Webinar Series: Diabetes Epidemic & Action Report (DEAR) for Washington State Session 3 Clinical Interventions that Can Help Prevent and Manage Diabetes June 17, 2015
Qualis Health A leading national population health management organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington The QIO Program One of the largest federal programs dedicated to improving health quality at the local level 2
Today s Speakers Berdi Safford, MD Medical Director, Vice President of Quality Family Care Network Glenn Puckett, MPA Program Manager Washington Dental Service Foundation 3
Diabetes Quality Management How do we do this? Bertha H. Safford MD Family Care Network
Once upon a time.. Group practice of 20 physicians in a few sites Attended IHI Collaborative on Diabetes 1999 Attended WA state collaborative on Diabetes 2000 What did we learn?
Model of Chronic Illness Care Registry Pre-planning Patient-centered visit Sustained active follow-up Recall
What Is Pre-planning? Agreement on evidence-based guidelines Needed care organized ahead - templates Informed trained healthcare team Lab tests obtained before visit
What is patient-centered visit? Patient s agenda respected without sacrifice of important needed care Co-morbidities addressed Time and attention given to management issues from patient s perspective
What is Sustained Active Followup? More frequent visits or phone check-in when not at target Asking about diabetes at non-diabetes office visits? Health coaching? Treat-to- target with RN and standing orders
Recall Standardized for consistency (3 months, 6 months) Systematically done not physician dependent (use of smart phrases) Standing orders for lab orders Phone follow-up
Living Happily Ever After Train all new clinicians into the system Train the teamlet together new clinician + clinical assistant Follow-up chart review Value the work membership in Family Care Network for physicians dependent on quality review
How does this really work? Person with diabetes 1. She receives a reminder letter and calls for appointment. The letter includes her lab orders. 2. Appointment staff hears that she is scheduling a diabetes visit and reminds her to get her labs drawn at least 3 days before the appointment. The appointment is labeled routine diabetes visit.
Patient with diabetes cont. 3. She has her labs drawn which come to me through EMR and I review and sign them, seeing that she has appointment scheduled. 4. She arrives for her appointment and the receptionist hands her a diabetes questionnaire to complete. 5. The clinical assistant takes her to the exam room to complete the visit intake.
In the exam room Clinical Assistant Reviews the patient s agenda for the visit and begins the process of establishing what will be addressed. Checks vital signs, retaking the BP after 5 minutes of rest if initial reading is > 130/80. Checks preventive services due, and either reminds patient (ex mammogram) or actually performs (ex flu shot, pneumovax).
Clinical assistant.cont. Reviews completed diabetes questionnaire and enters results into EMR (includes blood sugar readings, review of systems for diabetes, hypertension and hyperlipidemia). Prints and gives patient our Know your ABCs handout, which includes patient s most recent lab results Reviews medications, notes any changes.
Clinical assistant cont. Reviews needed services for diabetes performs foot exam if indicated; checks on eye exam reminds patient if due, gives patient a form for eye dr. to complete and fax back. Enters text in visit summary reminding patient.
In the exam room.physician (or ARNP or PA-C) Re-sets and confirms the agenda with patient Discusses any concerns, reviews ABCs with patient Establishes patient s treatment goal(s), adjusts medications if needed. Prints visit summary to give to patient.
In the EMR note Physician completes assessment and plan in note, including the quicktext 3mo or 6mo which automatically flags the diabetes recall desk (an LPN) and lists the needed labs for the next routine diabetes visit. Go back to (#1) the cycle begins again
The Oral Health Delivery Framework: Impact on Diabetes and Patient Care Diabetes Epidemic and Action Report Webinar June 17, 2015
Objectives Show why oral health is a priority for primary care s diabetes management Present a framework for integrating oral health in primary care Describe a new project to support the delivery of oral health preventive services in primary care settings 21
Four of the Ten Recommended Goals of the DEAR Ensure people with diabetes and gum disease have access to guideline-based oral health treatment. Ensure all appropriate populations have access to Chronic Disease Self-Management Education programs in Washington. Increase access to healthy foods and beverages where people work, learn, live, play, and worship. Increase stakeholder involvement in policymaking that pertains to diabetes. 22
Oral Health: Part of Diabetes Care Diabetes undermines oral health, poor oral health accelerates diabetes Interventions to preserve oral health are effective 23
Health impact Diabetes and periodontal disease are chronic conditions that commonly occur together and exacerbate each other. Untreated periodontal disease puts patients with diabetes at risk for complications 24
Periodontal Disease & Diabetes 25
Periodontal Treatment Reduces Medical Costs for People with Chronic Conditions Lower Annual Medical Costs Reduced Hospital Admissions $2,840 (40.2%) $1,090 (10.7%) $2,433 (73.7%) 21.2% 28.6% $5,681 (40.9%) 39.4% Diabetes Stroke Heart Disease Pregnancy Jeffcoat et al. Am J Prev Med 2014;47(2):166 174 26
Access: Why primary care? Regular, frequent contact with high-risk groups: Children Pregnant women Adults with diabetes Skills: Primary care providers are prevention experts Risk assessment, screening, triage Help patients navigate the healthcare system 27
Oral Health Screening in Primary Care Risk Assessment Identifying high risk patients Tobacco use Diabetes Case Finding Detecting signs of disease gums & teeth Treatment: Reduce risk Treatment: Referral & in-clinic therapy 28
Partnership for Prevention 29
Oral Health in Primary Care: PCMH Implementation Tools Project Sponsor: Consultant: Funders: 30
Goal: Equip primary care practices with the information and tools they need to deliver oral health preventive services and coordinate referrals. Guidance: Informed by a Technical Expert Panel that includes primary care and dental providers; medical and dental associations; payors and policymakers; patient and family advocates. Leveraging: Lessons from successful efforts to integrate behavioral health services in primary care. 31
Product Contributions 1.White paper published June 2015 and available now! 2.Implementation guide toolkit for primary care practices (2016) Sample workflows Referral agreements Risk assessment/screening question Patient education resources Clinical training resources Case studies Impact data 3. Recommendation to PCMH Recognition programs (2017) All resources will be free and publically available. Embedded into a well-used practice transformation resource library. 32
The Oral Health Delivery Framework 33
Oral Health Delivery Framework DRAFT 34
Oral Health Delivery Framework Ask: About oral health risk factors and symptoms of oral disease Pain, bleeding, burning, dry mouth Dietary patterns Adequacy of fluoride Oral hygiene Time since last dental visit Look: Signs that indicate oral health risk of oral disease Oral hygiene Dry mouth Obvious caries Inflammation Exposed roots Mucosa abnormalities DRAFT 35
Risk Assessment vs. Screening Risk Assessment Identifying patients at increased risk for oral disease: Maternal caries Sugar in diet Snacking habits Oral hygiene Inadequate fluoride Meds affecting saliva Screening Detecting early signs of disease: Plaque White chalk mark Obvious caries Discernible risk factors? Detectable signs of disease? 36
Oral Health Delivery Framework Act: Clinical intervention 1. Reduce risk: Oral hygiene training Dietary counseling Medication changes Fluoride Others 2. Referral for treatment Document and follow-up Close the loop Provide documentation to patient/family Structured data to support QI DRAFT 37
Field-Testing a Conceptual Framework 16+ diverse primary care practices Private practices (4) adults with diabetes & pregnant women Safety net sites (2) w co-located dental offices peds & all well visits FQHCs (8) peds & adults with diabetes Project design underway: Oregon Primary Care Association (4 FQHCs) 38
Data Snapshot, First 3 Months (n=298) Percentage of patients receiving oral health services during well visits: Of the 96 patients screened, 18 (13%) had findings suggestive of oral disease. Of those, 14 (78%) received a referral to dentistry 39
What have we learned from working with practices? Oral health is an engaging topic in Primary Care Leadership support is extra essential Requires internal/intrinsic motivation 40
If we re successful? A new standard of care Oral health preventive services delivered in primary care as a regular part of comprehensive preventive care 41
Q & A 42
Contact Lisa Packard at Qualis Health Everyone With Diabetes Counts Program: LisaP@qualishealth.org Diabetes Epidemic and Action (DEAR) Report: doh.wa.gov/dear For evaluation survey: https://www.surveymonkey.com/s/tjkvmn5 For more information: medicare.qualishealth.org/edc This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-EDC-QH-1816-06-15 43