RWJ DI ADSM SPFMRP Four Steps to Patient Self Management Support in Primary care: What we have learned

Transcription

1 RWJ DI ADSM SPFMRP Four Steps to Patient Self Management Support in Primary care: What we have learned RWJ Diabetes Initiative Advancing Diabetes Self Management

2 Go Team SPANK! Newsletters Traditional group visits Walking clubs MA classes at Boldt MA planned visits Self management classes for patients Focus groups Patient mentoring program Fish bowel focus groups Provider visits BBSWAR CDEMS registry Provider progress reports CDEMS run charts Radiant Communication plan Provider and group visit forms Elma spread Exercise video Patient survey s Resident SM curriculum SMG goal cycle Action planning/goal setting MA training curriculum Mini group visits Pedometer program Organization capacity matrix selfevaluation tool Project Innovation with Orca and asthma project Do It For Me drawing contest Exercise club Power 90 posters in the lobby Community outreach letter Restaurant guide Open office sessions Monthly team SPANK staff meetings

3 The Patient The Medical Assistant The Provider Leaves with scripts, referrals, and instructions

4 The Patient Other Activated Patients The Non Clinical Staff The Medical Assistant Integrated plan Medical & SMG The Provider

5 One Planning and preparation MA planned visits and CDEMS/Centricity registry includes action planning

6 Two The Provider learn how to negotiate a medical plan and integrate with a patientoriented self management action plan (SMG) NON DIRECTIVE COUNSELLING B B S W A R

7 Three and Four Patients helping patients 3) The MINI group visit 4) The Open Office Group visit Both involve action planning Stressors, depressed mood, barriers, difficulty coping ALWAYS covered Know your tripwires

8 What s different? MA:patient develop a closer relationship that the patient believes is MORE VALUABLE MA:provider partner with the patient to effect real behavior change Shared responsibilities begin to develop Provider perceives they have more time during their visit because of the pre planning and preparation, and grouping of patients PATIENTS SELF MANAGE Outcome and process measures improve

9 By the numbers Patient Self Management Goals = 1781 made by 71.5% of our patients with range from 1 to 24 and average of 6 Planned visits = 289 patients have had 1175 PV s (60.6% of total patients) Group Visits = 99 patients have attended 15 GV s (20% of patients) and 35 patients have participated in 18 mini GV s (7.3%)

10 Goal Quality Improvement, Phase I Clinic SMG By Date Mar May 01 Jul 01 Sep Nov 01 Jan 02 Mar May 02 Jul Sep 02 Nov 02 Jan 03 Mar 03 May Jul 03 Sep 03 Nov 03 Jan 04 Mar

11 Does it make a difference? The HbA1c Phase I: The mean change = 0.42 P value = HbA1c First Last

12 Phase II Snap Shot Average HbA1c Change by Population H b A 1 c D ec rea se/in c re ase W e ig h t ( lb s ) Average Weight Change by Population Average Number of High Quality Goals Saw yer Planned Visit Group Visit Clinic Service Patients Saw yer Patients (15) Planned (50) Visit Group (29) Visit (29) Average Clinic (254) Average Decliners Service (26) 0 (15) (50) (254) Decliners (26) Saw yer Patients Planned Visit Group Visit (29) Clinic Average Service Service Maximizers (15) (50) (254) Decliners (26) Service Maximizers # o f Q u a lit y G o a ls 0.49 Service Maxim izers

13 End of Phase II: HBA1c P e r c e n t P e r c e n t % with most recent HbA1c < 6.5 % with most recent HbA1c < 8.0 Percent of Patients with HbA1c < 9.5% Total Pop SPANK I Compared participants Total Pop SPANK to practice as a whole Total Pop Goal SPANK at end of Phase II Participants are patients with 7 or more PV s or 7 or more Group visits, and 10 or more SMG s p e r c e n t Months Months Goal = 85% O ct 05 O ct 05 N ov 05 O ct 05 N ov 05 D ec 05 N ov 05 D ec 05 J an 0 6 D ec 05 J an 0 6 F eb 06 J an 0 6 F eb 06 M ar 06 F eb 06 M ar 06 Apr 0 6 M ar 06 Apr 06 M ay 0 6 M ay 06 Apr 06 J un 0 6 J un 0 6 M ay 06 J ul 0 6 J ul 06 J un 0 6 Aug 06 Aug 06 J ul 06 Sep 06 Sep 06 Aug 06 O ct 06 O ct 06 Sep 06 O ct 06

14 Foot exam and eye referral Percent of Documented Foot Exam Goal: 90% P e r c e n t P e r c e n t O ct N ov 05 D e c 0 5 J a n 0 6 Total Pop Goal SPANK Goal: 70% Percent of Documented Dilated Eye Exam F eb 0 6 Total Pop Goal SPANK M a r 06 Apr 06 May 06 J u n J ul Aug 0 6 Sep 06 O ct O ct 05 N ov 05 D ec 05 J an 0 6 F eb 06 M ar 06 Apr 06 M ay 06 J un 0 6 J ul 06 Aug 06 Sep 06 O ct 06

15 Blood Pressure Percent of Patients with BP < 140/90 Total Pop Goal SPANK Goal = 80% p e r c e n t O ct 05 N ov 0 5 D ec 0 5 J an 0 6 F eb 06 M ar 06 Apr 06 M a y 06 J un 0 6 J ul 06 Aug 0 6 Sep 06 O ct 06

16 Count Count LDL beginning to end First LDL Last LDL

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18 What is next Centricity Registry (Kryptic?) SMG Centricity Forms MA training curriculum (Jan Wolfram) Independent Practitioner Planned Care Initiative, local collaborative P 4 grant for teaching the future of family medicine Institute of Health Care Improvement AADE Annual meeting STFM Annual meeting Research Triangle Institute International Manuscript and papers in progress and on and on and on