Dfd for Diabetic Management System

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Dfd for Diabetic Management System Powered By Docstoc
1.   A few of the slides you created for your previous storyboard might remain consistent,
     (i.e. Aim Statement, list of key measures, list of team members.) The exception would
     be if the directors provided comments/edits to any of these areas on your monthly
     report. You need to remain consistent and have the AIM statement, list of key
     measures, etc as they appear on your monthly report.
2.   You will have submitted two monthly reports by learning session two. You are either
     TESTING ideas under each component of the Chronic Care Model and/or have already
     IMPLEMENTED changes under the components of the Care Model. (remember, that
     means that the change would not go away in your organization if you ended participation
     in the Collaborative process today…!!) The tests of change and changes implemented is
     the new information you will be sharing at learning session two. Most of the information
     you‟ll need is already in your monthly report. Keep the description short and to the
     point but with enough description that the reader can get the major points from your
3.   Update your data and insert the graphs from your excel file on slides as demonstrated on
     slide #13 and 14. Make the graphs large enough so that they are easy to read…no more
     than 2 to a page, if possible. Therefore, you will need more than 2 slides to display your
     progress for all measures that you are tracking. DO NOT SUFFER IN SILENCE !
     Please post a ticket to the Help Desk on SharePoint as soon as possible if you need help
     accomplishing this step.        NE Cluster  Chronic Condition:Diabetes
Cluster: Northeast

      DFD Russell Medical
  Learning Session #2
  May 12-14, 2005
  Atlanta, Georgia
                     NE Cluster   Chronic Condition:Diabetes
 DFD Russell Medical Center

Leeds, Monmouth, and Turner Maine
10 medical, 2 mental health providers

Family practice, OB, mental health

Population Served

  –1% Hispanic
               NE Cluster   Chronic Condition:Diabetes
Team Members

Name                           Title                      Role on Team
Laurie Kane                    CEO                        Senior Leader
Diane Handler                  PA-C                       Provider Champion
Denise Fahey                   COO                        Team Leader
Melissa Gauthier               MA                        Registry Key User
Max Barus                      MD                         Clinical/tech Expert
Tia Knapp                      PAC                        Community Support
Kris Rubino                    Admin.                     MIS Contact
Sharon Hathaway                RD                         ADEF dietary instructor

   Team Leader Contact Email:                  Telephone:
   Denise.fahey@dfdrussell.org                       207-524-3501

                       NE Cluster    Chronic Condition:Diabetes
AIM Statement


 75% of DFD Monmouth‟s diabetic
 patients will have documented self
 management goals. Additionally, 70%
 will have their last BP < 130/80

            NE Cluster   Chronic Condition:Diabetes
Selected Measures
Average HbA1c of 7.0% for DM Patients
90% Dm Patients with Two (or More) HbA1c in Last 12 Months
   (>90 days apart)
70% Dm Patients with SM Goal Setting in Last 12 Months
40% DM Patients with BP <130/80
70% DM Patients with LDL <100
Cardiac Risk Reduction Option 1: 60% Patients on ACE inhibitors
   or ARBs age 55 or older
Cardiac Risk Reduction Option 2: 70% Patients on statins age 40
   or older

50% DM Patients will have a Depression Screening in Last 12

                    NE Cluster   Chronic Condition:Diabetes
Currently Testing:
   SMG follow-up by MA with patient after provider visit
   Self management goal handout at the time of check-in
   Assistance provided to low literacy patients
   SMG goal F/U at every visit
Implemented into our Delivery System:
   Utilizing newly developed self management goal tool
   MA discussion of SMG with patient pre-provider visit
   Utilizing DFD MA staff as lay “Move More” educator

                        NE Cluster   Chronic Condition:Diabetes
Currently Testing:
   Legislation to increase ADEF reimbursement
   Referral to PAC for community assist linkages
   Community awareness projects
   “Move More Diabetes” community kick off

Implemented into our Delivery System
   Community resource handout to assist patients with SMG

                        NE Cluster   Chronic Condition:Diabetes
       Healthcare Organization
Currently Testing:
   Spread of Collaborative process to other
    Monmouth providers
   Spread of Collaborative process to other
    Monmouth support staff
Implemented into our Delivery System:
   Quality Assurance Plan includes Care Model
   Collaborative team report submitted at monthly
    BOD, support staff and provider meetings
   HDC patient awareness project
   Inclusion of quality measures in provider
    incentive program
                     NE Cluster   Chronic Condition:Diabetes
    Decision Support
Currently testing:
   Utilization of revised diabetes protocol
   Development of diabetes standing orders for protocol
    driven labs and referrals
   Posted standing orders on computers in all Monmouth
    exam rooms
   Glucometer support program
Implemented into Delivery System:
   ADEF program
   Referral to PAC for financial assistance to meet DM
    patients‟ health care needs

                        NE Cluster   Chronic Condition:Diabetes
    Clinical Information
Currently Testing:
   Use of Crystal reports for monthly reporting
Implemented into Delivery System:
   Diabetes tracking system for patient recall
   Addition of self management goals to the diabetes registry
   Separation of data flow from billing system to EMR for
    accurate PCP and location of care
   Use the registry to track, report and communicate results
    and outcomes of care effectiveness over time and across
    providers and populations

                         NE Cluster   Chronic Condition:Diabetes
      Delivery System Design
Currently Testing:
   Care Model implementation support
   Creation of EMR DM recall letter
Implemented into Delivery System:
   Care Model Implementation (Depression)

                  NE Cluster   Chronic Condition:Diabetes
          Functional and Clinical

Measures                                       Goal                      as of
   Registry size                                                       115
   2 HbA1cs in last yr                        90%                      88.7%
   Average HbA1c                              <7.0                     6.8%
   Documented SMG                             75%                      23.5%
   BP < 135/80                                70%                      45.2%
   LDL < 100                                  70%                      58.4%
   ACE/ARB inhibitor patients ≥ 55            60%                      80.5%
   Statins patients ≥ 40                      70%                      52.8%
   Depression Screening     NE Cluster        50%
                                          Chronic Condition:Diabetes    31.3%
NE Cluster   Chronic Condition:Diabetes
National Key Measures

       NE Cluster   Chronic Condition:Diabetes
NE Cluster   Chronic Condition:Diabetes
NE Cluster   Chronic Condition:Diabetes
NE Cluster   Chronic Condition:Diabetes
NE Cluster   Chronic Condition:Diabetes
NE Cluster   Chronic Condition:Diabetes
NE Cluster   Chronic Condition:Diabetes
NE Cluster   Chronic Condition:Diabetes
    Senior Leadership
    Making the Case for Change

   Our CEO is an integral member of our
    Diabetes Collaborative Team and attends all
    HDC meetings. Our BOD, providers and staff
    are updated monthly with data generated
    from the weekly Collaborative meetings and
    monthly reports.
   DFD‟s HDC awareness project has included
    the display of our DM storyboard in the
    patient waiting room, direct mailings
    promoting ADEF classes and presentations
    delivered by the CEO.
                NE Cluster   Chronic Condition:Diabetes
Communication Plan (How are
you communicating your progress at the center level and within
your community)

   At the center level:
    * Waiting room Storyboard display
    * Board of Directors meetings
    * Provider meetings
    * Management meetings
    * Staff meetings
    * Staff trainings

   At the Community level:
    * ‘Move More’ partnership
    * ADEF legislation
    * Wellness mailings promoting ADEF classes
    * Marketing plan promoting ‘Care regardless of ability to pay’
                      NE Cluster   Chronic Condition:Diabetes
       Anticipating Barriers and
    Those that the team                         Those that leadership
       can resolve:                               needs to address:
•   Adopting best practices with            •   Future funding for Care Model
    providers                                   integration

•   Integrating changes to work flow        •   Supporting best practices

•   Coordinating community resources        •   Legislative changes

•   Accuracy in reporting                   •   Decreasing barriers to care

                               NE Cluster   Chronic Condition:Diabetes
 A story to share….the
Since joining the Collaborative we have introduced
the Self Management Goal as a component of
Diabetes care. We have encountered a variety of
responses from patients in introducing the new
concept to their care. One patient who was recently
diagnosed was initially very discouraged and felt
helpless. She was enrolled in our new ADEF classes
and began seeing the benefits of Self Management
Goals. She decided to utilize „Move More‟ , a
Diabetes exercise support program, to improve her
exercise plan. She was so inspired by the benefits
that she experienced that she is now becoming
trained as a lay „Move More‟ educator.
                  NE Cluster   Chronic Condition:Diabetes
 A story to share….our staff
Initially, some staff were less than enthusiastic for
yet another project. As we began to spread the
testing of PDSA cycles to additional providers and
support staff at our Monmouth site our efforts in
keeping staff informed during the pre-work and
early stages of the Collaborative paid off. At our
very next Collaborative meeting the MA on the
team came with many questions and ideas
generated from staff over the week. A far from
apathetic group!
                    NE Cluster   Chronic Condition:Diabetes
A story to share….the
Over the past few years we have made an effort to keep
staff informed of our involvement as an organization in the
Collaborative process. Initially, we used broad terms to
educate staff including: Care Model, reducing disparities, self
management goals, outcome measures and PDSA cycle. In
joining the HDC we are now providing monthly reports to
clinicians on outcome measures that are both organization
and provider specific. We are beginning to see staff become
familiar with the process and the Collaborative philosophy of
reducing disparities. Providers now seek monthly outcome
measures of their patient panel and have those measures
tied to their incentive program. In addition, MAs are
interested in finding solutions to improvement
documentation of patients‟ yearly eye exam.
                       NE Cluster   Chronic Condition:Diabetes

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