Program Introductions

1. Program Introductions

2. Today • Working together to address health system challenges • AstraZeneca Canada Healthcare Solutions “Pathways Programs” Overview • Discussion • Next Steps

3. Chronic disease management for diabetes and vascular disease could result in the avoidance annually of 8000 heart attacks, 4000 strokes, 8000 unnecessary deaths, 1200 cardiac bypass and balloon angioplasties and 369 amputations — Ontario Health Quality Council Report of May 2008 Few mechanisms exist to implement practical solutions

4. AZC Healthcare Solutions “Pathways” Programs • Developed by expert faculty in consultation with teams, disease experts and guidelines implementation leads • Focus on practical approaches to care delivery “The How” • Diabetes Practice Management Program • Group Patient Visits Program • Diabetes Days

6. PROGRAM FACULTY Stewart B. Harris, MD, MPH, FCFP, FACPM Canadian Diabetes Association -Chair in Diabetes Management Ian McWhinney Chair of Family Medicine Studies Professor-Schulich School of Medicine & Dentistry, The University of Western Ontario London, ON Brian Craig, MD, CCFPLecturer, Dalhousie UniversityChief, Department of Family Medicine, Atlantic Health Services, St. John, New Brunswick Rick Ward, MD, CCFP Calgary Foothills Primary Care Network Calgary, AB Patsy Smith, MN, RN PLS Consulting Inc. Halifax, NS Lorraine Tessier, MD, MCFP Hôpital Du Sacre-Coeur De Montreal Montreal,QC Kenneth Bayly, MD, MCFPPhysician/General Practice, Saskatoon District Health Saskatoon, SK CONTRIBUTORS Maureen Clement,  MD, CCFP Medical Director, Diabetes Education Centre Vernon Jubilee Hospital Assistant Clinical Professor, University of British Columbia Alice Y.Y. Cheng, MD, FRCPC Endocrinologist Credit Valley Hospital and St. Michael's Hospital Assistant Professor, Dept of Medicine University of Toronto Durhane Wong-Reiger  BA, MA, PhD Institute for Optimizing Health Outcomes, Canada Steve Szarka, B. Eng, M. Eng, MD, CCFP Assistant Clinical Professor, McMaster University, Faculty of Family Medicine Hamilton Family Health Team John McDonald, MD Lead Physician - PrimaCare Family Health Team President and Chair – Association of Family Health Teams of Ontario Jann Paquette-Warren, MSc Research Associate - Centre for Studies in Family Medicine Schulich School of Medicine & Dentistry The University of Western Ontario

7. Diabetes Care in Family Practice Teams require practical, implementable approaches to care delivery 1. Canadian Diabetes Association. http://www.diabetes.ca/diabetes-and-you/what/prevalence 2. Harris SB, et al. Diabetes Res Clin Pract 2005; 70:90-7. The Challenge: Diabetes a complicated, growing disease: • Incidence and prevalence of diabetes in Canada continue to increase1 • Control is not improving: 50% of Type 2 Diabetes patients in Canada are not meeting their blood glucose targets 2 Implications and burden for primary care practice: • Over 80% of type 2 diabetes patients will be under the care of their Family Physician with an average of 8 visits per year2 What is the solution? Governments & CDA promoting interdisciplinary team approach & enablers • MD, RN, NP, Diabetes Educators, Pharmacists, Family Health Teams and Primary Care Networks • Flow-sheets, registries, incentives etc…. • Informed & empowered patients

8. Therapeutic Goals Metabolic Targets: • Goal of treatment is to minimize the risks of the macrovascular and microvascular complications of diabetes by aiming for the following metabolic targets: Process Targets: • Quality Targets for Primary Care Physicians: Example:2 The Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada., Can J Diabetes. 2008;32(suppl 1):S1-S201 Ontario Ministry of Health- Quality Targets for Primary Care Physicians: http://health.gov.on.ca/en/ms/diabetes/en/about_diabetes_care_rep.html

9. Systematic Approach to Diabetes CareCDAGuidelines Recommendations Teams require practical, implementable approaches to care delivery CDA 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Can J Diabetes. 2008;32(suppl 1):S1-S201

10. Team Efficiency High performing teams Common challenges Time Pressure to provide both acute and preventative care Volume pressure After hour access Long wait times Focus on task substitution vs. teamwork Underutilization of inter-professional health team • Delegate key tasks to non-physicians • Coordinated patient flow strategies • Group visits: shared medical appointments • Disease-specific targeted “Mini” Clinics • Integration of specialist care http://www.eicp.ca/en/resources/pdfs/enhancing-interdisciplinary-collaboration-in-primary-health-care-in-canada.pdf McMurchy D. CIHR, 2009; retrieved from: www.chsrf.ca Kirsh S, et al. Qual Saf Health Care 2007;16:349-353.

11. Pathways to Diabetes PracticeManagement • Program Objective: • Optimize practice efficiency • Promote team effectiveness • Increase patient access to treatment • Improve Patient Health outcomes Based on individual need, goals, using existing resources CDA 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, Can J Diabetes. 2008;32(suppl 1):S1-S201

12. FACILITATED APPROACH Prior to CHE Continuing Health Education Program (CHE) Post CHE

13. CHE Supported by Practical Strategies, Tools & Materials DM Practice Guide Program Forms, Materials, Web-key Practice Management Reference Manual • Medical Management • CDA Organizations of Care • Practice Management Strategies • Patient Registry and management • EMR, scheduling and planning tools • Regional Diabetes Tools • Forms , Flow Sheets etc DM Patient Education Toolkit Canadian Nurses Association DM Toolkit

14. Pathways Program Implementation 1 2 3 2 Follow-up Team Continuing Health Education Program Clinic Needs Assessment Webex with Facilitator 30 -60 mins 1 day 1 day Prior Who Participates? Members of the clinic team who manage patients with diabetes. Minimum 1 Physician ‘ champion” + 1 Nurse/AHCP champion What is the Cost? There is no cost to participate

15. Measuring EffectivenessClinic DM Dashboard Form

16. Pathways ScorecardNarrative Report Form Key Changes Describe changes made in the way you care for patients with diabetes PDSAs List two or three critical PDSAs that helped you achieve the changes above) Impact on Outcomes Describe how you believe these changes impacted outcomes you are monitoring What next? Describe what you will be doing regarding future improvements.

17. Program Implementation – Detailed Overview Nationally CFPC Accredited up to 8 M1 Credits

18. Improving Diabetes Mellitus Patient Care Delivery & Outcomes M1 Nationally Accredited CHE “Diabetes Days” A Practice Efficiency Strategy Nationally CFPC Accredited 1 M1 Credit

19. Diabetes Days

20. Program Outcomes: Summary Primary Objectives: Following the Pathways DM program, participants will be able to: • Develop and implement a clinic diabetes action plan • Treat DM patients as a team • Establish outcomes to assess results • Utilize strategies and tools that will optimize type 2 diabetes patient management in their clinic Secondary Objectives: Following this program, participants will be able to: • Maximize team based care using available resources • Increase trust within team • Apply new models and options for managing type 2 diabetes

22. Faculty Developed by: Rob Wedel, MD, CCFP, FCFP Family Physician, Associate Medical Centre, Taber, AB Palliative Care Physician, South Zone, Alberta Health Services Co-Chair, Alberta AIM Chair, Advisory Committee on Primary Care, College of Family Physicians of Canada Board of Directors, Quality Improvement and Innovation Partnership, Ontario  Mel Cescon, MD, MCFP, Family Physician, Kitchener, ON  Board Quality Improvement and Innovation Partnership, Ontario Lorraine Tessier, MD, MCFP Hôpital Du Sacre-Coeur De Montreal Montreal, QC Faculty: Kenneth Bayly, MD, CCFP Physician General Practice Saskatoon District Health Saskatoon, SK Brian Craig, MD, MCFP, Family Physician, St. John, NB Contributor: Maureen Clement, MD, CCFPC, Medical Director, Diabetes Education Centre, Vernon Jubilee Hospital, Vernon, BC This program was supported in part by an Educational Grant from AstraZeneca Canada.

23. What are Group Patient Visits? • An effective means to deliver integrated healthcare • An expanded medical appointment delivering most elements of an individual visit including: • Personal examinations (e.g., collection of vital signs, history taking, physical exam) • Formal and informal education • Social and psychological support Patient Self-mgmt

24. Why Conduct Group Patient Visits? Increased practice efficiency and effectiveness • capacity to care for more chronically ill patients in less time •  efficiency as a result of staff working in appropriate roles and assuming appropriate responsibilities •  job satisfaction among staff •  delivery of quality patient care

25. Implementing Group Patient Visits Step 1: Planning Group Patient Visits (PLAN) • Select Group Patient Visit model • Create Plan of Action Step 2: Conducting Group Patient Visits (DO) • Identify specific patients (Case studies: Diabetes and COPD) • Organize resources Step 3: Measurement and Evaluation (STUDY) • Evaluate results Step 4: Refine and Repeat (ACT)

26. Group Patient VisitsProgram Implementation 1 2 3 Implementation and Follow-up Clinic Assessment Team ContinuingHealth Education Program 2.5 hr interactive CHE Nationally CFPC Accredited 2.5 M1 Credits

27. DISCUSSION