We are located in North Vancouver

1
Dr. Anis Lakha's Office

• We are located in North Vancouver
• A single GP office
• And
• We have about 65 Diabetic Patients

2

Team Members

• We have 3 Team Members
• Dr. Lakha email anis_at_visram.com
• Cheryl P/T MOA email cherylrivard_at_msn.com
• Tanya P/T MOA
• Dr. Lakha and Cheryl have been with the
  collaborative since the beginning. Tanya joined
  our team about 3 months ago

3
AIM and Key Measures

• Improve and maintain optimal diabetes control for
  all my diabetic patients with vigilant 3 monthly
  reporting. Also to improve patients understanding
  of their chronic condition (diabetes) and
  therefore affect their lifestyle changes to
  improve glycemic control.

• Key Measures
• gt90 of patients with Diabetes will have an A1C
  test every 3 months 
• gt90 of patients with Diabetes will have an A1C
  of lt7.0.
• gt90 of patients with Diabetes will have a BP
  test every 3-6 months
• gt90 of patients with Diabetes will have a BP of
  lt130/80
• gt90 of patients with Diabetes will have an LDL
  done annually.
•  gt90 of patients with Diabetes will have an
  annual dilated eye exam.
•  gt90 of patients with Diabetes will have an
  annual ACR.
•  gt90 of patients with Diabetes will have an
  annual lower extremity exam.
•  gt90 of patients will have a self-management
  goal documented annually.

4
Clinical Information Systems

• Status of Your Toolkit
• We have 58 patients in our registry
• We currently have 1 MOA trained on entering
  information
• The New MOA is in the process of learning how to
  use the toolkit.
• Use of the Toolkit in planning care
• We currently use the recall system, to bring
  patients with outstanding tests into the office
  We use the data extremes to single out the
  patients who do not meet the set criteria
• Our Patient data is entered into the computer
  after every visit. We find this system keeps our
  data up to date

5
Delivery System Design
Cutting down on Patient Visits and Catching Over
Due Blood Work Plan Making diabetic Recall
more time efficient for patients and
doctor Do Identify 10 patients with out
standing measures Act Call patient inform them
they have blood work due. Instead of having the
patient Return to the office To pick up
requisition the moa would fill out requisition
and fax it to the lab of their
choice. Study Out of the 10 patients 6 called
back and had requisition sent to the lab. Only
approx 2 have had blood work completed and have
returned to go over it. 4 Patients have not
called back at all.
6
Delivery System Design
PDSA Recall System 1 Plan Creating a recall
system Do Give Patients Lab form to get HgA1C
every 3 months 6 patients chosen will patients
be responsible in making the 3 Month appt after
blood work Act List of Patient small easy for
doctor to recall Study Only 3 patients got
blood work done 1 had to be recalled 2 Made
own appt one week after blood test Learning 3
patients forgot to get blood tests when asked
they admitted to being too busy just
forgot. Poor way to recall patients to give them
requisition form which are left at the lab
anyway Try another way of recall
7
Delivery System Design

• PDSA
• Recall System 2
• Plan Second attempt at a recall system
• Do Use the computer generated recall list and
  call patient in for outstanding tests
• Act Started at the top of the recall list and
  began making phone calls and recalling patients
  for appointments.
• Learning Depending on the size of the list it
  can be time consuming at first. This was
  effective because patients just need at reminder
  that they need to come in. Also by calling
  patients could avoid coming in. We will review
  the recall list once a month they way it will
  keep it small and up to date.

8
Delivery System Design

• PDSA
• Entering Information
• Plan Establish a routine of entering information
  into the tool kit
• Do Print encounter forms for blue charts
• Study Identify Diabetic patients-to enter data
  regularly
• Act Each patient has an encounter form with the
  most recent information attached to the inside of
  the chart. The doctor fills out the information
  at each visit. Once the doctor is done with the
  chart the information is entered into the tool
  kit. A new encounter sheet is printed off and
  place back in the chart.
• Learning At first the charts were left to one
  MOA to enter into the computer (we have 2 part
  time MOAs). This was time consuming so both
  MOAs were trained on how to use the tool kit.
  The doctor has the most recent information at
  each visit and it is easy to identify which
  diagnostic data is missing. By having the
  encounter sheet in the front of chart you never
  miss filling it out at a visit.
• Also Doctor needs to leave encounter form in
  front of chart so MOA can enter Data before
  filing in away.
• Also some patients come more frequently the Q3
  monthly, so date is taken more often.
• Doctor has to check whether form needs to be
  filled or not. Previously doctor checking
  everything on the form at every visit too time
  consuming

9
Delivery System Design

• PDSA
• Identify Diabetic Patients
• Plan To easily identify diabetic in the office
• Do Change color of charts to blue
• Study We only have 60 diabetes total cost only
  about 50.00 ( might be more for a larger
  practice. It doesnt take any addition time you
  do it while you are entering the information. It
  is just one extra step.
• Act MOAs take list of diabetic patients and try
  to change 3 charts a day
• Learning Very Easy to identify diabetic patients
• Doctor checking everything on the form at every
  visit too time consuming

10
Self-management

• PDSA Group Visits\
• Plan Group visit with patient, doctor and a
  nurse educator sponsored by GSK
• DO Select a date choose 5 patients (patients
  ranged from new diabetics to old diabetics) to
  learn more about their condition and how to
  manage it.
• Act Nurse Educator came into our office and saw
  patients one at a time for an hour each. The
  nurse would go over medication, show them how to
  use there glucometers and any concerns that the
  patient had. The doctor would attend the last
  ten minutes of the session to help set goals and
  arrange follow up.
• Learning All 5 five showed up to the session. 3
  patients we pleased to have the extra attention
  and found the session informative. 2 patients,
  husband and wife, did not want to be involved
  when they saw the drug company name they felt
  that they were going to be pressured to buy
  things and would receive junk mail. The patients
  were informed that no personal information was
  being released to GSK and that it was only a
  nurse providing information about diabetes that
  would be given to them in the room. After about
  30 minutes the patients agreed to complete the
  session. These patients left the session very
  happy and well informed. We are planning to do a
  follow up session at 6 months and 9 months with
  the same patients. We have asked GSK to prepared
  a information sheet for the patients explaining
  what their involvement in the project is and that
  no personal information is taken out of the
  doctors office.

11
Self-management

• Second Planned Visit
• Plan Have a follow up visit with the diabetic
  nurse educator
• Do GSK provided us with a date when the nurse
  was available. Select 5 patient (preferable the
  same one we have last visit) call them to arrange
  a 1 hour visit with the nurse and doctor.
• Act The same 5 patients were called from last
  visit. 3 were able to return. 1 was unable to
  come because she does not speak very good English
  and her daughter who comes with her had to work.
  The fifth patient was not invited back as we
  have a newly diagnosed diabetic that we felt
  could use the help of nurse and another diabetic
  patient who was struggling with his was ask to
  come in place of the patient who was unable to
  make it. Patient were called the night before to
  remind them of there appointment. Charts were
  prepared for the nurse containing CDM flow sheet,
  a note from the doctor suggesting area of concern
  for each patient and the previous nurse note (if
  it was there 2nd visit). All the patients
  personal information except for name and birth
  date were removed from the forms.
• Study Patients filled out a questionnaire. They
  felt it was useful but might be better targeted
  to new diabetics only. The sessions ran
  smoothly.
• Learning We will have another session in 3
  Months. We may want to look at our target
  population. May try a different set of patients.

12
Self-management

• Plan Teaching older population how to use
  glucometers
• DO Johnson and Johnson provided 5 glucometers to
  
• Act Provide a 1 hour teaching session to train
  the patients to use the glucometers.
• Study Following up visit with myself to answer
  any questions
• Follow up every 3 months after that.
• Learning After one month follow up patient were
  enthusiastic. They had been diligent about
  checking their sugars. Small improvement in diet
  noted So far so good.

13
Community
Relationships or Partnerships in the Community

• We use the Diabetic day centre at Lions Gate
  Hospital
• We have had a Nurse Educator funded By GSK come
  into our office
• The JohnsonJohnson Company supplied our office
  with 6 One Touch Ultra Smart Glucose Monitoring
  system. They also provided a day of teaching for
  the patients.

14
Describe the Spread of Diabetes Management in
your office

• Tool Kit
• Identified patient by changing color of chart to
  blue
• Gave all initial information to MOA to enter in
  to CDM Toolkit
• Once data was entered into the computer the MOA
  was in charge of planning visits, using the
  monthly reports
• Visits
• Diabetic Days not really an option small office,
  a challenge to get all diabetic patients to come
  on same day
• Office Planned Visits worked well. MOA identifies
  the missing Problem in the chart
• Patient was recalled and I would address the
  issue with the patient
• Most patient are now well educated in that they
  will follow-up in 3 months time
• My MOA is invaluable in tracking the diabetic
  almost on a weekly basis- not many patients fall
  through the system however we do have
  non-participants who refuse to come for follow
  up. They have been phoned several times with no
  response
• Our office rule is 3 phone calls and then we back
  off.
• If the patient is not engaged in their own care
  then they are not ready to participate in this
  program. Over time with more education we may
  be able to engage them in their diabetic care

15
Describe the Spread of Diabetes Management in
your office

• How did you spread Patient Self-management?
• Small PDSA Diet Diary
• Wt- BMI
• Exercise Diary
• Using Glucometers

16
Describe the Spread of Diabetes Management in
your office

• Challenges or barriers you overcame you spreading
  the Chronic Disease Model to your peers
• Small PDSAs to establish whether these self
  management changes would be effective.
• Diet Diary difficult to maintain. Only those
  that are committed with time on their hands
  (retired) are able to keep up with this
• Most patients can tell me what they ate over last
  24 hours
• WT or BMI excellent idea! They weigh themselves
  every 3 months in the office. I calculate their
  BMI- they see the weight dropping engaging more
  with each visit but it takes time to educate the
  patients.
• This is a slow process but I hope to get all my
  patients involved by Summer 2005.
• Presently 8 patients are involved, I am
  increasing them number slowly. Patient selected
  has to be motivate to make change in lifestyle.
  Initially a leap of faith, but easy to convince
  patients once they start to see results

17
Describe the Spread of Diabetes Management in
your office

• Exercise Diary Works for some not for others.
  18 actively monitored exercise program Start
  exercising 20 minutes increase gradually to 45
  minutes.
• Patient will tell me how much time they have and
  how often. We negotiate.
• Encouraging blood sugar checks before and after
  walking, helps to see immediate results
• Using the Glucometers
• 6 Glucometers donated to the office for patient
  use. Five longstanding diabetic with no idea how
  to be in control of their blood sugars chosen.
  Everyone understood by the end of session how to
  check their own blood sugar/
• 2 Patients seen in follow-up Enthusiastic
  continue to check regularly

18
Describe the Spread of Diabetes Management in
your office

• Who have you spread to
• Only in our office. Our plan is to expand to
  other remote offices via computer internet
  services. Trying engage Vancouver Costal Health
  to assist with this
• How did you go about spreading the Clinical
  Information System?
• We Have not done much about this
• Use of recall Excellent reminder for Patients
• Data collection and input MOA completely at ease
  with entering all information including follow-up
  with ophthalmologist , blood test results ect.

19
Functional and Clinical Outcomes(List your
current level)
20
Key Measures
21
Key Measures
22
Key Measures
23
Summary and Next Steps

• Describe briefly what have you accomplished in
  the Collaborative?
• I have identified my diabetic population and how
  to effectively manage their care with the help of
  the CDM Toolkit in a timely manner
• What is still left to do? what are you planning
  to test next?
• More diabetic patients to understand weight
  management and exercise as a part of their daily
  routine. To get 80 of all my diabetic patients
  engaged in all the self management strategies
  used in my office
• What challenges and/or barriers do you face in
  sustaining the changes you have made?
• Other chronic care collaborative on the horizon,
  I hope I can keep up the vigilance in my diabetic
  population, especially the self management
  strategies I have set up with patients .
  Hopefully at 3 monthly interval we will continue
  to monitor whether they are still following the
  self management plans we have set up together.

24
Female Diabetic Patient 77 Years Old Non-Insulin
Dependant Diagnosed 1999

• Beginning Of Collaborative
• HgA1C 6.4
• BP 140/80
• ACR Target 3.6
• Weight (lbs) 239
• BMI 39

• Today
• HgA1C 5.8
• BP 130/70
• ACR Target 2.4
• Weight (lbs) 199
• BMI 33