Cardiovascular Prevention

Cardiovascular Prevention Susie Bowles LPN Community Care Coordinator Washington State Collaborative Learning Session 3 September 11-12, 2006

Pomeroy Medical ClinicGarfield County Hospital District Pomeroy Medical Clinic is a primary care Rural Health Clinic offering clinical care by appointments and on a walk-in basis. Staffed by our community Physician, Dr. Syed Zafar, and our Advanced Registered Nurse Practitioners, Suzanne Grove and Sandy Marcy, the clinic offers a wide range of services to the residents of Garfield County which currently number about 2400. Pomeroy is 30 miles west of the Clarkston-Lewiston Valley.

Pomeroy Medical Clinic Team Members • Senior Leader-Andrew Craigie, CEO • System Leader-Syed Zafar MD, Medical Director • Day-to-Day Leader-Susie Bowles, LPN, Community Care Coordinator • Other Team Members-Suzanne Grove, ARNP; Sandy Marcy, ARNP; Judy Landkammer, RN; Kayleen Bye, RN; Kay Lockard, Clinic Support; Mary Allbright, Clinic Coordinator.

Health System Organization Of Health Care Our culture for our organization is centered around “ Caring for Generations”. Our mission is to create an environment where it is possible for each individual to experience the healing touch of our community. Through our purpose, mission, values, and vision, we hope to achieve exactly that: Caring for Generations!

Purpose – Why We Exist Our purpose is to serve others by Caring for Generations.

Our Purpose Is Caring For Generations Caring for Generations means that we commit to approach every undertaking in a way that honors the wisdom of the past, lives with the realities of the present, and maintains a vision for the future. We believe that a sustainable healthcare system is built on a foundation of uncompromising values. We believe that integrity is maintained through the commitment of generations of people to serve generations of people who contribute to generations of sustainable healthcare. Caring for Generations also reflects the value we place on family. We recognize that in our small community there is a warmth and genuineness that is very special and worthy of celebrating. Caring for Generations values the family, acknowledges the legacy of our organization, our community and the relationship of both. Together we share a rich history, a diligent attention to the present and a fascination for the future.

Mission – What We Do Our mission is to create an environment where it is possible for each individual to experience the healing touch of our community.

Mission - Experience The experience is much more than the care a person receives from our team. Experience relates to every aspect of our relationship with the patient, resident, family, and community. Perhaps it starts with that first phone call before they even arrive in our building and flows through every aspect of what we do; how it looked, felt, sounded, and even smelled. The experience is for everyone including the team.

Mission - Healing Healing results from what we think, say, and do. Ultimately we seek to reduce the burden of injury, illness, and human frailty for each individual. Healing also extends to family, staff, and community. We work as partners with the individual to help heal the whole person; physically, emotionally, socially, mentally, and spiritually.

Mission - Touch Touch is more than physical touch. People are touched by many things in their environment. Touch includes: the sound of words, music, wind, the smell of fresh baked pie, hot coffee, a spring rain, the physical touch of a warm blanket, a soft hand, hair brush through your hair, even the emotional touch of a smile, a wink, or a kind word. Touch impacts us.

Mission - Community The community is all of us: residents, patients, family, staff, our town and region of the state. It is the special place we relate to as home. It is where we want to be. Our rural community is the place we feel most welcome. Our community is a warm and charming place where people care, where you can always find a friend, and people know your name.

Values – Who We Are We value: 1) Caring 2) Loyalty 3) Quality 4) Safety 5) Family Our values are our code of morals and ethics that define what our organization stands for, believes in, and considers acceptable in our quest to achieve our vision. They are the standard by which we measure every activity we undertake and the foundation on which we stand.

Values – 1) Caring We believe in being available to meet the needs of others. We believe there is no greater gift than the gift of devoting oneself to the service of mankind. We commit to being dependable and accountable. We thoughtfully listen and lovingly give of ourselves in the service to others. We demonstrate compassion, mutual respect and dignity for the individual by the work of our hands, expression of our self, and the words we speak. We Care.

Vision – 2) Loyalty We believe in mutual respect, collaboration, and team work. We honor the commitment of the individual to be accountable, trustworthy, and put the needs of others above their own. We will always seek to give more and better of ourselves than was expected of us. We are faithful in our commitment to working together and lifting others up with encouragement and compassion. We Are Loyal.

Vision – 3) Quality We believe in continuous learning and improvement. We believe that exceptional performance requires high standards, constant communication, and reliable tools and methods. We are dedicated to seeking benchmark performance that is productive, efficient, and the results are the greatest value to the individuals we serve. We value Quality.

Value – 4) Safety We believe in creating and maintaining a safe environment to live and work in. We believe that safety requires commitment, knowledge, and safe behavior. We are dedicated to adhering to safe practices and common sense. We keep our eyes open and always look out for others. We will always maintain an environment that is clean, orderly, and in good repair. We are resourceful without sacrificing safety. We always take the time to follow through with good communication and thoughtful actions. We are Safe.

Value – 5) Family We believe in the comfort and protection of our family. We honor the sense of belonging that unites all of us as individuals; residents, family, staff, and community. We welcome the joys and sorrows of the patterns of life; and we trust one another as family. We demonstrate respect and compassion while we share in the experiences of life; the laughter, celebration, sorrows, and pain. We seek to be truthful, accepting, gentle, and kind. We are Family.

Vision – Where Are We Going Our vision is to define the country hospital experience. “Creating Home & Building Community”

Creating Home & Building Community Garfield County Hospital District will set the Critical Access Hospital Benchmarks in patient care, operational excellence, and financial performance. We will define the country hospital experience. Our mission is what we do to fulfill the vision that is anchored to our purpose. Our mission is the “doing” aspect of our organization, our purpose is the “being”, and our vision is the “seeing”. Our vision is future focused and defines what we want to be. It provides a stable sense of direction to guide our organization. It paints a picture in every person’s mind of where we want to be in the future. Our vision communicates our direction to everyone.

Registry System In Use We have been using the CDEMS program with every collaborative effort that we have participated in. Currently we have three Diabetes registries, the Adult Preventive Health Services, as well as the Cardiovascular Prevention people all populated in the CDEMS program.

Cardiovascular Prevention Pilot Population The people being monitored throughout this collaborative have visited the clinic at least once within the past year unless there is documentation that the patient has transferred to another clinic, moved from the area, or passed away. These people: 1. Do not have Diabetes; 2. Are over the age of 18; 3. Have current BPs of 140/90 or above;

AND / OR They have one or more of the following findings: 1. Total Cholesterol > 240 mg/dL 2. LDL is > 160 mg/dL 3. Triglycerides > 200 mg/dL 4. HDL < 40 mg/dL. (The people in this population can be in the Adult Preventative group also which requires double entering info into CDEMS. The people in the Diabetes groups can also be in the Adult Preventive registry. Diabetes and Cardiovascular people cannot be followed together.)

Aim Statement Introduction Pomeroy Medical Clinic will implement the Chronic Care Model for those patients who are at risk for cardiovascular disease. We will implement this model in order to provide measurable improved care for our patients.

Aim Statement Measures We will aim at accomplishing the following with our patients: • 90% will have their most recent LDL < 160 mg/dL; • 60% will have a BP < 140/90 mmHg; • 95% will have documentation of Diabetes Screening; • 30% will have a documented self-management goal; • 80% of tobacco users will be offered cessation counseling; • 30% will have a documented Framingham Risk Score; • 50% will have most recent HDL > 40 mg/dL.

Aim Statement Conclusion Effective changes will be spread to the remaining patients within the year the changes have been implemented who are identified to be at risk of developing cardiovascular disease.

The Planned Care Model

Key Changes in Self-Management Support • Create a user friendly self-management form for patients to work on while waiting for provider. • Form was tweaked several times using provider and patient suggestions to make it purposeful and effective. • Educated patients that they need to be specific with their goals and use baby-steps when creating their plan of how to reach that goal. Example: Instead of “I want to loose 50 pounds”, could say “I want to loose one pound per week between now and when I see Dr. again and I’m going to attend TOPS weekly to help me reach that goal”.

Delivery System Design • With Jackie’s terrific help, installed all available updates in CDEMS program. Clean up several different areas in CDEMS so reports will all be calculated using the same terminology and be consistent. • Program Framingham Risk Score into the CDEMS to be automatically calculated like the BMIs are. • Teach nurses to calculate Framingham Risk Score manually until it is programmed into CDEMS. • Laminate materials used for calculation for nurses to have at their desks and in each patient exam room. • Customize page two of the print outs from CDEMS to be educational yet easy for patients to understand.

Decision Support • Correct procedure guidelines reviewed with nursing staff to ensure accurate blood pressure readings are being reported to and acted upon by the providers. • Current goal readings of blood work and blood pressure readings gone over with the patients to educate them about their own health issues to help them take charge of their own health care.

Clinical Information Systems • Created letter to inform the pilot population of our new endeavor in the area of cardiovascular prevention. Letter was written and re-written at least four times before the mass mailing to the pilot population of people occurred. • Queries to be run each month to find who is due for labs and/or a clinic visit. • Reminder cards or phone calls sent to these patients who are due for labs and/or visits. • Add to the Diabetes Tool Boxes in the exam rooms, information that is appropriate for cardiovascular prevention participants. • Update demographic screen in Soapware at each visit and get insurance information scanned into Soapware as well. • Create notebooks for all patients in the cardiovascular collaborative that has pertinent educational material for them to keep.

General Contents of “Partners For Life” Book 1) Front of book has a page with dates of lab draws and office visits, as well as info describing what the book is about 2) Medication section 3) Running chart of blood sugar, blood pressure, and LDLs section 4) Nutrition section 5) Exercise section 6) Miscellaneous Sample Books at Story Board Table to View.

Community Resources • Created sheets of all exercise possibilities available in Pomeroy; time frames, cost, contact person. • TOPS meets weekly-very supportive group. • Multiple programs available through the Health Department as well as the Senior Center, need to list and laminate for all staff in clinic. • Transportation Vans available • Church clergy have resources available at times to assist a crisis person with emergency medication needs as well as housing, ect. • Local pharmacists set up some folks meds and report any unusual behaviors or findings to that persons provider. • Specialty areas such as Specialty Physicians, Diabetes Education Centers, Cardiac Rehab Centers, YMCAs and shopping malls are as close as thirty miles away for those that wish to use these services or their providers have referred them to those services.

Productive Interactions Informed, Activated Patient Prepared Practice Team A Typical Planned Visit In The Clinic *Reminder card sent to patient to notify of need for a lab draw and clinic visit. *Labs drawn approximately one week prior to visit. *CDEMS form placed on superbill for Provider to write on. *Receptionist gives Self-Management Form to patient to work on in lobby while waiting for provider. *Nurse ushers patient to exam room: completes height, weight, vitals, updates medication list, discusses Self-Management Goals with patient. *Provider – patient encounter. Lab values, education, med changes, etc. Provider notifies patient at end of visit when due for labs and visit next. CDEMS form returns to Susie to get entered.

Run Charts-Expected Result

Run Chart-Expected

Run Chart-Not Expected

Barriers Due to the fact that we have been involved with several collaboratives, we have no problem obtaining buy in from the providers or upper management. The team is accepting of the fact that we are improving patient care. We on the team deal with the ever present TIME issue. We are small enough that we wear multiple hats and have multiple process improvement projects going on simultaneously so we need to keep our minds and priorities on track. We have noted with this session that it has been hard to come up with PDSAs that we test and re-test after “tweaking”. We have found things that work well with our patients as they are accepting of our efforts to improve the health care that they are part of.

Keys to Success We have made it a point to keep open communication a priority in our facility. If an individual finds something that we are working on that just isn’t what they thought or wanted, we share openly. We also have total support from the administration on down so with that in effect, HALF our work is already done. We feel fortunate to live in a rural area that is small enough that we have tremendous support in our projects!

Thank – You!!! A gigantic THANK-YOU must go to Jackie who has spent a huge amount of time (hours and hours) helping to tidy up our CDEMS program. It had been installed when Pomeroy first started participating with the collaborative efforts and had never had any updates applied. She has been my guide and my mentor for learning the ins and outs of the CDEMS program which I could never have done without her. Jackie, YOU ARE AMAZING!!!

Cardiovascular Prevention