DevelopmentKnowledge Transfer

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Development-Knowledge Transfer

• Survey results over time
• Recognition of CCGC name was 49-50 in 2002
  moving up to 74 by 2003
• Ranking of most useful guidelines
• 2002 Diabetes, Depression, Asthma
• 2003 Colorectal, Pediatric Immunizations,
  Diabetes
• 2009 (May) Asthma, Gestational Diabetes, SBIRT
• Sustained interest in having CCGC continue to
• Develop guidelines
• Convene stakeholders
• Help practices prepare for systems change

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EVALUATE
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Guideline Uptake

• Survey published in Critical Pathways in
  Cardiology (June, 2008)
• Guideline use before and after dissemination
  rates varied between 42.9 and 51.2

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Implementation-systems integration

• Rapid Improvement Activity (RIA)
• Fit Now Results
• By 12 months participants had lost, on average
  11.3 pounds when compared to baseline weight
  (plt.01, 95 CI 4.318.4 pounds) which
  corresponds to a 5.6 loss of original body
  weight. Changes between 6 and 12 months were not
  significant.

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• Fit Now Colorado RIA Sites by County
  Referrals/Enrollment
• 92 Patients enrolled

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SBIRT Colorado Progress to Date

• 46,598 patients screened
• 54 of patients scored in low or no risk category
• 29 scored at risk for tobacco only
• 12 scored in moderate risk category (BI)
• 2 scored in high moderate risk category (BT)
• 3 scored in high risk category (RT)

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Pneumococcal Immunization Rates
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Pneumococcal Immunization Rates
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• CCGC Tobacco Program
• June 9, 2009

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CCGC Tobacco Team

• Co-Directors
• Alison Long, MPH
• Michele Patarino, MBA, MSHA
• Project Managers
• Debbie Dion
• Emily Gingerich

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Tobacco Program Overview
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Show Me The Data
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Tobacco Program Provider Participation
www.coloradoguidelines.org/tobacco
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• Grants to Healthcare Organizations

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Grants to Healthcare Organizations

MedSouth
www.coloradoguidelines.org/tobacco
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Grants to Healthcare Organizations

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• Tobacco Rapid Improvement Activity
• (TRIA)

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TRIAs
Examples of Practice Changes Following the TRIA

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Tobacco Rapid Improvement Activity (TRIA)

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TRIA Results

www.coloradoguidelines.org/tobacco
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IPIP Tobacco Measures
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Additional Data Source Colorado QuitLine
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RIA Flyers
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Questions?VISIT www.coloradoguidelines.org/tob
acco Email tobaccoinfo_at_coloradoguidelines.org
CALL 720/297-1681
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Boulder, Colorado http//sprucestreetinternalmedic
ine.com
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Hillary Browne, MD, FACP

• Colorado
• Practice Coaches Debbie Barnett Deb Maltby
• Improving Diabetes Care
• Start date January 2007
• Number of diabetes patients in the registry 250

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Description of Practice

• Boulder, Colorado
• 3500-4000 active patients, 5 Medicare
• 3.5 full time equivalent providers
• Aim to provide excellent, comprehensive
  diabetes care NCQA certification
• Staff Manager, Phone receptionist, 2 front
  office, 4 MAs, 4 file clerks, part time
  dietician.
• Quality improvement team 1 front office, 1 back
  office (MA), office manager, 2 providers, QI
  coach

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Data collection

• Reach My Doctor (RMD) portal with diabetes and
  asthma registries
• Special features we use
• Care plan/flow sheet
• labs automatically populate flow sheets
• email reminders
• labs can be emailed with our comments
• patients can view their care plans

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Planned care at Spruce Street how it works

• Registry
• Protocols
• Patient makes appointment and DM goes on the
  schedule
• File clerk pulls the chart (red dot) and prints
  the flow sheet
• MA notes that patient has DM and removes
  patients shoes
• If annual sensory exam is due, she performs and
  documents the exam
• Visit with provider focuses on flow sheet, which
  is given to patient at the end of the appointment
• Self-management goals and reminder

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Retinal Exams
6/07 to 5/08
6/08 to 5/09
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Adopting a clinical protocol overcoming provider
insulin resistance!

• Registry enabled us to clearly identify patients
  with hgb AICs gt 9
• Leading to a conscious decision to relearn
  insulin regimens to achieve better glycemic
  control
• MAs now trained to teach patients to administer
  insulin and monitor blood sugars

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Spruce Street Internal MedicineA1c gt 9
5/08 to 4/09
6/07 to 5/08
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Spruce Street Internal MedicineA1c lt 7
6/07 to 5/08
5/08 to 4/09
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Spruce Street Internal MedicineBP lt 130/80
6/07 to 5/08
5/08 to 4/09
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Spruce Street Internal MedicineBP lt 140/90
6/07 to 5/08
5/08 to 4/09
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Spruce Street Internal MedicineLDL lt 100
6/07 to 5/08
5/08 to 4/09
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Spruce Street Internal MedicineKidney
Assessment6/07 to 5/08
6/08 to 5/09
6/07 to 5/08
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Spruce Street Internal MedicineFlu Vaccine
6/07 to 5/08
6/08 to 5/09
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Spruce Street Internal MedicineFoot Exams
6/07 to 5/08
6/08 to 5/09
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Sustainable improvement

• Routine protocols with immediate correction if
  not followed
• Staff feels responsible and integral to
  successful patient outcomes
• Patients develop stronger connections with
  ancillary staff
• Ultimate outcome is improved satisfaction for
  patients and staff

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Next steps

• Focus on high-risk patients (hgbAiC gt 9)
• Challenge ourselves to attain goals on individual
  diabetes measures.
• Asthma registry initiated
• Move forward with plan include COPD and
  heart/stroke
• Coordinate timely office follow up after
  hospitalization to prevent readmission.

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Thank you

• To all of our providers and staff for their
  exceptional performance
• And to Allyson Gottsman, Associate Director, and
  Marjie Grazi Harbrecht, MD, Medical/Executive
  Director of the Colorado Clinical Guidelines
  Collaborative

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LDL in control

• Chet Cedars
• Lone Tree Family Practice

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Lone Tree Family Practice

• Two physicians and two nurse practitioners One
  physician spends ½ time in clinical work and ½
  time in practice management. One nurse
  practitioner spends ½ time clinical work and ½
  time as Care Manager. (three FTE)
• Use Allscripts/Misys EMR with imbedded orders in
  Preventive Health Module based on sex, age and
  diagnosis.
• Query Reports to pull patient lists based on Dx
  and other clinical data.

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Patients with 1 LDL in last 12 months
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LDL lt 100
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System that Underpins Performance

• Improvements can be applied at any point to make
  the system perform better

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To improve timely LDL measurements

• Print list of patients with LDL gt100
• Mailing labels for outreach
• Last LDL date and value available at time of
  service
• Informal provider consensus regarding how often
  to measure assists with consistent messaging to
  patients

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Interventions to Help Patients Achieve LDL Target

• Lab values auto imported to diabetes tab,
  including LDL
• Informal consensus among providers regarding
  management
• Aggressive follow up
• Print out of trends from PHP registry
• Guidelines and targets shared with patients
• Provider directed self management strategy
• Some assistance with DAPs for Rx as needed

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Sustaining Activities when at Target

• Periodic re-measurement
• Reinforcement of care plan
• Positive reinforcement with trending graphs

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Appropriate Follow Up

• Aggressive follow up encouraged
• Patients engaged in progress toward goal
• Patients recognize ongoing follow up essential
  for optimal outcomes

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Still working on

• Strategy to get patients in based on last date of
  LDL
• More data points auto populated for diabetes care
  parameters

• Continuing process to eliminate double data entry
  
• Documentation of self management goals

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Improving Performance in Practice - Evaluation
Data

• June, 2009
• Perry Dickinson

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Elements

• Registry data performance measures
• Assessment of Diabetes Management (clinician
  survey)
• Patient data from trial practices
• Qualitative data from practice interviews
• Chart audit data for trial practices coming
  soon
• In slides means plt.01, means plt.05, means
  nearing significance

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Diabetes Process Measures
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Diabetes Outcome Measures
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Asthma Measures
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Patient Measures

• Only those 11 practices involved in the
  randomized clinical trial
• Patients recruited from a list of diabetic
  patients provided by practice
• Same patients at baseline, 9, 18 months
• 244 patients at baseline, 235 at 9 months
• 18 month f/u data soon!
• Patient self report regarding various aspects of
  their diabetes care

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Checked in Past 12 Months
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Overall Diabetes Process of Care

• Process A1c, urinary protein, cholesterol, eye
  exam, foot exam done over past year
• SMS Self-Management Support - Dietary
  counseling, goal setting, home glucose monitoring
  dealt with over past year
• Total checks PSMS

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Clinician Survey

• Assessment of Clinician Diabetes Management
  (ACDM) designed to measure the level of
  implementation of elements of the Chronic Care
  Model
• 42 practices 181 clinicians at baseline, 80
  post-intervention

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ACDM
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Qualitative Data

• Interviews of key informants (lead physician,
  practice manager, key staff) from 8 IPIP
  practices regarding issues around their diabetes
  improvement efforts through IPIP
• All practices had engaged to the point of
  reporting measures
• Qualitative interviews of the trial practices are
  in progress

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Practices Interviewed

• Six from Denver metropolitan area, one from
  Pueblo, and one from Colorado Springs
• Ranged from three to seven clinicians,
• Three belonged to an IPA in the Denver area, two
  to other IPAs, and three were independent
• Primarily family medicine, with one internal
  medicine

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Clinical Changes

• Practices all implemented mechanisms to identify
  and track their patients with diabetes
• Most used flow sheets to assist with data
  management and point of care decision support
  key in organizing care
• Virtually all developed a distinguished diabetic
  visit- helped focus visit activities
• Most expanded MAs activities, including
  screening questions, assessment and performance
  of needed labs or services
• Many developed patient recall systems to bring
  patients in when visits and services were due.

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Barriers

• The major barrier was time
• Substantial financial costs mostly personnel
• Insufficient staff
• It is hard to have more than one person in the
  practice trained and up to speed on doing this,
  and they tend to be upwardly mobile.
• Staff and clinician turnover an issue
• Problems getting information from consultants

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IT Barriers

• Duplication of effort in data entry a huge issue,
  especially in practices with EHR
• Lack of ability to enter data once and have it
  show up in the appropriate places for
  administrative, clinical, and quality data
  reporting and use
• Often easier for practices without an EHR to
  implement a registry
• Practices with paper charts - charts not always
  available, time spent tracking them down.

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Benefits

• Improved quality of care
• Power of having better data for managing
  patients.
• Possibility of financial benefit through bonuses,
  pay-for-performance, higher coding, group visits,
  and bringing patients in for services
• Improved organization and efficiency of work flow
• Improved morale for clinicians
• Greatly improved staff satisfaction
• Staff more engaged and invested in the practice
  -felt like they were more an important part of
  patient care

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Colorado April 2008 v March 2009
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Measures reported March 2008
Measures reported April 2009