1. September 2012 Webinar Overcoming Clinical Inertia with Stepped Care Self-Management Support: Kathleen Drozdiak: Clymer Family Medicine, Indiana, PA

2. Overcoming Clinical Inertia with Stepped Care Uncovering the Root of the Problem and Then Addressing It

3. Clinical Inertia in Diabetes Care “Clinical inertia encompasses both failure to initiate therapy when indicated, and failure to titrate therapy until evidence-based clinical goals are achieved. Over 80% of diabetes patients are on pharmacotherapy for glucose control, and in many settings, over 70% of heart disease patients are on statins for LDL control. Yet, many patients on treatment are not at their evidence-based goals. This suggests that failure to uptitrate therapy may be the lion's share of clinical inertia in chronic disease care.” Improving Diabetes Care by Combating Clinical Inertia. Commentary by Patrick J. O’Conner, assistant medical director and senior clinical research investigator, HealthPartners Research Foundation. Health Serv Res. 2005 December; 40(6 Pt 1): 1854–1861. www.ncbi.nlm.nih.gov/pmc/articles/PMC1361230/ www.ncbi.nlm.nih.gov/pmc/articles/PMC1361230/

4. Let’s Look at LDL<100

5. Failure to Initiate or Failure to Titrate?

6. Addressing Clinical Inertia Through Stepped Care Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more) First choice medication Either increase dose or add second medication, and so on Includes referral guideline Self-mgmt support for lifestyle change Add medication Intensify medication Specialty referral?

7. Standing Orders to Reduce Clinical Inertia Evidence based guidelines built into care Allows someone other than the provider to help Could be as simple as: if BP high on lisinopril 5mg, increase to 10mg Could be: LDL high, increase statin Could be: advancing medications for glucose control Develop consensus in practice around evidence- based guidelines

9. Antihyperglycemic Therapy in Type 2 Diabetes: General Recommendations Inzucchi S E et al. Dia Care 2012;35:1364-1379 Copyright © 2011 American Diabetes Association, Inc.

10. Have Any Questions? South Central – Sharon Adams 814-344-2222, sadams@scpa-ahec.orgsadams@scpa-ahec.org North West – Patty Stubber 814-217-6029, pstubber@nwpaahec.orgpstubber@nwpaahec.org

11. Self-Management Support: Advice from PA CCI Practice Kathleen Drozdiak: Clymer Family Medicine, Indiana, PA

12. CLYMER FAMILY MEDICINE 2009 - 2012

14. “For the things we have to learn before we can do them, we learn by doing them.” Aristotle

15. CHANGES THAT HAVE IMPROVED CARE Regular follow-up visits scheduled based on severity of disease Pre-visit work Planned care at every visit Physician & Practice “report cards” “Close the Gap” reports and F/U letters to pts. Education Center classes and support group Clinics for retinal exams, flu shots Earlier referrals to specialists Use of standing orders

16. HbA1c < 7 Trending 2009 – 2012

17. HbA1c > 9 Trending

18. HbA1c Interventions Close Tracking of A1c’s independent of physician orders Lab requests sent to patients Classes at Health Education Center One-on-one nurse visits with Care Manager Physician Care – more aggressive with meds Reinforcement and rewards for patients with improved outcomes

19. Cholesterol Trending 2009- 2012 (LDL < 100)

20. Cholesterol Trending (LDL < 130)

21. Cholesterol Population Management Patient Visits are scheduled by disease severity Pre-visit work requesting labs when necessary Semi-annual reports to round up patients who have not had annual lipid profiles Reports of statin use are given to docs, hard sell to the patients. Keep trying. Queried entire practice, over 4,000 patients. Identified 44 patients with CAD not on statins.

22. Blood Pressure Trending 2009-2012 BP < 130/80

23. Blood Pressure Trending BP < 140/90

24. Blood Pressure Population Management Free and frequent BP rechecks Offer walking program Docs prescribe medicine One doc uses red reminder cards on charge slips. Nurses check for medication compliance and timing Nurses encourage low salt diet, decrease in caffeine intake

25. Walk with Clymer Family Medicine!

26. 56 Patients’ Outcome Measures 2009 - 2011 Pre and Post Intervention Data: – HbA1c’s – BPs – Cholesterol

27. Healthy Life Styles Class Participants

28. Patient Care Pre-visit work completed, using standing orders Planned care at every visit Self management stressed, help patient understand they can control their disease not the other way around Self management goals are reviewed, renewed and recorded in pt. record at every visit Patient visits and lab frequency is determined by risk assessment “Process Measure Round Ups” e.g. pneumonia vaccine, aspirin, GFR assessments, etc. Clinical outcomes are tracked and information given to patient and to physicians Patient attended classes at learning center THE ABOVE INTERVENTIONS in addition to the clinical decision making of a caring, involved physician

29. Interpretation A paired-samples t-test was conducted to evaluate the impact of the interventions on A1c, Systolic BP, Diastolic BP, and Weight. There was no statistically significant difference found in Systolic BP and Weight. There was a statistically significant decrease in A1c from 2009 (M = 7.43, SD = 1.78) to 2011 (M = 6.69, SD = 1.11), t(51) = 3.118, p =.003 (two-tailed).

30. Interpretation The mean decrease in HgA1c was 0.73 with a 95% confidence interval ranging from 0.26 to 1.20. The eta squared statistic (0.16) indicates a large effect size. This means there was a large effect, with substantial difference in the A1c scores obtained before and after intervention.

31. Interpretation There was a statistically significant decrease in Diastolic BP from 2009 (M = 79.13, SD = 12.22) to 2011 (M = 75.04, SD = 9.60), t(55) = 2.39, and p = 0.020 (two-tailed). The mean decrease in Diastolic BP was 4.09 with a 95% confidence interval ranging from 0.66 to 7.51. The eta squared statistic (0.09) indicated a moderate effect size. This means there was a moderate effect, with some substantial differences in the Diastolic BP obtained before and after intervention.

32. Self Management Emphasize the patient’s central role in managing his illness Assess patient self-management knowledge, behaviors, confidence, and barriers Provide effective behavior change interventions and ongoing support with peers or professionals Assure collaborative care-planning and problem- solving by the team Provide self-management support at all visits

33. Where is CFM in Self Management? Opened Clymer Family Medicine Health Education Center Classes and educational resources available for patients Walking program available for patients Assessment of self management knowledge, behaviors, confidence and barriers is done in the classes and in one on one sessions with care manager Self management goals are discussed and recorded at each “planned care” visit

34. Clymer Family Medicine Health Education Center

39. Where is CFM in Self Management? continued Patients receive disease education information with mailed reminders from their physician to “close the gap” in their care Shift in use of our language to the patient, it is more patient centered, i.e. team up to help you, working together

40. Process Measures Success Driven by team leader and done by staff members Training for “planned care” visit These measures tend to stay on track if patient comes for visit Use of queries to inform physicians. For example who is NOT on aspirin, who needs a flu immunization, etc.

41. Specialty Care Trending 2009-2012 Aspirin

42. Specialty Care Trending 2009-2012 Flu Vaccine

43. Specialty Care Trending 2009-2012 Foot Assessment

44. Specialty Care Trending 2009-2012 Kidney Assessment

45. Specialty Care Trending 2009-2012 Self Management

46. Retinal Screening Trending 2009-2012

47. Eye Exam Interventions Quarterly retinal exams on site. Queries done quarterly Patient Education Letter sent with Highmark card

48. Retinal Screening Letter

49. Retinal Screening

50. Tobacco Use Population Management Every patient asked if they smoke Every smoker receives motivational interviewing and a packet of materials to take home Semiannual smoking cessation classes held at Clymer Family Medicine Health Education Center. Taught by local drug and alcohol center. Patients are identified through queries, letters sent to them informing them of classes. We follow up with phone calls.

51. Smoking Status Assessed

52. Smoking Exposure Counsel

53. Other Projects using Population Management Interventions Colorectal Cancer Screening Project Mammogram Screening Project PAP Screening CAD Query Pneumonia Vaccine Aspirin Query

54. Where do we go from here? Population Management Project for Each Month of the Year Continue learning the query systems of Allscripts Get Patient Portal in place Continue developing our CM program Continue work on Physician Buy-In and continued staff training Finish interface from our office to the local hospital

55. Far and away the best prize that life has to offer is the chance to work hard at work worth doing. - Theodore Roosevelt