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Focus on Quality Diabetes A1c Uncontrolled and Untested January 31, 2018 Indiana Primary Health Care Association

Agenda Recap of IQIN’s Shared Strengths work group Review of changes and PDSAs performed during Shared Strengths from health centers Data overview on diabetes measure Open Discussion Clinical Leadership Conference Health center changes to improve diabetes measure Future Strategy of Quality Trainings

Today’s Objectives Participants will gain an understanding of the range of activities that your peers are using to improve diabetes outcomes. Identify one new strategy to try to improve diabetes outcomes.

Past Model: Shared Strengths Two Pillars used to drive quality improvement Transparency Collaboration Met once per month Alternated between two distinct groups: Leadership Group: Responsible for strategy, direction Data/QI Group: Discussed data and workflows Intention: Share best practices and introduce interventions not yet implemented

Possible Interventions Group Visits CHWs Outreach Case management Standing Orders Gaps in care process These are from June F2F Meeting

PDSAs Each heath center chose an intervention and implemented it as a PDSA Cycle PDSA examples: Patient Navigators/Care Coordinators Diabetes Pathways Program Point-of-Care Testing Care Guidelines Follow-up protocol Next, we’ll dive into some success stories.

Riggs Community Health Center POC Testing- PDSA What were your plans for change? Decrease the number of diabetic patients with no A1c result for the testing period Who was the target population? Adult diabetic patients seen in our Adult/Internal Med department What team of people were responsible? Medical Assistants, Nurses, Unit Managers Who monitored the data and measured progress? Quality (me)

Riggs Community Health Center If not completed, what phase of the PDSA are you in? Phase 3 and holding at the moment, we have lots of projects going on and had some staff turnover that has made going to Phase 4 difficult

Riggs Community Health Center What are some outcomes to date? We decreased our untested number of diabetics slightly and increased our overall percentage of diabetics with A1c testing done at least 1x in the last year to 88% (1184 diabetics) 82% in 2015 (1026 diabetics) 86% in 2016 (1106 diabetics) We found that most of the patients staff were doing POC on were compliant with lab draws and already had an A1c on file This led to a procedure change We found that doing POC was not cost effective for our self-pay patients; it is better for them to have labs drawn under our agreement with Labcorp if they need other testing.

Riggs Community Health Center Next Steps: We are working on Pre-Visit planning that will include reaching out patients prior to appointments to come in for labs. We don’t seem to have any continuity to this process currently, some providers have them come before, others wait until the day of the visit.

Questions?

Patient Care Coordinators Role in Diabetic Populations NorthShore Health Centers January 29, 2018

Patient Care Coordinator Role Implemented Patient Care Coordinator program beginning in June 2016 “The Patient Care Coordinator is responsible for facilitating patient care services while aligning with Patient-Centered Medical Home (PCMH). The ultimate goal of the position is to improve access to care, quality of care, and patient outcomes through the self-care process.” AADE Diabetes Paraprofessional Course

Target Populations Diabetic Population New Diabetics ER Utilizers Diabetics Hypertension Uninsured/Homeless and Depression Referrals from Care Team Diabetic Population New Diabetics Diabetics Referred by Provider Diabetic Patients with an HbA1c > 9

Patient Care Coordinator Process In collaboration with the care team, assess and manage the health needs of the patient Follow up with patients in the program to address their needs, continuously updating personalized health plans and engaging and empowering patients

Outcomes and Next Steps Quality Team and Patient Care Coordinators collaboration Continuous follow-up with patients Next Steps: Improving documentation Widening population

PDSAs on Diabetes- Other Centers Progress What were your plans for change? Who was the target population? What team of people were responsible? Who monitored the data and measured progress? If not completed, what phase of PDSA are you in? What are some outcomes to date and next steps?

Azara Users Diabetes Data review

Diabetes A1c <9 or Untested (NQF 0059) : Trailing Year *Rate represents 12 health centers with data in Azara DRVS

Diabetes A1c <9 or Untested (NQF 0059): Trailing Year *Rates reflect patients seen within the current month and the previous 12 months who had a qualifying visit and had a A1c of 9 or greater or did not have a A1c test

Diabetes A1c >9 ONLY

Diabetes Untested ONLY

Interactive Dashboard View

Open discussion

Open Discussion POLL Clinical Leadership Conference attendance? Diabetes breakout attendance? Did you use/follow-up any of the following? Huddles Community health workers Rooming cards Other highlights

Open Discussion POLL Are you working on diabetes measures as a part of your quality improvement plan? How many track diabetes measures regularly? How often? Monthly, quarterly, annually…

Open Discussion- Diabetes Improvements/Changes What are you doing specifically to improve diabetes? What were your biggest challenges/lessons learned? What worked well/successes? What Population Health Management tools are utilized to manage diabetic patients (e.g. Registries)? What questions do you have for the group on how to improve this measure?

Future Structure and strategy for quality trainings and initiatives at IPHCA Moving Forward

FQHCs & Look-Alikes

PCA & IQIN Collaboration Changing HRSA focus Practical challenges Health center feedback Workplans

Quality/Performance Improvement Strategy: Rationale Coordinate Activities Leverage Resources Streamline Engagement Reduce Participation Burden

Alignment of Goals HRSA PCA Goals HRSA HCCN Goals Clinical Quality Improvement ↑ health outcomes and disparities: diabetes and colorectal cancer screening ↑ 5 Healthy People 2020 Goals Operational Performance Improvement ↑ Health centers w/ costs < national average ↑ Value, efficiency, effectiveness PCMH ↑ PCMH recognition and advancement ↑ PCMH recognition Data Quality ↑ UDS EHR reporting on all patients for all clinical measures

Roles Data Engagement Framework PCA & IQIN staff Advisory group Health centers Roles Common measurements Streamlined quarterly monitoring Needs assessment Coordinated tracking and evaluation Data Predictable monthly webinar engagement Focus on topics Combined training and peer learning model Supplemental engagements Engagement Please reach out to IPHCA if interested by Feb. 7th

Next Steps ECRI Diabetes CME Online Offering Scheduled to meet monthly - Starting in March (2nd Wed. of month) Any other last minute items, updates, announcements….