Lake Superior CHC Duluth, Minnesota Midwest Cluster

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Lake Superior CHCDuluth, MinnesotaMidwest
Cluster
May 2005 Atlanta, Georgia
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Lake Superior Community Health Center

• Duluth, Minnesota
• 2 providers, 4 MAs, 1.6 RNs,1 counselor, 4 SW
• Programs
• Adult and pediatric health care
• Mental health care
• Health Care Access Office
• Population Served
• 2080 total patients
• 128 patients with DM seen in 2004
• 111 patients with DM now active in registry
• 1.1 of patients served identify themselves as
  homeless
• 90 Caucasian, 3.4 African/American,
  1.5Native American

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Team Members

• Vicki Andrews, NP, provider/coordinator
• Dana Bergstrom, IT support
• Danielle Brown, Social Services Secretary
• Clyde Holmes, education/counseling
• Kristi Johnston, medical receptionist
• Rachel Lackner, medical assistant
• Sandy Larson, medical assistant
• Wende Nelson, Executive Director
• Ani Othmann, RN
• Sandy Popham, MD, team leader
• Chris Sandal, RN, chronic disease management and
  education
• Claire Smith, Medical Records Specialist
• Brooke Scharte, medical receptionist
• Lindsey Scharte, Lead MA
• Leisa Schwab, MA
• Rachel Wooley, medical receptionist
• collaborative team members

Sandy Popham, 218-722-1497, gspopham_at_charter.net
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AIM Statement

• Using the 6 components of the Care Model, LSCHC
  will redesign our diabetic care and
  education/self management program to
• 1. activate patients to be involved partners in
  managing their chronic illness
• 2. ensure that diabetic care provided in our
  clinic improves outcomes by achieving
  established, evidence based goals.
• Our goals will be measured by established,
  evidence based outcomes measures (see key
  outcomes slide)
• We will track outcomes measures using the PECS
  data registry

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Key Measures
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Additional Measures

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Self-management

• Currently Testing
• Follow-up phone calls by RN with patients to
  discuss self management goal chosen by patient
• Mail self management questionnaire to patients
  one week before their diabetic clinic vist
• Monthly newsletter to patients in registry,
  focusing on one self management goal monthly
• Monthly letter to all diabetic patients who
  smoke, with different focus each month on value
  of cessation, with reminder of resources
  available
• Implemented into our Delivery System
• Self Management Goal set by patient during
  diabetic clinic visit, with either RN, counselor,
  nurse practitioner or physician
• Sticker into behavior section of chart to
  indicate patient current self management goal,
  for easy access by the team
• During diabetic clinic visit patient has
  additional 30 minutes with counselor/RN
• Self management tools tool kit developed and
  available for use.
• Diabetic notebook completed and being provided to
  all diabetic patients in registry at appointments
  this quarter, and all new diabetic patients in
  future

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Community

• Currently Testing
• Obtaining small grants for dedicated projects re
  diabetic care
• Utilizing volunteers to assist with manual labor
  aspects of paperwork
• Begin to publicize collaborative within our
  clinic, as article within monthly clinic
  newsletter, presentation to board, display of
  storyboard in main lobby
• Implemented into our Delivery System
• Transportation assistance for all diabetic
  patients
• Low cost YMCA memberships

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Healthcare Organization

• Currently Testing
• Implemented into our Delivery System
• Chronic care nurse 0.6 FTE for Duluth site
• Full time medical assistant to assist with extra
  work associated with new processes
• Funding for diabetic educator course for all RNs
  and counselor at both sites
• Funding to send additional 1 additional staff to
  each learning session, including two from
  Superior site
• Funding for dilated diabetic eye exam for all
  uninsured diabetic patients
• Funding for computer dedicated to
  PECS/collaborative efforts

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Decision Support

• Currently testing
• Implemented into Delivery System
• PECS data form from prior visit used at clinic
  appointment to ensure key measures are addressed
• Weekly team meeting to discuss diabetic patients
  on hot call list

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Clinical Information System

• Currently Testing
• Implemented into Delivery System
• PECS data entered weekly by MA
• Monthly reports on key measures generated, and
  posted in lobby.
• Med lists entered into computer, and generated
  for use and updated at each visit
• PECS used to generate categoriges of patients to
  focus interventions, e.g. smokers

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Delivery System Design

• Currently Testing
• Chronic disease management RN to contact patients
  on weekly, bi-monthly or monthly basis if not at
  target for A1c or BP
• Implemented into Delivery System
• Diabetic clinic note in use for all diabetic
  visits (as guide)
• Send letters (on monthly basis) to patients more
  than 4 months overdue for diabetic visit
• MAs have all diabetic patients remove shoes at
  beginning of visit
• Follow-up lab letter sent by RN after labs
  reviewed and PECS form completed by provider

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Functional and Clinical Outcomes

• Measures Goal as of 05/01/05
• 2 HbA1cs in last yr gt90 48.6
• Average HbA1c lt7.0 7.7
• Documented self gt70 36.9
• management goal setting
• BP lt 130/80 gt40 41.1
• ACEi/ARB for pt over age 55 gt75 90.7
• Statins gt60 77.9
• Eye exam in past year gt90 46.8
• ASA/antithrombotic for pt over age
  40 gt80 91.5
• LDL lt 100 gt70 46.4
• smokers lt25 40
• Microalbumin screening gt90 84.7
• Pneumovax gt90 74.8
• Influenzae offered gt90 55.9
• Foot exam twice yearly gt90 77.5

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Diabetic Registry

• By end of 2004, all diabetic patients seen in
  clinic in 2004 were put into registry. By the
  end of January 2005, we had inactivated patients
  found not to be active in our clinic. Since
  then, weve added all new diabetic patients
  presenting to our clinic into our registry.

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Key Measure 2 A1cs in one year

• To improve the percentage of patients having two
  diabetic visits in one year, we have two
  initiatives
• Letter sent to all patients not seen for 120 days
• Restaurant gift certificate (10) at end of year
  for patients with 3 diabetic clinic visits in one
  year

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Key Measure Average A1c

• To improve average A1c in our registry
• Self management goal setting by patients
• Weekly, bi-monthly or monthly nursing follow-up
  by phone to patients not at goal
• RNs and counselor completing diabetic educator
  course
• Providers adjust hypoglycemics at visit based on
  reported BGs
• Education to patients regarding target A1c

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Key Measure Self Management Goal Setting

• To improve of patients with self management
  goal
• At diabetic clinic visit, patients meet with
  diabetic educator to set self management goal
• Follow-up phone calls to patients two weeks after
  visit re self management goal
• Sticker into behavior section of chart for easy
  access to all team members to review self
  management goal with patient at subsequent visit
• Self management newsletter monthly to all
  patients in registry

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Key Measures BP lt130/80

• To improve of patients at BP target
• All providers aware of goal
• Patients educated as to new goal at clinic visit
• Follow-up visits with RN to recheck BP after
  intervention in clinic

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Key Measure ACEi/ARB for patient over age 55

• On a monthly basis, PECS report generated of
  patients age 55 or greater who are not on
  ACEi/ARB, and reviewed by provider, with changes
  made as appropriate

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Key Measure Statins

• On a monthly basis, PECS report generated of list
  of patients not on statins, and reviewed by
  providers, with changes made as appropriate

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Key Measure Eye exam in past year

• Grant available to pay for dilated diabetic exam
  for uninsured patients
• Diabetic clinic note
• MAs ask all patients during diabetic visit when
  their last eye exam was, and if greater than one
  year, need explained to patient, and appointment
  scheduled
• As of May 2005, 46.8 of our patients have had an
  eye exam in the last year our goal is gt90

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Key Measure ASA/Antithrombotics

• On a monthly basis, PECS report generated of list
  of patients not on ASA/antithrombotics, and
  reviewed by providers, with changes made as
  appropriate

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Key Measure LDL lt100

• On a monthly basis, PECS report generated of list
  of patients not at goal for LDL, and reviewed by
  providers, with changes made as appropriate

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Key Measure smokers to be less than 25

• As of April 2005, 40 of our diabetic patients
  smoke. Nationally, 25 of diabetic patients
  smoke.
• Smoking cessation confers as much cardiac benefit
  as use of aspirin, ACEi/ARB and statin combined
• Monthly letter to all smokers reviewing a
  different reason each month to stop smoking, as
  well as reminder of resources available to assist
  with cessation

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Key Measure Microalbumin screening

• On a monthly basis, PECS report generated of list
  of patients who are overdue for microalbumin, and
  reviewed by providers.
• PECS form shows date of last microalbumin as
  reminder to order.
• Currently, 85 of our patients have had
  microalbumin screening in the last year, an
  improvement from 55 in January 2005

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Key Measure Pneumovax

• Our goal is to increase the percentage of
  diabetic patients offered/immunized against
  pneumovax to 90 of our population.
• Currently, 75 of our patients have been
  immunized.
• We plan to obtain a list from PECS of the
  non-immunized patients, and put a note on their
  chart to remind the provider to offer the
  immunization at the next appointment

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Key Measure Offer Influenza vaccination during
flu season

• Our goal is to offer the influenza vaccination to
  90 of our diabetic patients during the flu
  season.
• We will post a reminder about flu shots in our
  monthly diabetic newsletter
• During the flu season, the MAs ask all eligible
  patients about the influenza vaccine, and leave a
  note on the chart for the provider reminding them
  to order it if appropriate.

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Key Measure Foot Exam twice yearly

• Every time a diabetic patient is seen in clinic,
  the medical assistants have the patient remove
  their shoes and socks.
• Provider conducts foot exam as appropriate.
• Our goal is that gt90 of patients have a foot
  exam at least twice yearly

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Senior LeadershipMaking the Case for Change

• Our Senior Leadership is fully committed to
  ensuring we are providing care that meets/exceeds
  national standards of care. We did not have to
  convince them that this work was important, and
  funding to allow additional staff to pursue this
  project was lined up even before participation in
  the collaborative.

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Communication Plan

• At the center level
• Storyboard from each learning session displayed
  in waiting room
• Monthly charts indicating our progress towards
  goals are posted.
• Will present collaborative at July 2005 board
  meeting
• Summary of collaborative efforts into newsletter
  for May, and will continue monthly updates.
• At the Community level
• pending

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

• Chronic care nursing role in assisting patients
  with goals is still in transition, but increasing
  availability is helping with this.

• Future staffing needs in terms of medical
  providers

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A story to share.the patient

• AT is a 52 yo black female with Type II DM on
  insulin who presented to LSCHC stating Im in
  denial about my diabetes, and want to get back on
  track. She attributed her denial to a history
  of depression, and reported she received a letter
  from our agency advising she was overdue for
  diabetic care and follow-up. She said, It meant
  a lot to me to know that someone cared. A1c at
  time of initial visit 11.4, at follow-up visit 2
  months later, A1c improved to 9.8. Has started
  exercise program, compliant with all meds
  including anti-depressant, and completed eye exam
  appointment.

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A story to share.our staff

• LSCHC has enlisted every staff member to help
  manage and improve the health of our diabetic
  patients. It gives a whole new meaning to it
  takes a village. We have all learned that we
  play a role in the care of our patients from the
  front desk to the provider. We are a team with a
  goal, and a mission.
• One of the Medical Assistants went to a brief
  diabetic conference. When asked what she learned,
  she reported that although the conference was
  informative it mainly reinforced what she had
  already learned. When she was asked how much she
  knew about diabetes before the collaborative, she
  replied, nothing.
• With the collaborative, and the support of our
  leaders we are able to obtain the resourses and
  tools we need to deliver the care our diabetic
  patients need.

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A story to share.the organization

• The Lake Superior Community Health Center has
  experienced marked increases in the number of
  clients seen for primary health care. The
  complexity of their medical problems, and the
  time needed to address this is also increasing.
  In addition, we have seen an increase in the
  level of poverty served, and all its subtleties.
  
• The health center also experienced turnover in
  the one staff physician, a position held by one
  doctor since 1979 . While the agency was
  recruiting for this position, some part time help
  was obtained, but the bulk of the work fell to
  the Family Nurse Practitioner and other medical
  staff.
• The Diabetes Collaborative began 7 months after
  the new staff physician came on board.
  Organizationally, it has allowed us to join
  together as a team. The work of restructuring
  our work has allowed us to better manage our time
  while giving our clients the care they require.
• The Diabetes Collaborative has brought its
  challenges, yet, organizationally, it has
  provided us with a focused, unifying force and a
  new method to meet ongoing staff and client
  needs.