should be easily actionable Simple changes often have the greatest impact Maximize use of interdisciplinary team Measurement… start with small steps- don’t try to measure everything

67 Action Plan Presentations
Each Clinic Team will review their Clinic Action Plan Ask questions Make suggestions Share experience FACILITATOR 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

68 All materials can be found in the Participant Workbook
Workshop Outline Implement, track progress and evaluate ACTIVITIES Plan-Do-Study-Act Cycle Clinic Action Plan Implementation and Measuring Effectiveness Reflect upon the solutions generated today and how the team can be successful MATERIALS Clinic Action Plan Clinic Diabetes Management Dashboard Participant Workbook WORKSHOP #5 Total Time Allotted: 30 minutes FACILITATOR 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

69 Plan-Do-Study-Act Cycle
identify and plan ahead for change, analyze and predict the results execute the plan, taking small steps in controlled circumstances check and study the results FACILITATOR 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 process The process is flexible… Engage in continual planning, study and refinements at all stages

70 Model 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 Improvement What 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? PLAN DO STUDY ACT The Model for Improvement was developed by Associates for Process Improvement (http://www.apiweb.org/API_home_page.htm ). The Model for Improvement [1] focuses on three questions to set the aim, establish measures and select changes, and incorporates Plan-Do-Study-Act (PDSA) cycles [2] 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. [3] References 1. 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.

71 The PDSA Cycle for Learning and Improvement
ACT PLAN What changes are to be made? Next cycle? Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) STUDY DO Testing 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. [1] 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. Reference Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data

72 Multiple Cycles to Implement a Change in Diabetes Care
Improving Diabetic Foot Exam Rates Foot exam protocol in place within one month of initial test Learning Cycle 5: Implement process for all patients as a clinic protocol Cycle 4: Put foot care stamp in EMR to prompt RPN. Test. All patients received foot exam Cycle 3: RPN rooming patient removes shoes and socks. Test w/ 5 patients next day. 4 of 5 feet examined. RPN forgot to one patient This 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.

73 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

74 Clinic Diabetes Management 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

75 Team Implementation We'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.

76 Clinic Team Regroup Share
Clinic Team interaction Action Plan development Overall input/collaboration with other Clinic Teams What 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

77 Wrap up Parking lot Measuring 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.


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