Improving Perfect Diabetes Care Performance Improvement Leadership Develop Program

1. Improving Perfect Diabetes CarePerformance Improvement Leadership Develop Program February 19, 2010

2. Members of the Team and our Advisors • Karl Kochendorfer, MD (Dir. of Clin. Inform.) • Phil Vinyard, MHA, MBA (Clinic Manager) • Donna Neal, RN (Nurse Manager) • Rhonda Polly, APRN (Chronic Care Nurse) • Jan Gace, LPN (Phone + Floor Nurse) Advisors: • Carl Hooker, MHA (Finance) • Tim Hogan, PhD (Dept. QI Officer)

3. Family Medicine • 8 Clinics in Columbia + Mid-Missouri • ~100,000 ambulatory clinic visits/year • Pilot with Green Meadows Green Team • 450 patients with diabetes • 7 Faculty members • 1 Fellow • 9 Residents • 1 Chronic Care Nurse • 9-11 Nurses • 7 Clerical

4. Chronic Disease and Diabetes Burden • Half of all Americans have at least one 1 • 70% of all deaths 2 • > 75% of health expenditures 1,3 • 1/5 of health dollars are spent on pts with diabetes 4 • Only 50% of recommended care is delivered 5 1) Wu. Projection of chronic illness prevalence and cost inflation. RAND Health; 2000. 2) Kung. Deaths: final data for 2005. National Vital Statistics Reports 2008. 3) Hoffman, C. Persons With Chronic Conditions - Their Prevalence and Costs. JAMA. 1996. 4) ADA. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care. March, 2008. 5) McGlynn. Quality of Health Care Delivered to Adults in the US. NEJM. 2003.

5. Broken healthcare system “Good Luck with the American Health-Care System” cards

6. Diabetes Summary

7. DM Quality Measures

8. Concept of Perfect Care Healthcare IT News. 9/2008

9. Min. improvement after 1 yr Clinics w/ Care Coordinators: • 2 FM Clinics b/w 10-15% • 2 FM Clinics b/w 5-10% Clinics w/o Care Coordinators: • 4 FM Clinics close to 0% • 2 IM Clinics close to 0%

10. Aim Statement The Family Medicine Green Team will increase the percentage of our diabetic patients with perfect care from 10% to no less than 50% by June 30, 2010.  This will be accomplished by using a multidisciplinary approach, process change, education and utilization of eight quality measures.

11. UMHC & FCM Mission & Focus • UMHC Mission: advance the health of all people, especially Missourians • UMHC Focus: Six Columns of Excellence   • Quality People Service Growth Community Finance • FCM Mission: enhance health and primary care for our communities • FCM Research Focus: preventing and caring for patients with chronic disease

12. Fishbone Diagram

13. Driver Diagram

14. Interventions Considered • Opportunistic Approach: • Every time a patient with diabetes comes for a clinic visit, review their quality measures and take action • Proactive Approach: • “Run the list” of diabetic patients and pro-actively contact them about missing items • Patient Engagement Approach: • Educate the patients about the types of services they should be receiving

15. Process Flow Chart

17. Outcomes to Date Decided to focus on diabetes quality indicators as a practice improvement project Completed workflow process and began piloting and training for our intervention

18. System-wide ROI • Eye exams (Mason): • $25,000/yr from GM Green Team patients • When all clinics get to 80% referral rate • $225,000/yr in new and return visits • $75,000/yr in facility fees •  GM Quality of Care: priceless • From < 10% to 20% in a few months • Target 50% by June 30th, 2010

19. Lessons Learned • Having data doesn’t mean improvement • Integrate the data into your workflow • Training needs • Learning how to use the reporting tools • Documentation, e.g. eye and foot exams • Team effort (e.g. buy-in, resources, meetings) • Physician led team • Automate, Automate, Automate

20. Future Steps • Present to FCM Faculty on March 24th • Celebrate target achievement on 7/1/10 • Publish an article in a national journal • Present at Practice Improvement conf. • Integrate PDSA • Continue Meeting (1x/mo) • Work on “Proactive” approach • Work on “Patient Engagement” approach • Expand to other FM + IM Clinics • Assist our docs with their Board cert.

21. Questions?