EXCELth, Inc. Primary Care

Algiers CHC

Diabetes ChallengeLPCA Pre-ConferenceHCCN TA/Training Day

10/15/14

CHANGE TEAMDr. Monir Shalaby, MDDr. Wylea Winfrey, FNP

Emelda Price, LPNMarjorie Brooks, LPN, QI Field Nurse

Aurelia Celestine, MSN, RN, QI Coordinator

DATA SEGMENT (POPULATION OF FOCUS)

Patients with HgA1c >8% & Patients who have not been screened (HgA1c) in the last 12 months

Measures

3/1/13 – 2/28/14

Outcome

DM (Type I/II) 633

Receive A1c testing 64.14%

Patients with no A1c

test

11.53%

Plan/Approach

•Identify from a registry, of patients with diabetes, those with HgA1c >8%.

•Identify from a registry, of patients with diabetes, those who have not been screened in the last 12 months.

•Contact these patients in follow up and confirm follow up appointments withthem in order to teach appropriate health care and further address any interventions that have already been implemented or needed. Emphasize (through more intense education) proper diet, exercise, self-monitoring, and taking medications as appropriate .

•Improve documentation and consistently document in the same place within the EMR for more accurate data capture.

•Develop relevant protocols, as needed.

Challenges/Barriers

•Not documenting consistently in the same fields

•Need for consistently reinforcing patient education

•Inconsistent follow up regarding progress in goal achievement, lab values,referrals

•Inconsistent pre-visit planning process

Clinical decision support and guidance design

• Develop a practical system of identifying patients who need HgA1c testing during their visit

• Develop a system of reminding patients of HgA1c test needed prior to next visit

• Establish HgA1c test monitoring and follow-up protocol & tracking system

• Patient care planning discussions via huddles

• Establish standardized documentation of progress of patient self-management goal(s) achievement

Engage the Care Team

• In-service clinical staff regarding utilizing a system of identifying patients who need HgA1c testing during their visit, the importance ofpatient reminders, tracking/monitoring and follow-up

• Encourage ideas and strategies from staff

• Identify a project Champion Provider

Engage patients and their families

• Continue to empower the patient by providing ongoing patient and family education

• Include patient/family self-management goal setting

• Continue to provide care summaries to patients upon visit completion

• Recognize any patient goal setting achievements

Manage Care• Develop and provide care plans; utilize plan of care templates

Devise policies/procedures/protocols as needed• Review and revise lab testing policies/procedures as needed• Establish HgA1c test monitoring and follow-up protocol

Monitor, gather and analyze data, report, train and re-train • Report findings to appropriate staff• Implement corrective actions• Corrective actions follow-up

A PDSA was conducted with a small sample of diabetic patients at the Algiers CHC who were patients of 2 providers.

The patients already had appointments scheduled and were due to have a HgA1c screening within the next 6 weeks.

The Clinical Care Team Nurse used the registry to identify the patients.•Each patient’s EMR was reviewed to verify the date of the most recent HgA1c and

the result. •In validating the registry report regarding patients with diabetes who had no

HgA1c, it was discovered that All Patients at the Algiers CHC had their HgA1c done in the past year.

•The patients were contacted via telephone by the nurse prior to their appointmentdate and were informed that they would be reviewing instructions/information related to diabetes and goal setting. Patients were also reminded of any needed lab/HgA1c tests.

•Patients were to also be referred to the local Walgreens Pharmacy Diabetes Program for further education, as needed.

•Patient referral needs (ophthalmology, podiatry, RD, etc.) were flagged in the EMR in order to alert their PCP

•During their appointments, diabetes self-management was reinforced through education by the PCP and again by the nursing staff. Patients were provided a Diabetes Self-Management Goals form (DSMG) and indicated their self-management goals, demonstrated use of test equipment and logs. They weregiven the form as a reminder tool of indicated goal(s), referrals, appointments. Although the nursing staff assisted with referral appointments,patients were directed to make their dental appointments themselves. The PCP has no access to the Dentrix EMR used by the dental clinic.

•Patients, along with their referral appointment dates and HgA1c results were placed on a tracking log. The tracking log was visited at least every 2 weeks.

•By the end of month 3 of the Diabetes Challenge, 8 of the 10 patients had their HgA1c that was due. Five of the 8 had HgA1c <8. All, but one, remain on waiting lists to see specialists.

Results

0

2

4

6

8

10

12

14

16

Pt1 Pt2 Pt3 Pt4 Pt5 Pt6 Pt7 Pt8

HgA1c 1

HgA1c 2

The study will continue. The next cycle will include further monitoring of HgA1c results and the referral follow-up process.