Diabetes Collaborative

1
Bay Clinic, Inc. Health Disparities Collaborative
2
Pacific West Cluster
Bay Clinic, Inc.
Learning Session 2May 12-14, 2005Atlanta,
Georgia
3

Our Mission

• Bay Clinic, Inc. is community-directed and
  committed to improving the health and well-being
  of all people.
• OUR MISSION WILL BE ACCOMPLISHED BY
• Providing high-quality accessible healthcare in a
  patient-centered environment, regardless of an
  individuals ability to pay.
• Working with the community in preventive
  healthcare and education.
• Ensuring our services are sensitive to the
  cultural diversity of our community.
• Taking a holistic approach to the treatment of
  our patients.
• Advocating for improved healthcare and living
  conditions wherever the need is
  evident.
• Cooperating and collaborating, whenever possible,
  with other medical providers and organizations to
  improve the delivery of healthcare in our
  community.
• Forming a partnership with our patients in
  planning a healthy future for themselves and
  their families.

4

Bay Clinic, Inc.

• 8 SERVICE SITES, 4 PRIMARY CARE, 4 SUPPORT
  SERVICES WITH A TOTAL STAFF OF 104, COVERING
  2,048 SQUARE MILES FROM LAUPAHOEHOE TO HOOKENA
• HILO BAY CLINIC
• PAHOA FAMILY HEALTH CENTER
• KEAAU FAMILY HEALTH CENTER
• KAU FAMILY HEALTH CENTER
• KEAAU WIKI WIKI BUILDING WIC, KEAAU YOUTH
• BUSINESS CENTER, FUTURE BAY PHARMACY
• PAHALA WIC SERVICE SITE
• NAALEHU WIC SERVICE SITE
• OCEANVIEW WIC SERIVICE SITE

5

• Population Served
• 17,000 UNDUPLICATED PATIENTS
• 38,000 VISITS IN 2004
• 30 OF PATIENTS ARE UNINSURED
• 60 OF PATIENTS ARE AT OR BELOW FEDERAL POVERTY
  LEVEL
• 320 PATIENTS DIAGNOSED WITH DM1 OR DM2

6

Team Members

• Lorraine Sonoda-Fogel, MD
• Charlotte Grimm, APRN
• Eileen Lovell, RN, MSN
• Maile Estabillio, LPN
• Dinny Branco, CMA
• Kimberlin Barnes, MIS

Team Leader Key Contact Info Charlotte Grimm
Phone [phone] Email
cgrimm_at_bayclinic.org
7

AIM Statement

• The Bay Clinic, Inc.s practice will be
  redesigned so that 70 of patients with diabetes
  are involved in self-management activities and
  90 of patients will have an HbA1C below 9.0.
• This will be achieved by implementing all
  components of the care model

8

Selected Measures

• Average HbA1c for DM Patients
• Dm Patients with Two (or More) HbA1c in Last 12
  Months (gt90 days apart)
• Dm Patients with SM Goal Setting in Last 12
  Months
• Cardiac Risk Reduction Option 1 Patients on
  statins (gt40 yrs)
• Cardiac Risk Reduction Option 2 Patients on ACE
  inhibitors or ARBs (gt55 yrs)
• Patients with BPlt130/80
• Patients with LDLlt100
• Influenza Vaccination
• Foot Measures

9
Self-Management

• The Change Develop/find and test a culturally
  appropriate SMG form for diabetic patient use.
  Several forms have been reviewed.
• Test Collaborative member nurses/providers are
  testing sample SMG forms to see which one is best
  received by patients.
• Prediction Testing continues to determine the
  most effective SMG format and adjust format to
  our diabetic population. The number of documented
  SMGs will be higher than baseline data for Hilo
  Bay Clinic diabetic registry patients.
• Data Collection patients will be asked to rate
  the SMG tool on a scale of 1-5 for effectiveness
  and what suggestions they may have for
  improvement .
• Results A collaborative nurse reviewed 3
  different self management tools. No preference
  determined testing continues.

10
Community

• The Change Continued outreach into the community
  to identify and educate diabetic patients.
• Test Data Collection 28 RBS done through the
  Bridges program
• Prediction Outreach activities into the
  community will identify new diabetics and
  diagnosed diabetics needing diabetic education
  and closer management of their diabetes.
• Results 10 elevated BS
  
• Community Involvement and Partnerships with
• Hui Malama Na Oiwi
• University of Hawaii at Hilo
• Keaukaha Community Center
• Keaukaha Elementary School
• Panaewa Community Center

11
Decision Support

• The Change Revise diabetic flow sheet which is
  currently used in paper charts and template to be
  used in EMR. At the most recent providers meeting
  it was decided a combination DM/HTN flow sheet
  was preferred
• The test Use of revised flow sheet in chart of
  3-5 patients diabetic collaborative member
  providers, review then expand to all DM registry
  patients of DM Collaborative providers
• Prediction The use of a revised diabetic flow
  sheet will increase provider awareness of
  standard of care and increase the of patients
  meeting key requirement.
• The Change Develop a process for in house
  testing of HgbA1c.
• The test testing procedures and protocols
  developed for the use of the machine on 3-5 DM
  patients, then on all DM patients due for
  glycohemoglobin x 1 week, if successful then
  implement.. Who/where Hilo bay Clinic DM
  registry patients. Nurses to test A1C in DM
  patients quarterly during screening process.
• The prediction The use of in house HgbA1c will
  increase the number of diabetic registry patients
  with quarterly recorded HgbA1c. Status
  glycohemoblobin machine purchase in process.

12
Clinical Information System

• Currently Testing
• We are currently using a combination of NextGens
  Electronic Medical Record system and the paper
  medical record chart for accessing clinical
  information of our patients
• We have four (4) computer workstations with
  access to our network, placed in the Providers
  office and is in the process of installing more
  computer workstations within our exam rooms and
  nursing triage areas
• We are not using the PECS registry flow sheet due
  to using EMR
• Implemented into Delivery System
• We currently use PAMM as our appointment
  scheduling system which does not flag patients in
  our EMR system or within itself
• Our EMR system is maintained by our MIS
  Department and all clinical systems tasks are the
  responsibility of our MIS Department
• EMR is capable of tracking, reporting and
  communicating results and outcomes of care
  effectiveness over time and across providers,
  clinics and populations

13
Delivery System Design

• The Change The nursing staff will have DM
  patients remove their shoes and socks prior to
  the provider entering the exam room. The nursing
  staff will also make sure a microfilament is in
  the exam room.
• Test whether the removal of shoes and socks and
  the availability of microfilaments will increase
  the number of DM patients with a foot exam.
• Who/Where 10 Hilo Bay Clinic diabetic registry
  patients.
• Prediction Removal of shoes and socks and
  availability of microfilaments will increase the
  number of DM foot exams.
• Data collection Charts were reviewed after the
  patient/provider encounter were completed
  Results All of the DM patients that removed
  their shoes and socks and where a microfilament
  was available had a documented foot exam.

14
Functional and Clinical Outcomes

• Measures Goal as of 11/2004
• 2 HbA1cs in last yr gt90 46
• Average HbA1c lt7.0 7.3
• Documented self gt70 1.9
• management goal setting
• BP lt 130/80 gt70 60
• ACE inhibitor for pt over age 55 gt75 56
• Influenza Vaccine gt70 67
• REGISTRY SIZE 100 158

15
National Key Measures
16
Additional Center Key Measures

17
Senior LeadershipMaking the Case for Change
Collaborative members have had discussions with
both the Executive Director, Stephanie Launiu and
the Medical Director, John Engle, MD as well as
discussions in the Quality Improvement committee.
These discussions revolve around the number of
outpatients with diabetes and the number of
patients admitted to the hospital with diabetes
as a chronic problem and the importance of the
collaboratives work as well as the interventions
the collaborative is testing. We have promoted
the work of the collaborative in staff meetings
and provider meetings as well as discussions with
community members.
18
Communication Plan

• At the Center level
• Staff Meetings
• Provider Meetings
• At the Community level
• Informally with our community partners

19
Barriers and Issues
Those that the team can resolve
Those that leadership needs to address

• Resistance to change in clinical practice both at
  the nursing and provider level
• In services for new equipment and new practices
• Saying no to interruptions during designated
  collaborative hours

• Financial resources to implement change
• Modification of clinic scheduling practices
• Up to date information systems

20
A story to share.the patient
A 42 year old, 325Lb Hawaiian female patient with
a long standing family history of diabetes was
recently diagnosed with DM2 a year ago, taking
both oral and insulin medications. Her sugar
fluctuated daily between 200-500. Her mother
died at age 58 with complications of diabetes
after battling several surgeries resulting with
bilateral below the knee amputations, and she
just lost a brother to diabetes several months
ago. She has another sibling diagnosed with DM2.
Very concerned, the patient did not want to see
her daughter struggling with this disease or
going through life without a mother at an early
age, so she set a goal for herself. She educated
herself through the help of her doctor and nursed
and also received help from the diabetic clinic
and Hui Malama Na Oiwi, a native Hawaiian
Healthcare organization, in partnership with Bay
Clinic, Inc. Her greatest adversary was rice and
soda, which account for Hawaiis highest
incidents of diabetes. She worked with a
nutritionist at Hui Malama Na Oiwi and Bay
Clinics nursing department to accomplish goals
best for her. She setup and exercise schedule no
less then 3 times a week and cutting all bread,
rice, and soda from her diet, successfully losing
75Lbs. Today she is medication free and
currently is in school working towards a nursing
degree.
21
A story to share.our staff
We were having problems acquiring monofilaments
to do foot checks for our diabetic patients. In
one of the e-mails we received, they were asking
how other clinics were ordering monofilaments and
how to obtain them. One of the replies were to
use fishing lines cut at 2-3 inches in length to
test for lower extremity neuropathy. This was a
wonderful idea and was used by our Director of
Nurses. She used a cribbage board with 2 pegs
separated at 3 inches, wrapped the fishing line
around the pegs then cut them to size. Using the
fishing line was a wonderful idea and we can make
them disposable at a fractional cost.
22
A story to share...the organization
It has certainly been a challenge working on this
diabetic collaborative. Our team has met hurdles
and oppositions from the start of the project.
One of our greatest challenge is requesting time
to work on the collaborative and still
maintaining quality care to our patients. The
collaborative is an ongoing work in progress and
trying to meet all of the requirements is
difficult. Everyone knows and understands we are
working to improve work standards for both
patients and staff but still meet resistance when
needing time. We are also finding it difficult
keeping u with the collaboratives pace.