SC PA Best Practice Sharing Practice 1 PDSAs

SC PA Best Practice Sharing

Practice 1 PDSA’s Included: Ø Identifying DM patients prior to and/or at time of visits Ø Identify who needs Urine Micro Albumin and Eye Exams Prior to visits ØShoes/Socks off at visit, Monofilaments completed if due How did these Impact the Staff/Work Flow: Ø Secretaries assisted in placing “Prep Sheets” with Encounters when registering Ø All MA’s trained in Monofilament exams Ø Referral MA ran reports and placed calls to diabetics to get eye exam info.

Diabetic Patients PA Spread REMINDERS • HPI entered “Pt. is a Diabetic” • Have patient take shoes and socks off at every routine visit!!! • Monofilament Foot exam completed within the last year? ? ? If no, PERFORM exam today!!! • Urine Microalbumin done within the last year? ? ? If no, COLLECT urine sample and send!!! • Retinal Eye Exam done within the last year? ? ? If no, enter REFERRAL for diabetic eye exam!!!!

Practice 1 Moving Forward… v Pre-Visit Chart Preps v Daily Huddles (Providers, MA, etc…The whole team!) v RN Care Coordination for patients who need “extra care” v “High Risk” Meetings for Complex Patient Care Plans v Expanding the PCMH Module to other Diagnoses and eventually “All Patients”

Practice 2 MAJOR CHANGE Implementation of EMR • All charts are now electronic with PMR scanned and saved to appropriate folders. All labs, orders, medications, letters and communication notes are in the EMR. OUTCOME • Improved continuity of care with greater access for all providers • Easier tracking and searching for test/results • Ability to set Protocol Template allowing quick look for gaps in care

Practice 2 MAJOR CHANGE Pre Visit Chart Preparation • Health Coach uses EMR to Plan upcoming patient visit. Focus on Diabetic patients. • Uses a Needs List Worksheet & completes with Gaps in Care identified. • Worksheet is given to MA for review with patient at visit & standing orders to be completed. Physician to be made aware of other orders needed to complete Gaps in Care. OUTCOMES • Microalbumin testing increased by 9% • A 1 C Trending down • More staff engaging w/pt visit

Practice 2 MAJOR CHANGE PCMH Health Coach • Pt is referred to Health Coach at time of visit or referral made for teaching which could include diet, exercise and/or insulin titration to target based on standing orders. • Continued point of contact for pt. & f/u calls made by PCMH Team. • Recognize when further needs or Recourses are needed & assist w/referral. OUTCOMES • 70 y/o w/history of DM, HTN, OBESITY and Hyperlipidemia Meet w/health coach, titrated insulin via phone calls & standing orders Date: A 1 C LDL TRIGLYCERIDES WEIGHT 7/10/12 8. 5 127 276 307 LBS 3/01/13 6. 5 63 132 291 LBS

Practice 2 MOVING FORWARD: • Begin work on Self-management goals. Patient will be given handout that list several types of goals (healthy diet, exercise etc. ) and asked to pick one realistic goal for them. • High Risk Management: RN Care Coordinator will contact patient to assist with any transitions of care. • Regular communication with physicians regarding care of High Risk to include regular meetings for management strategies.

Practice 3 Major Change • Pre-visit Planning – Huddle • Developed a Standard Protocol • EMR Monthly Reports • • Hgb. A 1 c > 9. 0 LDL > 100 • Medication Adherence Hgba 1 c > 11. 0 • In House Lab Testing

H AR C M Y AR U BR FE * Y* U AR N JA R 80% EC EM BE 90% D R BE M R BE C TO VE O N O R ST U BE EM PT SE AU G JU LY E N JU M AY IL R AP Hb. A 1 c <8% 100% HEDIS GOAL 74. 7% 70% 60% 50% 40% 30% 20% 10% 0%

H AR C M Y AR U BR FE * R Y* AR N U JA BE EM R 90% D EC BE M R BE C TO VE O N O R ST U BE EM PT SE AU G JU LY E N JU M AY IL R AP Blood Pressure < 140/90 100% HEDIS GOAL 76. 70% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Best Practice Changes Practice 4 • Formed a Quality Management Team with a Quality Management Supervisor. – One of the responsibilities is coordinating and performing Pre-Visit Preparations • Consists of a check list of orders, reminders, immunizations, results, etc. required to be in the chart based on age, gender and chronic conditions. • Pre-Visit Preparations are conducted 24 -48 hours prior to all previously scheduled appointments

Best Practice Changes Practice 5 • Care Guide implementation for chronic conditions – Tool allowing provider to document care plan, goals, self-management abilities, educational material, etc. • Diabetes, Asthma, Smoking • Patient Recall Registry – Report generated from EHR data indicating patients in need of tests, procedures, immunizations, etc. – Outreach is performed to ensure patient receives appropriate care.

Best Practice Changes Practice 6 • Created a Patient Navigator Position – Helps complete Pre-Visit Preparation – Reviews Quality Measures • Care Guide implementation for chronic conditions • Implemented Auto-Fax – Inbound faxing ability – Eliminates the need to scan paper faxes

Best Practice Changes Practice 7 • Care Guide implementation for chronic conditions • Transition of Care (TOC) follow-up – Made/making arrangements with hospital systems to notify site(s) of patient discharge – Implemented TOC Nurse and Office Visit Note • Provides structured documentation for nurse phone outreach after discharge and provider office visit follow -up

Best Practice Changes Practice 8 • Patient Registry – Identified patients with elevated A 1 C and over due for DM office visit • Used this information to outreach to patients via 3 phone calls • If no response sent series of 2 letters – Statistics – 32 patients were sent letters, 15 patients scheduled due to receiving the letter(s) » 47% success rate • Care Guide implementation for chronic conditions

Best Practice Changes Practice 9 • Pre-Visit Preparation – Enters reoccurring Reminders for routine and preventative testing • Learning how to address the Reminders and over due Orders at time of visit • Nurses perform DM Foot Exams – Nurse practitioner worked with nursing staff to teach proper foot exam technique – Nurse enters result into EHR • Ensures proper documentation within EHR for reporting purposes

Best Practice Changes PAL-Eastbrook Family Health Center • Implemented the use of Standing Orders – Protocol for Strep screening – Protocol for A 1 C blood draw – Protocol for Lipid screening • Care Guide implementation for chronic conditions • Pre-visit Preparations

Best Practice Changes Practice 10 • Pre-Visit Preparations by the Quality Management Team – Enters Reminders and Orders to make the most of each visit • Quality Team meetings to discuss what is working for each individual site • Transition of Care follow-up

Best Practice Changes Practice 11 • Patient Registry – Outreach to identified patients has evolved into case management • Coordinated diabetic learning sessions at Millersville University • Involvement with PA SPREAD has prepared the site(s) for PCMH