Using EHR to Establish a Workflow Process for Referring Patients to Diabetes Self- Management/Chronic Disease Self-Management Programs Leonard Wonnenberg, PA-C May 18, 2016 Horizon Proprietary
= Data + Theory Horizon Proprietary
Provider/Clinic Goals Run DM data monthly A1C <7%, 7-9%, >9% No A1C in 6 months EHR has some limitations Shared Folder with data accessible to providers/nurses EHR database Horizon Proprietary
Type 1 vs Type 2 Change Type 1: Creating more work. Type 2: Creating a new process Aim at reducing work Want sustainable change Avoid Ruts Introduce Chronic Disease Self Management and Diabetes Self Management Horizon Proprietary
Type 1 vs Type 2 Change Type 1: Creating more work. Running monthly DM lists. Type 2: Creating a new process Placing recurrent patient alerts allows orders to be observed and followed through on routine basis Manual order is initially type 1 change Once placed, we eliminate steps in our Workflow to create type 2 change Horizon Proprietary
Provider vs. patient goals Establish trust with patients to reach goals Provider goals/expectations Minimize/Reduce risk Medication adherence, eye exams, dental exams, immunizations, foot care, kidney care, diet, exercise, weight loss, depression, glucose log etc. Patient goals/expectations Not always the same as provider Meds too expensive, I feel good, so I don t want to come in, I don t like needles, I don t like insulin. I have so many questions but forget when I get to my appt. Education is reciprocal Shared Decision Making Self Management skills and goals Horizon Proprietary
Community Goal Providers, patients, persons. Creating a healthier, safer and more educated community. Horizon Proprietary
Working with your patient Provider goal - minimize risk of problems associated with DM How? Treat blood sugars effectively EHR Measure A1C <9% Patient goal Feel better, treat diabetes, better understand DM How? Ensure patients are actively managing DM through surveillance of A1C, regular visits, patient education, self management. EHR Measure No A1C in 6 months Care Plan completed EHR Measure CDSME/DSME order Horizon Proprietary
Sample Patient Alert Horizon Proprietary
30 % Patients without A1C in 6 months PDSA 1 28.07 25 20 15 10 PDSA 1 March 14: Appt. cards PDSA 2 March 28: Staff working list PDSA 3 April 7: Admin sending letter PDSA 2 13.68 5 0 2016/02 2016/03
A1C >9% Goal 18% 60 55 50 45 40 40 30 26 29 33 31 28 2016/02 2016/03 20 10 0
100 % DM patients with A1C less than 9% 90 Goal 82% by end 2016 80 70 72 67 68 71 69 70.73 64 60 50 PDSA 1 March 14 PDSA 2 March 28 PDSA 3 April7 59 40 2015/08 2015/09 2015/10 2015/11 2015/12 2016/01 2016/02 2016/03
My Diabetes Care Plan Name: «PatientFullName» Clinic Name: «OfficeLocationName» DOB: «PatientDateOfBirth» Clinic Phone #: «OfficeLocationPhone» Provider : «EncounterProviderName» Date: «CurrentDate» Mark the days and times to check blood glucose Days: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Every day of the week Times: Before Breakfast After Breakfast Before Lunch After Lunch Before Dinner After Dinner PRN Goals: Pre-Meal 90-130 or 2 hours after meal 110-160 Bedtime 110-150 Use the results: Write them down on a log sheet or record book. Bring them to your next appointment. Look for patterns in numbers. The results help you and your provider make decision about your diabetes treatment plan. Labs and Exam Goal How Often My Results A1c Less than 7% or Every 3 months Blood Pressure Lipid Panel Less than 140/80 Twice a year «VitalsBloodPressure» LDL less than 100 or HDL >40 in men >50 women Triglycerides <150 Once a year, more frequently if treating to goal TSH Annually Microalbumin Normal Once a year Dilated Eye Exam Once a year Yes/No Foot Exam Once a year or _ Yes/No Dental Check Up Weight Flu Shot Pneumonia Shot Taking ACE-I Aspirin therapy Twice a year Short-term goal 2-4 times a year «VitalsWeight» Promotes good kidney health Cardiovascular Disease Prevention 65+ OR at diagnosis (if less than 65) Speak with Provider Yes/No Yes/No Yes/No Does Not tolerate/refuses Horizon Proprietary
Hepatitis B Depression Screening PHQ2/PHQ9 Annually 19-59 years My Self Management Plan My Action Plan: I will work hard to keep my A1c below 7 I will exercise (walk) 30 minutes days per week. If I notice chest pain, shortness of breath or chest tightness I will seek medical attention I will check my feet daily I will follow my diabetic and low fat diet to reduce my blood sugar and cholesterol I will try to attain a goal weight of pounds. I will lose pounds by my next office visit I will take an 81 mg. aspirin or enteric coated aspirin every day I will stop smoking I will have an eye exam every year or as indicated I will check my blood sugar as instructed and will call if the results are consistenly below 70 or above 180 I will talk about how I feel about having diabetes to my family and/or friends. I will attend a Diabetes Support Group. I choose goal(s): How likely are you to follow through with these activities prior to your next visit? Not Likely 1 2 3 4 5 6 7 8 9 10 Very Likely When to call the healthcare provider: 1. If your blood sugar falls below 70 and you don t know why or if you become unconscious. 2. If you are sick and unable to take liquids because of nausea or vomiting. 3. If you have a fever over 101 or pain that lasts. 4. If your blood sugar is 250 or higher with or without ketones 5. If you are just unsure of what to do Allergies: «Allergies» «MedcinCounselingEducation» My Medications «MedsCurrentWithSig» «MedsNewWithSig» Referral (s): «ReferringProviderFullName» «ReferringProviderAddress1» «ReferringProviderCityStateZip» «ReferringProviderPhone» «MedcinPlan» «Allergies» Future Appointments: Horizon Proprietary
Patient Tools Exit care education Information at fingertips My Horizon Chart Meds, allergies, diagnoses, labs, visits Communication with provider Direct messaging Self Management Program
Chronic Disease Self Management Program Lay Leaders Complete Training Community based Train others with DM, at risk for DM or simply want to learn more about DM Want Community Leaders 6 sessions that discuss wide variety of topics
Introducing Self Management at your clinic Team Consensus Want sustainable change Nominal Group Technique Provide initial education to staff Current practice data with organizational goals Justify reasons to implement Self Management Programs Identify Champions within clinic Share with other staff to reduce resistance Share on a monthly basis Start with willing worker Horizon Proprietary
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Creative Order Maximize potential of EHR Reduce Bottlenecks Flags, Patient Alerts CEM rule Allows team to work towards goal Trackable Horizon Proprietary
Self Management Program Order Horizon Proprietary
Successes Patient Centered Medical Home Building community relationships Diabetes Day, MyPlate example Clinical Staff/Hispanic Interpreter serving as DSME Lay Leaders Harnessing power of Willing Worker Celebrating success in clinic Using DSME to be more proactive! Horizon Proprietary
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Bottlenecks Mitigating bottlenecks/limiting type 1 change Create policy for standing orders and educate staff Working Monthly reports create bottlenecks Setting up patient alerts in charts allows nurses to work orders on a more regular basis Allows patients to have orders performed when being seen by other provider for acute reason Horizon Proprietary
Workflow Optimization 101 Kevin Atkins, CAHIMS Engagement Manager HealthPOINT
Reason We Are Here Provide an introduction to Workflow Optimization Present a real-life example Stimulate your workflow optimization thinking 26
Workflow Optimization Is it worth the time? Workflow Optimization Can Lead to a better understanding of how tasks interact and depend on each other. Create better communication amongst staff. Provide staff with a better understanding of how their tasks feed into the larger clinic workflow Provide a framework for the coordination of different processes. Help save time and money; create greater staff satisfaction; provide better/safer patient care. Side Benefits Provides tools for training new hires. Provides documentation for creating best practices. 27
Documenting Current Workflow When documenting current workflow be prepared for statements like the following: I never knew you did that We have always done it this way No special tools needed Whiteboard Pencil/Paper Sticky Notes 28
Workflow Optimization: The process 1) Identify the process to optimize 2) Coordinate schedules 3) Group/individual meetings 4) Observation 5) Draft of current state 6) Review/Update 7) Draft of future state 8) Review/Update 9) Implement 29
Documenting Current Workflow: Questions to ask What are the tasks or steps involved? What are the variations to these processes? Are there specific reasons for variation by this site? Who completes the process? Do several staff perform the same tasks? Is this cross-training or a duplication of efforts? Where are the bottlenecks; i.e. process is slowed down? Are there places where the process regularly stalls? Do some tasks need to be done more than once? Must the same data be entered at different points during the process? 30
Documenting Current Workflow: Using sticky notes (example) 31
Documenting Current Workflow: Creating a flowchart Turn this: Into This: 32
Putting all of this into action 33
Putting all of this into action 34
Putting all of this into action 35
Q & A Thank you for participating in today s webinar. Kevin Atkins, CAHIMS Engagement Manager, HealthPOINT Kevin.Atkins@dsu.edu 36