A Diabetes Program in Family Practice: How to Do It!

1. Anne Barber RN(EC) MScN Michele MacDonald Werstuck, RD MSc CDE Lisa McCarthy, RPh BScPhm Pharm D Inge Schabort, MB ChB CCFP A Diabetes Program in Family Practice: How to Do It!

2. Disclosure • The presenters perceive no conflict of interest with this presentation. • Slides will be available at: www.stonechurchclinic.ca

3. Session Objectives • At the end of the session, participants will be able to: • Discuss strategies to identify patients with diabetes including screening approaches, disease registries. • Describe options for maximizing your capacity for providing care including flowsheets, templates, connecting with an interprofessional team. • Access a library of vetted patient and provider resources.

4. Objectives • To help you... • Identify your patients with diabetes • Start a diabetes clinic /diabetes day • Build a diabetes team • Experiment with group medical visits • Access resources to get you started

5. Who are we? • Provide primary care for nearly 30 000 patients in Hamilton and surrounding area • 2 clinical teaching units affiliated with McMaster University and Hamilton Health Sciences

6. Who are we? Stonechurch MFP Physicians 16 (12.7 FTE)‏ 13 (7.5 FTE)‏ Family Medicine Residents 32 (10-12 full-time at any one time)‏ 34 (12-13 at any one time)‏ RN(EC)s 4 (3.5 FTE )‏ 4 (4.0 FTE)‏ Dietitians 2 (1.0 FTE)‏ 1 (0.8 FTE)‏ Mental Health Therapists 3 (2.6 FTE)‏ 3 (2.4 FTE)‏ Clinical Pharmacists 2 (0.8 FTE)‏ 2 (0.8 FTE)‏ Consultants Palliative Care, Psychiatry, Geriatrics, Internal Medicine

8. Caring for Patients with Diabetes • Step 1: Identify your patients with diabetes • Do you do this in your practice? • If yes, what has been your experience? • If no, how might you approach it?

9. Step 1: Identifying Patients with Diabetes • Do you currently track your patients with diabetes (paper, EMR)? • Is your registry accurate? • What criteria did you use to create your registry?

10. Step 1: Identifying Patients with Diabetes • Lessons Learned: • Tidy up data • Team meetings to reinforce consistent data entry (EMR), documentation • Those with confirmed diabetes enter into your registry

11. How do you screen for patients with diabetes? • Periodic health exam • Other chronic disease visits • Maximize screening during opportunistic encounters • Whatever your strategy, think sustainability

12. Step 2: Maximize Your Interprofessional Team • What practitioners do you have available? • What are the essential components for patient care? • How can you maximize scopes of practice for each professional?

13. Bottom Line “The vast majority of people don’t need glitzy miracles; we need sound, evidence-based, timely, respectful and well communicated primary health care from a team dedicated to getting it right.” Steven Lewis, a Saskatoon-based health policy consultant and part-time academic

14. Interprofessional Diabetes Team

15. The Need for Teamwork • Consider: • Number of patients with diabetes • Number of visits per patient per year • Can be overwhelming to manage alone

16. MYTH:Stress has no effect on diabetes.FACT:Stress can increase your blood sugar and throw your diabetes out of control. Ask for help with stress management.

17. Step 3: A Diabetes Clinic (Day) Should your practice have one? • What resources are available to your patients with diabetes right now? • What Diabetes Education Clinic (DEC) services exist? • Do you have providers with a keen interest in diabetes management?

18. Diabetes Clinic Cont`d • Who will you service? • Determined by: • Patient needs • Skills of your team (e.g., comfort with managing insulin) • What resources already exist within the community

19. Preparing for Your Diabetes Clinic • Referral system • Triaging system • Team meetings • e.g., case review, team building • Debriefing

20. Time for Team Education

21. Offering a Diabetes Clinic • Let’s brainstorm... • What equipment will you need? • What patient and provider resources do you have available? • Which will you need to locate or create?

22. Offering a Diabetes Clinic: Equipment • Insuiln (consider in-house supply) • Equipment • Glucometers, one-time use lancets, ketone tests (blood and urine) • Hypoglycemic Emergency Kit • Glucose tablets, juice boxes, injectable glucagon, instructions about how to use kit

23. Offering a Diabetes Clinic: Resources • If it exists, use it (with permission, of course)! • Don`t forget team education, training with resources • HHS patient education library • www.stonechurchclinic.ca • Goal setting sheet • Diabetes Clinic Follow-Up Visit (list of expectations, what to bring) • Starting with Bedtime Insulin • Diabetes Passport

24. Step 4: Using a Diabetes Flowsheet • A management MUST! • Try using different flowsheets to find your favourite • If using EMR • Link flowsheet with disease registry and incoming labs

26. Step 5: Maximize Use of Templates • For example: • Stamps for documentation (electronic or paper) • Frequently used patient education materials • Goal setting, action planning sheets • Hypoglycemia • Starting insulin therapy

27. Diabetes Group Medical Visits • What is the difference between the group education and group medical visit? • What are the benefits of the group medical visit? • What are the challenges of the group medical visit?

28. Diabetes Group Medical Visits

29. Sharing our Experience: What It Looked Like • Introductory Session • (planned 20 minutes, really 60 min!)‏ • Evolved into discussion with patients • Patient sharing of experiences • (planned 20-30 minutes, could have been longer)‏

30. What It Looked Like Cont’d • ‘The Circuit’ • Planned 30 min, Really 45-60 min • Stations for: vitals, foot exam, doctor check-in • Floating IHPs to do goal setting while awaiting the circuit • Group Wrap-Up • Planned 10 minutes, Really cut short!

31. How We Did It… Find and prepare patients Determine roles, logistics Preparation!!! Deliver Document and Debrief 6) Plan for the next one

32. Finding Patients • Identified potential patients through EMR • Assumes disease registry or some other mechanisms to identify • Physician vetted list • RPN reached out to recruit • Reminder calls day before

33. Preparing Patients • Persuasive RPN  • Do labs week before, bring all medications, supplements etc., blood glucose records, 3 day food diary, glucometer, told vitals and feet would be examined, consent and confidentiality required • Biggest Draw: extended visit with THEIR family doc!

34. Preparing Ourselves • Define roles • IMPACT BC Guide (http://www.impactbc.ca/practicesupport/pspmodules/groupvisits) • Logistics • room set up, finding time (evening?), booking space and equipment

35. Preparing Ourselves Cont`d • Planning the Visit (many team meetings) • Presentation • Intro, what to expect from group visit and for future care, patient sharing of experiences, goal setting • Detailed chart review, • Prepare labs, flowsheet for physician • (most time consuming)

36. What We Learned • Minimum 15-20 patients registered • Patient packages helped to speed up process • Factor in preparation and documentation time • Patients Loved this Experience!

37. Group Introductory Visits • Building on prepared patient concept • Initial session offered to patients referred to DM clinic • Introductory diabetes education • How to prepare for follow-up visits • What to expect • What to bring

38. Resources • Visit our website • www.stonechurchclinic.ca • Canadian Diabetes Association • www.diabetes.ca • Dietitians of Canada • www.dietitians.ca • Hamilton Health Sciences Patient Education Library • www.hamiltonhealthsciences.ca • The Diabetes Food Guide • www.centretown.chc.org

39. Slides will be available at: www.stonechurchclinic.ca Contact Information: ischabo@mcmaster.ca lmccart@mcmaster.ca macdonmic@hhsc.ca Thank you!