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Using Data to Drive Quality in Diabetes Care This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity.

Faculty Disclosure In compliance with ACCME Guidelines, I hereby declare: I do not have financial or other relationships with the manufacturer(s) of any commercial services(s) discussed in this educational activity. Name: Kristine Mc. Vea, MD, MPH Title: Chief Medical Officer Disclaimer The information provided at this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

AAFP Credit This activity has been reviewed and is acceptable for up to __1__ (Prescribed or Elective) credit by the American Academy of Family Physicians. The AAFP invites comments on any activity that has been approved for AAFP CME credit. Please forward your comments on the quality of this activity to cmecomment@aafp. org. At the conclusion of this activity, participants should be able to: Participants will learn how to link their strategic plan to data driven initiatives at the department and individual clinician and staff level. � Participants will understand how to make data meaningful and motivating to all members of their diabetes team. � Participants will learn how to analyze data on their diabetic patients to determine who to target for more intensive intervention given limited resources. �

Where I Practice �Free Clinic � 7 total staff �No resources 9 Sites Exponential Growth 58% Uninsured

Every Site is Unique and Challenging! If we can do it, you can do it!

The Golden Thread Alignment of Purpose from Strategic Vision through Execution at the Individual Level Strategic Plan Department Dashboards Individual Report Cards Employee Performance

Our Strategic Plan Identifying Clinical Quality as a Priority for the Organization

Prioritizing and Defining Quality At Department Level � Yearly Provider/Nursing/Support Staff Retreat § Review Data, Discuss in Small Groups – Everyone Participates! § Nominate Potential Focus Areas § Vote on SMALL, Do-Able Number � Subsequent Bi-Weekly Meetings § Determine Measures of Success, Goals § Define Action Plans § Review Progress Everyone Understands the Organizational Goal and Interprets What that Means for the Department

Clinician Dashboard

Dashboard Detail DEFINITION: Numerator: Number of patients in the denominator whose last systolic blood pressure measurement was less than 140 mm Hg and whose diastolic blood pressure was less than 90 mm Hg. Denominator: Patients between 18 85 who have been diagnosed as hypertensive prior to June 30 of the measurement year and have been seen twice during the reporting year. Action Plan: Clinical Pharmacy BP Checks Provider Rechecks BP if High

Clinician Report Cards

Sharing Clinical Performance Considerable Variation Among Providers Within Same Practice • Identify Best Practices Within Your Organization Accelerates Learning 1. 2. 3. 4. 5. 6. A 1 C Last 6 Months- Harry Diaz (96%), Kelly Houfek (88%), Hans Dethlefs (87%) Hypertension Controlled- Kelly Houfek (75%), Leah Jorgensen (74%), 2 Providers at 67% Michelle Christensen, Kris Mc. Vea LEAP- Kelly Houfek (80%), Stephanie Hall (77%), and Ledy Davidson (76%) LDL in Last Year- Kelly Houfek (93%), Eloise Poyner (86%), Vicki Bangert (83%) Microalbumin- Kelly Houfek (91%), Vicki Bangert (86%), and 2 Providers at 82% Don Allison and Stephanie Hall Optometry- 2 Providers at 74% Don Allison and Stephanie Hall, Hans Dethlefs (69%)

Sharing Clinical Performance Considerable Variation Among Providers Within Same Practice • Identify Best Practices Within Your Organization Accelerates Learning A 1 C Last 6 Months. Harry Diaz (96%), Kelly Houfek (88%), Hans Dethlefs (87%) Hypertension Controlled. Kelly Houfek (75%), Leah Jorgensen (74%), 2 Providers at 67% Michelle Christensen, Kris Mc. Vea LEAP- Kelly Houfek (80%), Stephanie Hall (77%), and Ledy Davidson (76%) LDL in Last Year- Kelly Houfek (93%), Eloise Poyner (86%), Vicki Bangert (83%) Microalbumin- Kelly Houfek (91%), Vicki Bangert (86%), and 2 Providers at 82% Don Allison and Stephanie Hall Optometry- 2 Providers at 74% Don Allison and Stephanie Hall, Hans Dethlefs (69%)

Examples of One. World Best Practices for Hb. A 1 c > 9 � Schedule monthly follow up visits until < 9 � Be Aggressive about med & insulin titration § Almost everyone at this level needs Insulin – Talk about it NOW § Titrate Insulin up by 10% � Do not rely on BS values to titrate Insulin � Self Titration of Long Acting Insulin (1 unit/day for am BS > 140) � “Just Try it for One Week” Approach to Insulin � Same Provider Every Time, but Take Care of Business if you Cross Cover! � Praise Patients Whenever Possible

Using Report Cards For Other Staff � Nursing � Health Staff – LEAP Exams Assistants – Retinal Photos � Diabetic Educators – Diabetic Huddles on Time All Staff Members Understand How Their Personal Performance Contributes to Organizational Goals

The Golden Thread Alignment of Purpose from Strategic Vision through Execution at the Individual Level Strategic Plan Department Dashboards Individual Report Cards Employee Performance

Using Data to Characterize Your Population

Using Population Data To Prioritize � 1750 Patients with Diabetes � 298 Patients with Hb. A 1 c ≥ 9% � 530 Patients on Insulin That’s a lot of patients! How should the Diabetic Educators and Case Manager spend their time?

Diabetic Educator Approach � Focused on Insulin Users only � Called monthly � Over 10 attempts to call some patients per month � Controlled Diabetics loved it, but no insulin changes made • Time wasted on unmotivated patients • Patients in control got most resources

� Patients Not Seen for > 120 days � Started with the letter “A” each month � Sometimes got thru “L” � Called from 8 -9: 00 am � Often pulled to answer phones � “Lost to follow up” patients appeared each month � Lists run only monthly – needed to consult EMR before calling A Case Manager Approach Oh Boy – Not effective on so many levels.

Using Data to Prioritize Resources � Diabetic Educators focus on “At Risk” patients § New Diagnosis § New start Insulin § Active Insulin titration § Out of Control or Hb. A 1 c > 8 � MOTIVATED PATIENTS ONLY § Instituted “Diabetic Huddles” with providers quarterly to determine intensity of contact

Case Manager � Monthly, Work then Daily Report – Real Time � Adequate time to Manage Population � Contacted by Phone (different times/days) followed by Post Cards � Protocol for Inactivating “Lost to Follow Up” patients � Developed “Supervision” Reports for Oversight of Population Management

Case Manager Empowered � Given “Carte Blanche” to offer appointments, financial assistance, medications, transportation – Whatever it Takes! � Case § § § Manager offered: Appointment with PCP Anytime – evening appointment not usually scheduled Free Visit Free Meds Transportation

Failed! � Patients still “NO SHOWED” their appointments If you are working harder than your patient, something is wrong

Characterizing our Population � Chart review of DM patients out of control: § 25% New Diagnosis or Working on Control § 25% Not Motivated § 50% Not Engaged, Not Reachable MOTIVATION, not Education, Resources were the Key!

Our Response � Training for Diabetic Educators, Providers, Case Managers in Motivational Interviewing � Resource: http: //www. chcf. org/publications/2006/08/video-with-techniques -for-effective-patient-selfmanagement

Characterizing Your Population “It seems like physicians are being more aggressive with insulin use in our practice compared to midlevels providers. “ Insulin Use % Hb. A 1 c < 9 Midlevels 25% 80% Physicians 45% 85% � Using insulin earlier made a difference! � Midlevels needed educational support to feel confident with Insulin

Diabetes Population Data � Better Prioritize Resources � Coordinate � Identify Care Staff Training Needs � Chart Reviews or EMR Reports Can Both Provide Valuable Information Looking Beyond the UDS Can Yield Valuable and Surprising Information

CME Credit Survey This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity. The following disciplines are qualified to receive credit for this webinar: MD, DO, NP, & PA. Nurses can receive a certificate of attendance. If you are seeking credit for this webinar training, please click the following link from your computer now: CLICK HERE for CME Credit Survey

Announcements Best Practice Story Contest - CLICK HERE This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity.