Focus on Quality Webinar July 2018 Indiana Quality Improvement Network Maureen Moynihan, PharmD Clinical Pharmacist Phone: 219-872-6200 ext.: 3777 Email: mmoynihan@healthlincchc.org

Indiana State Department of Health Primary Care Learning Collaborative Provider Team: Nurse Practitioner Registered Nurse Clinical Pharmacist Certified Medical Assistant One focus: ↓ # of uncontrolled patients with diabetes on provider panel

DIABETES A1C CONTROL v DIABETES A1C POOR CONTROL: *a lower percentage is better* Baseline: 37% Goal: 20% Current: 18.5% (as of 06/12/18)

v SUCCESSFUL PDSA Diabetes A1C Deficiency Call List: Plan: A deficient patient call list was generated. The provider team called those patients and scheduled appointments for them to come and address their gaps in care; they also flagged patients who were already scheduled for appointments, to discuss missing measures with them at the time of their visit. Do: Ran the test on a month-to-month basis. Diabetes: Aug 2017: 33.5%, September 2017: 28.7% Study: Provider team decided to continue with the call list as it notifies healthcare team and patient to the screening gap. Also the use of a pharmacy student to scrub the list and make the phone calls in order to maximize provider time. Act: Scrub the list quarterly for best use of time.

USEFUL RESOURCES Clinical Pharmacist Insulin Titration Follow-up Call List Insulin-treated patients with uncontrolled diabetes are followed up within 1-2 weeks period via phone to adjust insulin doses based on a collaborative practice agreement.

USEFUL RESOURCES Diabetes Self-Management Education All Provider Team Members Involved Set Class Curriculum: Meals Monitoring Movement Medications Long-term Complications Standards of Care Support System

USEFUL RESOURCES Opportunity to learn from providers and other patients Less time constraints than provider appointments to give comprehensive education on diabetes self-management Allows provider team to assess patient confidence in self-management skills Gives provider team the opportunity to identify and remedy deficiencies in diabetes patient education Gives a setting for patient to set self-management goals with check-ins at future classes

TAKE HOME TIPS Follow-up is KEY! Teamwork is KEY! Patient Education is KEY!