CHI Diabetes Toolkit Using Diabetes to introduce Population Based Care

1. CHI Diabetes ToolkitUsing Diabetes to introduce Population Based Care David Swieskowski, MD, MBA dswieskowski@mercydesmoines.org

2. CHI Ambulatory Quality Goal Starting with HgA1c data collection, CHI physicians and ambulatory care administrators will: • Make population based care a core competency of CHI primary care practices • Create a culture of measurement and continuous improvement in CHI ambulatory care practices

3. 4 P’s of the Population Based Care • Population based • Success is measured by the percent of the entire population that is meeting goals • Patient centered • Patient needs motivate care delivery • Proactive • Patients don’t need to schedule an appointment for the care system to reach out to them • Planned • Designed to be effective, complete, consistent, and sustainable

4. Rationale for Population Based CareThe current care delivery system was design for acute episodic care and does a poor job for chronic and preventive care. Until there is fundamental system change we will not do much better than the following: • Evidence based care given only 55% of time • (NEJM. 2003;348(26):2635-2645) • Blood sugar is controlled in only 37% of patients with diabetes • (JAMA. 2004:291(3):335-342) • Blood Pressure is controlled in only 35% of patients with hypertension • (Ann Intern Med. 2006;145(3):165-175) “Every system is perfectly designed to get the results it gets”

5. PMAC HgA1c QualityRecommendation All MBOs with FP or IM employed physicians should track HgA1c electronically for all patients with diabetes and report aggregate HgA1c data at least quarterly • Goal is to improve glycemic control in the diabetes population and to introduce population based disease management to the MBOs.

6. Initial Metrics • % of HgA1c tests ≤ 7.0 and • % of HgA1c tests ≤ 8.0 Defined by: NQF Measure # 14 • Most recent HgA1c value by range • ≤6.0, 6.1-7.0, 7.1-8.0, 8.1-9.0, 9.1-10.0, >10.0 • Denominator includes only patients seen in the last year • Remove upper age limit

7. CHI HgA1C Data – April 2008

8. Why not wait until the AEHR? • Most AEHRs do not function as registries that support population based care • It will take 5 years for system wide HgA1c reporting • The HgA1c data collection process is relatively easy, inexpensive, has a positive ROI immediately, and produces better health outcomes now • It is important to learn population based care prior to implementing an AEHR • Then design AEHR processes support it

9. CHI Diabetes Toolkit • The Toolkit is designed to help MBOs comply with the PMAC HgA1c quality recommendations • This PowerPoint Highlights the contents of the CHI Diabetes toolkit. • Scrolling through the slides is an easy way to learn what is available • All the documents on this powerpoint (and more) are available in the folders on the CHI web site • Communities » Knowledge Communities » Physician Practice Leadership » PMAC Members » CHI Diabetes Toolkit 2008

10. Communities » Knowledge Communities » Physician Practice Leadership » PMAC Members » CHI Diabetes Toolkit 2008

11. CHI Diabetes ToolKit File Structure

12. 1. Organization of Health Care“Chronic Care Model” • The Chronic Care Model provides the theoretical framework for redesign of care delivery • The Model has six domains that are all important to improve chronic and preventive care • The CHI Diabetes Toolkit is organized according to the six domains

15. Also in this section • Corporate bylaws establishing the MCI Quality Committee • Physician VP for Quality Job description • MCI Quality Mission Statement

16. MCI Quality Mission Strategies • Measurement • Information technology • Chronic Care Model • Standardization • Partnering • Transparency • Communication • Self-management support

17. 2. Decision Support • Guidelines are to set the goals and to help in the design of your QI program not for physician use during care of the patient • Standing Orders standardize care

20. Diabetes standing lab orders

21. Standing Orders Flowsheet

22. Framingham 10-year CHD Risk Assessment Calculator

23. 3. Information Systems – Registry “The single most important step to improve chronic care” • This section of the Toolkit contains: • A sample HgA1c Excel spreadsheet with practice data • A powerpoint describing how and why to create a HgA1c database in Excel

24. Business Case for Data Collection and Population Management

25. Properties of a registry • Create lists of patients: • With a defined condition • Overdue for care • Not meeting outcome goals • Create performance reports – that give the % of population meeting goals • By provider, clinic, or system • Create patient summary reports

26. How to Get started with and Excel Registry • Pick one provider to be the program champion and start the registry with his/her patients • Identify patients with diabetes • From billing or lab systems (HgA1c done) • Set up the registry in Excel • Back load one year of HgA1c data • Enter new data as patients come for visits • Write over any pre-existing data (save only the last value) • Create lists of patients overdue for care or not meeting goals and send them a letter to come in. • Prepare quarterly reports • Spread to a second provider when it is working well for the first provider • Finally add microalbumin to the registry to make the economic case

27. EXCEL Diabetes Registry • Keep only the most recent visit’s data • Sort alphabetically to enter data • Sort by date to find Pts. overdue for testing • Sort by value to find poorly controlled Pts. • Registry PowerPoint is in the toolkit

28. Data Needed for HgA1c Registry • Patient ID • Lastname, first name, birthdate • Provider Who ordered the test • May not be the patient primary care provider, but it is the easiest way to assign a provider • HgA1c data • Date of test, result

29. Where to find HgA1c Data • In office • Is there a log of all tests (CLIA requires this) • Use the log for your source of data • Reference lab • Can you get aggregated electronic reports • Enter them electronically or manually into the registry • If no electronic report then create a paper or electronic log as reports come in

30. On-going Data CollectionTest done in office • Keep a log of HgA1c tests in the lab • Columns in the log are: • Name, birthdate, provider, date done, result • Once a day or once a week add the newly done tests to the Excel spreadsheet • If there is already a result in Excel erase it and put the new one in

31. On-going Data CollectionTest done in reference lab • Log all HgA1c tests sent out • Name, birthdate, provider, date sent out, result • Log all HgA1c tests when they return • Add the result (this also confirms none are lost) • Once a day or once a week add the newly done tests to the Excel spreadsheet • If there is already a result in Excel erase it and put the new one in

33. Resources needed for A1C Data Collection • Average FP has 100 patients with diabetes • Average patient comes in 3 times a year • 300 diabetes visits and 200 working days • 1-2 diabetes visits per doctor per day • 7-8 diabetes visits per doctor per week • At 3 minutes of data entry time per visit • 5 minutes per doctor per day

34. Resources Needed for Diabetes Population Management Monthly • Sort Excel by Provider then A1c results • Give list of patients not at goal to provider • Sort Excel by Provider then Date of A1c • Give list of patients overdue for A1c to provider • Send letters to patients needing care • 5 letters per provider / month • Staff time required for sorting and sending letters • 1 hour per provider per month • Cost of letters $1.00 each

35. Resources needed for National Data Reporting Reported Quarterly • Local staff Collect the Excel spreadsheets for each clinic in the MBO • Paste into one spread sheet • Sort Excel by date and delete all rows with results greater than 1 year old • Sort remaining rows by value and calculate the percent < 7.1 and < 8.1 • E-mail the aggregate MBO result to CHI • Time: 1.5 hours a Quarter • CHI Central staff • Take results and create a national report by MBO • Time: 2 hours a Quarter

36. To Enter Data: Sort Alphabetically by Last Name Duplicates can be removed manually or in bulk using Excel features

37. To determine A1c values by range: Sort by HgA1c Result

38. To identify patients who are overdue for care: Sort by Date of most recent HgA1c

39. To Create performance reports: Sort by Provider and then value Dr. A % < 7.0 = 3/7 = 42.9% Dr. A % < 8.0 = 5/7 = 71.4%

40. Excel Spreadsheet for Expanded Diabetes Data Collection

41. Sample Patient LettersOne example

42. 4. Delivery System Redesign This section of the Toolkit contains: • Health Coach Position • Paper about office based health coaches • Job Descriptions • Three descriptions for different skill levels • Pre-visit chart review forms • Diabetes Flowsheets • Office visit charting forms

43. Downloadable at: http://www.mercyclinicsdesmoines.org/Quality/HealthCoachPaperAMGA208.pdf

44. Health Coach Job Description Essential Functions: • Oversees the disease registry database… • Conducts pre-visit chart review… • Works with patients and families on Self-Management Support… • Coordination of Care across the care continuum… • Involvement in QI activities Three job descriptions are available from the Inside CHI web site

45. Diabetes Audit form • Used for: • Pre-visit review • Order form • Data collection

46. Pre-visit Review Audit Form #1

47. Pre-visit Review Audit Form #2

48. Pre-visit Review Audit Form #3

49. CMS – PQRI Diabetes Data Collection form

50. Diabetes & HTN Standing Orders Flowsheet Done in Excel