Participants in the Program

Transcription

1 Type 2 Diabetes Performance Improvement Initiative: Chart Reviews Participants in the Program 318 clinicians have registered 192 have started the program 126 have started their initial chart review 26 have completed their initial chart review 19 have submitted their action plans and are awaiting their follow-up chart review Performance Improvement Enrolling in this PI program is the 1st step in improving care for your patients Key component to improvement is chart review Simple way to look at baseline measures of your practice Very act of reviewing charts can be illuminating 1

2 Chart Review Challenge Biggest challenge = time Ways to overcome this barrier: Ask support staff to review patients seen in past month with any ICD 9 code for diabetes and pull charts, or review electronic medical record Make a plan to complete this chart review Recruit another member of your team to help Schedule 2 one-hour sessions over the next week using administrative time or your lunch hour Type 2 Diabetes Project Make a commitment to yourself and to your patients to work toward improving care! Complete the chart review as soon as possible as your first step toward improvement If you are having trouble completing the chart reviews, please let us know. We can help! If you have any questions, please us at mentorqi@bu.edu or call us at

3 Patient Education and Promoting Self-Care in Type 2 Diabetes Jane Jeffrie Seley, MPH, MSN, GNP, CDE Diabetes Nurse Practitioner New York Presbyterian- Weill Cornell Medical Center New York, NY Diabetes Self-Management Education (DSME) Provides skills, knowledge, and the ability to perform self-care Helps patients make informed decisions and practice problem-solving skills Funnell MM, et al. Diabetes Educ. 2007;33: , DSME (cont d) Encourages collaboration with health care team Improves clinical outcomes and quality of life 1

4 Core Components of DSME Educational needs assessment Learning preferences, health literacy Barriers to learning, following regimen Developing education plan Behavioral goal-setting Practice skills Need for ongoing support & outcome measurement Content Areas to Cover Over Time Disease process & treatment options Nutrition Physical activity Optimizing medications Monitoring glycemic control Pattern management Preventing complications Psychosocial issues co-existing with diabetes Promoting behavior change & self-care Recommendations Disease process & treatment options: Type 1 vs Type 2, multiple defects in diabetes, glucose metabolism Nutrition: Identifying carbohydrates in meals, portion sizes, servings per meal, spaced meal times Physical activity: What? When? How long? How often? Be specific! 2

5 Recommendations (cont d) Optimizing medications: How antidiabetes agents work, best times to take, when not to take, review skills Monitoring glycemic control: Review skills, upgrade meter prn, determine best times to check BG on ongoing basis Recommendations (cont d) Pattern management: Work toward patient participation in modifying meals, physical activity, dose of insulin according to current BG Recommendations (cont d) Preventing complications: both acute and chronic, start with hypo- and hyperglycemia Psychosocial issues living with diabetes: screen for depression, anxiety Promoting behavior change & self-care through education, practicing skills, setting realistic goals, encouragement 3

6 Steps to Success Provide education AND support Encourage patient empowerment by facilitating self-care behaviors Set realistic, achievable, short-term goals Monitor outcomes and adjust treatment plan as needed Plan for difficult situations Motivate, motivate, motivate! Common Barriers to Self-Care Depression: up to 2x more common in patients with diabetes 1 Denial/despair around diagnosis Myths/poor understanding/culture I ve got a little sugar Little social support High cost of meds/supplies Lack of physical & cognitive ability 1. Brown et al. Diabetes Care. 2005;28: Tools to Encourage Self-Care Knowledge is power Back to basics: Re-assess prior knowledge & skills Look at all meds and supplies: Ask patients exactly what they do and when 4

7 Tools to Encourage Self-Care (cont d) Focus on comfort: examine & modify blood glucose and injection supplies Evaluate feasibility of treatment regimen in relation to patient ability and quality of life Tools to Encourage Self-Care (cont d) Blood Glucose Monitoring (BGM) Is a Motivating Tool Set short-term BGM goals based on current medications and potential treatment changes Review and discuss log book at each visit Consider periodic review of log by fax or phone between visits Tools to Encourage Self-Care (cont d) Create library of written materials to reinforce teaching More is NOT better: Choose 1 or 2 simple handouts on each main topic 5

8 Improving Care in Your Practice Elaine Fleck, MD Associate Clinical Professor of Medicine Director, Internal Medicine New York Presbyterian Hospital- Columbia University Medical Center New York, NY Identifying Practice Gaps and Setting Goals What gaps do you see between care as it is and care as it could and should be for patients with type 2 diabetes? Identify goals that you would like to accomplish over the next 2 weeks to 3 months Understand and implement techniques that can change the nature of care delivery in your practice What can you do to plan, do, study, and act? Institute for Healthcare Improvement. Available at: Accessed December 4, Plan, Do, Study, Act (PDSA) Cycles What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Study Plan Do 1

9 Is the Change Being Implemented an Improvement? Improvement is not about measurement, though measurement plays an important role Key measures are required to assess progress Specific measures can be used for learning during PDSA cycles Balancing measures are needed to assess whether the system as a whole is being improved A General Approach to Developing Measures Try to collect data before and after making changes Multiple measures are almost always required to assure that the system as a whole is improved Fewer than six measures is ideal; maximum of 10 Develop a list of measures that are useful and manageable Mix of outcome, process, balancing Feasible! Langley K, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers; Types of Measures in Improvement Projects Process measure - How often is a question asked? How often is an A1C being drawn? Outcome measure - What is actual result? A1C level Balance measure - Looking at a system from all directions/dimensions. What happens to the system as we improve the outcome and process measures? ie, costs rise dramatically for minimal improvement patients not seen for other teaching because nurse is using time for diabetes teaching 2

10 Integrate Data Collection for Measures in Daily Work Include the collection of data with another current work activity (for example, data from office visit flow sheets) Develop an easy-to-use data collection form... spend 10 minutes creating a form or make Information Systems input and output easy for clinicians Clearly define roles and responsibilities for ongoing data collection; or offer pizza for a lunch chart review Set aside time to review data with those who collect it... give back information to everyone... people like to know Example of Data Collection: Is Depression Screening, Evaluation, and Treatment Occurring in Patients With Type 2 Diabetes? Patient screened for depression in past 12 months? Yes No History of diabetes? History of depression? Treatment for depression in past? If patient s screen positive: Was patient treated with medication? Y N Was patient referred to social worker, psychologist, psychiatrist, or none? (Circle one) If patient was treated, was there follow-up? Y N Time frame to follow-up visit? Results of Chart Review on Depression Depression Screening and Evaluation Patients Screened for depression in past 12 months Intake form used Y N No documentation History of diabetes History of depression documented Treatment of depression in past If patient's screen was positive, was patient treated with medication? Was patient referred to social worker?...psychologist?...psychiatrist? If patient was treated, was there follow up? 5 4 3

11 Next Steps: Set AIM Statement and Attainable Goals AIM Statement: Improve rates of yearly screening for depression to 90% in patients with diabetes over next 3 months We will do this by giving feedback to providers on results, ie, only 60% screened yearly presently Incorporate flow sheet (already in existence but first one did not have depression screen) into paper chart, and ensure screening questions are in electronic medical record Educate providers and staff on evaluation, treatment, and referral options. Incorporate social workers and psychologists into plan Repeat chart review in 3 months Interventions in Patients at Risk for Complications Evidence-Based Medicine Patients with microalbuminuria are at greater risk for cardiovascular (CV) mortality. 1 Intensified treatment intervention aimed at risk reduction in patients with type 2 diabetes and microalbuminuria reduces the risk of CV and microvascular events by about 50%. 2 How are our process and outcome measures of BP, A1C, LDL cholesterol in patients with microalbumin >30? Use electronic registry and paper chart review Results of chart review: Assigned to a resident (n=11) 36% with adequate BP control 91% on angiotensin II receptor blockers 67% A1C >9 (vs. 13% in patient population at large) 36% LDL <100 67% had nutrition referral, or education documented 1. Bell DS. Endocr Pract. 2008;14: Gaede P, et al. N Engl J Med. 2003;348: Creating AIM Statement for Practice Improvement AIM statement: We will improve A1C control in patients with microalbuminuria and A1C >9 by 50% in next 4 months, using American Diabetes Association guidelines and patient-centered approach to care We will accomplish this by... 4

12 Next Steps: Set Attainable Goals Giving feedback to providers of chart review results... send and provide one-on-one feedback Identify patients with A1C >9 through registry; each house staff reviews own patients Educate providers: Discuss intensifying therapy if A1C >9 Use flow sheet in each chart Call patients to come in for nurse education Consider social work referral and VNS referral for better assessment of learning and identification of barriers to care Return to practice within one month of intervention Steps to Success in Promoting Self-Care and Practice Improvement Set realistic, achievable short-term goals More is NOT better: Choose 1 or 2 simple interventions to make change Monitor outcomes and adjust intervention plan as needed Plan for difficult situations Knowledge is Power Q&A 5