LEARNING & SHARING SESSION: BEST PRACTICES IN COMPREHENSIVE DIABETIC CARE AND PATIENT ENGAGEMENT. December 2017

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2 2 LEARNING & SHARING SESSION: BEST PRACTICES IN COMPREHENSIVE DIABETIC CARE AND PATIENT ENGAGEMENT December 2017

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4 Webinar 4 Help avoid background noise by muting your line or calling in from a phone 10 minutes for Q&A at the end of guest presentation Type your questions throughout the presentation in the chat box on the bottom of your GoToMeeting control panel Oregon Primary Care Association

5 Today s Topic at a Glance 5 Objectives: Learn how The Portland Clinic uses data to identify disparities and care gaps within their comprehensive diabetes care program Discover best practices for coordinating diabetes care with pharmacy Share ideas on delivering patient education to enhance patient engagement Oregon Primary Care Association

6 CCO Measure Review Diabetes Poor Control 6 Numerator Patients whose most recent HbA1c level (performed during measurement period) is > 9.0% Denominator Patients years if age who had a diagnosis of diabetes during or anytime prior to measurement period who received a qualifying outpatient service Benchmark (2017) 19% Measure specifications: 20-%202017%20(revised%20Feb%202017).pdf Benchmark (2018) 22.6% Draft measure specifications: 0Control%20-% pdf Oregon Primary Care Association

7 Comprehensive Diabetes Care at The Portland Clinic Paige Frederick, RN Quality Coordinator December 13, 2017

8 The Portland Clinic: Background 8 Established in 1921 Independent physician-owned, multi-specialty medical group Six clinic locations and two ambulatory surgery centers across the metro area Approximately 100 Providers Specialties Include: Internal Medicine, Family Practice, Pediatrics, Behavioral Health, Cardiology, Dermatology, Foot and Ankle, Gastroenterology, Gynecology, Infectious Disease, Manual Medicine/Osteopathy, Nephrology, Neurology, Ophthalmology, Orthopedics, ENT, Rheumatology, General Surgery and Urology Diabetes Department: One Full-Time FNP-CDE One Part-Time RN-CDE Patient Population: Approximately 20,000 attributed Primary Care patients Commercial (57.4%), Medicaid (13%) and Medicare (29.6%) Adult and Pediatrics Approximately 2,700 patients with active Type II Diabetes diagnoses Live on Epic since November 2011

9 Where we started 9 Diabetes Committee Led by Diabetes NP s Development of care pathways and best practice advisories BPA s pop-up in the patient s chart when a patient is overdue for something Pop-up fatigue among PCP s Reports were cumbersome and few people had access to them Data wasn t trusted because it didn t capture external tests/visits

10 Improving Diabetes Management at TPC 10 Why focus on diabetes? No standardization across Providers or Clinics Room for improvement on our diabetic quality measures Triple weighted outcome measures in our value contracts High needs population Limited access on our Diabetes NP s schedules Down to one NP in 2017 Participation in AMGA s Together 2 Goal Campaign (January 2016) help to jump start this work Improve care for 1 million patients with Type II Diabetes Performance reporting, access to educational resources and monthly webinars, comparison data Rollout was SLOW! Majority of the first year spent on data validation (critical for physician buy-in) Challenges finding physician champion due to turn-over What do we do with the data now that we have it?

11 Together 2 Goal Reports 11

12 Together 2 Goal Reports : Diabetes Scorecard RN s are reviewing patient s chart and entering A1c labs that are completed externally Clicking on the Last A1c redirects you to the patient s chart

13 Utilizing Healthy Planet 13 Diabetes Registry More actionable reports Pilot with a subset of PCP s from Quality Management Committee Differentiate Type I from Type II as management often looks very different Identify patients who have care followed by outside provider Ensure we obtain records from outside clinician Enter external results into the EHR to allow for capture in reports Health Maintenance clean-up Develop protocols based on A1c control (<7%, 7-8.9%, >9%) Office Visit and screenings Patients with poor control may need referral to diabetes, nutrition, behavioral health, etc. Standardized process for reaching out to patients Utilize current staffing for pilot Labs prior to OV, pended and sent to provider for signature Address all care gaps whenever possible (not just diabetes gaps) Data Transparency Diabetes measures and Provider Compensation

14 Utilizing Healthy Planet : Diabetes Registry in HP Report includes: most recent A1c value and date, last CMP/BMP, last lipid, last urine microalbumin, last outreach, upcoming appointments, patient portal status, etc. Ability to filter

15 Healthy Planet Diabetes Pilot 15 Goals and Purpose Patients are separated by level of control to prioritize patients with highest need HbA1c <7%- less frequent visits and testing HbA1c 7.0%-8.9%- monitor and adjust treatment as needed HbA1c >9%- require close follow up and treatment adjustments to achieve control Reduced variation across providers Capturing patients before they become due rather than after they are overdue Consider changing lipid to is patient on a statin

16 Barriers 16 Providers Ordering labs prior to Office Visit Agreement on protocols and standing orders to allow nursing staff to assist in the process Staffing Plan is to eventually add FTE s, but pilot requires us to use current staffing which presents challenges Educating staff so they understand why this work is important

17 Words of Advice 17 Don t be afraid to ask for help Reach out to other clinic groups who have already done the work Ask lots of questions about barriers, roll out, etc. Keep own clinic structure and culture in mind; what works for one group may not work for another Pilot with a smaller group of physicians Be prepared to change the process if it s not working Include providers and clinical staff in the process and ask for feedback They will be more likely to adopt the changes if they are involved in the process and feel their concerns are being addressed

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19 Group Sharing Learning from your Peers! 19 Consider your own clinic s approach to delivering comprehensive diabetes care and using data to identify disparities among your diabetic patients. 1) Based on the presentation from The Portland Clinic, what similarities or differences did you note? 2) What successes or challenges would you like to share with the group? Oregon Primary Care Association

20 Group Sharing Learning from your Peers! 20 Consider your own clinic s approach coordinating with pharmacy and conducting patient education for your diabetic patients. 1) What role does pharmacy play? 2) What resources or tools do you use to educate patients on how to manage their diabetes? 3) What successes or challenges have you experienced with engaging patients in their diabetes care? Oregon Primary Care Association

21 Clinician Resources 21 AHRQ Effective Healthcare Program» Diabetes Medications for Adults with Type 2 Diabetes» Behavioral Programs for Type 2 Diabetes Mellitus» Behavioral Programs for Type 1 Diabetes Mellitus National Diabetes Education Program» CDC Archived Webinars» Guiding principles, toolkits and more for health professionals» Diabetes Discoveries & Practice Blog Standards and Guidelines» 2017 ADA Standards of Medical Care in Diabetes» 2015 US Preventative Service Task Force Guidelines» Guiding Principles for the Care of People With or at Risk for Diabetes» Diabetes Mellitus: Screening and Diagnosis Programs» Lifestyle Change Program and National Diabetes Prevention Program» Diabetes Self-Management (DSMP) Oregon Primary Care Association

22 Additional Resources 22 Articles, Reports and Reviews CDC National Diabetes Statistics Report 2017 Diabetes Prevention: Interventions Engaging Community Health Workers Tools HITEQ Toolkit Improving Diabetes Outcomes Guides and manuals for group appointments Disparities Widget MyHealthFinder Widget Webinars Diabetes In Special and Vulnerable Populations: A National Learning Series Diabetes and Asian Americans: The Need to Screen at 23 Nutrition and Diabetes: Special Considerations for Clients who Are Unstably Housed Activating Shared Data Oregon Primary Care Association

23 Upcoming Opportunities 23 Chronic Disease Self-Management Program Where: Salud Medical Center in Woodburn, OR When: March 2-3, 9-10 from 9:00 AM to 4:00 PM Cost: Free Interested? Gizelle Polanco at AAPCHO Webinar - Housing Instability and Diabetes Outcomes in Agricultural Workers and LGBT Communities When: 12/14/2017 from 11:00 to 12:00 PM Register here! Oregon Primary Care Association

24 24 Let us know what you thought of today s call! Please take a few moments to complete the survey for this phone call. It will be ed to you right after this call. CLICK HERE TO ACCESS THE SURVEY Contact our team at data@orpca.org

25 APPENDIX

26 Engaging Your Patients in their Diabetes Care LAURA SHANE-MCWHORTER, PHARMD, BCPS, BC-ADM, CDE, FASCP, FAADE PROFESSOR (CLINICAL) EMERITUS UNIVERSITY OF UTAH COLLEGE OF PHARMACY

27 Objectives Review the role of pharmacy in comprehensive diabetes care Assess the need for individualized patient education and care planning Share toolkits for active patient education Introduce strategies to involve patients in their own care Reinforce motivational interviewing

28 TP TP is a 42 year old male who was diagnosed with type 2 diabetes today. His glucose is 284 mg/dl and A1c is 8.5%. He is referred to the pharmacist today to receive education regarding how to manage his diabetes. The provider stated that he should do the following: Start a new medication and watch for stomach upset Lose 15 lbs by eating healthy and eat fewer carbohydrates Start exercising at least 30 minutes a day Check glucose 2-4 times daily Make an appointment with the ophthalmologist Come back for other tests for kidney function and fasting lipids

29 Key Considerations Diabetes self management education (DSME) Knowledge, skills, ability necessary for DM self-care Should be ongoing Patient centered care Shared decision making Address DM-related distress Diabetes Care 2015;38:

30 TP Areas of Consideration A1c an explanation; including goals BP goals? Lipids total cholesterol, triglycerides, HDL, LDL Comprehensive Metabolic Panel what are the components and why is this important? Immunizations Eye exam Other labs needed? TSH, albumin/creatinine

31 Pharmacist s Role Offer a menu of options of Survival Skills What areas should be covered? What Medications should be taken? What to eat? How to monitor? Appropriate glucose levels? What to do if glucose is too high or glucose is too low?

32 Important Areas to Address? What is patient s knowledge of diabetes? Truths and myths What is the patient s interest in learning about diabetes? Has the patient accepted their diagnosis? What is the patient s willingness to take control and change behavior? Coping skills What are the pros and cons of diabetes care What questions does the patient have?

33 Key Components Healthy nutrition what does that mean? 24 hour food recall Food preferences history Plate method? Physical activity What is patient s occupation? How much physical activity is currently being done? How much computer time? How to start? How often? Consider seasonal variations

34 Key Components Medications Do a complete medication history Prescriptions, OTCs, supplements Adherence How long should they be used? How to take them what time of day? How to know if they are working? Side effects? How to manage them? Lifestyle issues Alcohol Smoking Importance of monitoring Blood glucose meter Blood pressure monitor Follow-up

35 WD WD is a patient with T2DM. The diabetes is better but the A1C is still elevated (8.9%; down from 11.2%). She is on the following meds: Metformin 1000 mg bid Glipizide 5 mg ER bid Pioglitazone 45 mg daily Linagliptin 5 mg daily Atorvastatin 80 mg daily Lisinopril 20 mg daily She does not want to start insulin. How would you help WD?

36 Motivational Interviewing State: Many people feel the same way as you do. Is it okay if we discuss why you do not want to use insulin? What have you heard about insulin? Consider importance On a scale of 1 to 10, how important do you think it is to have glucose be at a safe value? If patient states 8 to 10 state okay Why do you say that number? If patient states 5 state okay Why do you say that number and what would have to happen to get to a 7 or 8

37 Motivational Interviewing Consider conviction On a scale of 1 to 10, how likely do you think it is that you will take steps to get to a safer glucose value? If patient states 8 to 10 state okay Why do you say that number? If patient states 5 state okay Why do you say that number and what would have to happen to get to a 7 or 8

38 Practical Advice: Helpful Hints TEACH PATIENTS TO ASK the Ask-Me-3 Questions!!!! What is my main problem? What do I need to do? Why is it important for me to do this? USE TEACH BACK METHODS MEDICATION RECONCILIATION EACH TIME A PATIENT IS SEEN (for each med and evaluate dose/schedule, adherence) Should medications be adjusted?

39 Practical Advice: Critical Times for DSME and Support At diagnosis Once yearly Review knowledge, skills, behavior Review medication changes Address goals New factors that influence self-management Complications Complex regimens Emotional factors Transitions of care Changes in living situations, insurance changes, aging changes Diabetes Care 2015;38:

40 Practice What You Have Learned (on your own) You are counseling a patient that comes to clinic. You teach her how to use a blood glucose meter and ask her to check glucose twice a day fasting and 2 hours after the largest meal of the day. The patient states she is not sure if she really wants to check twice a day. What would you do?

41 QUESTIONS?