New Directions in Diabetes Care: Promising Practices by California Academy of Family Physicians

New Directions in Diabetes Care:

Promising Practices Quality improvements in clinical measures achieved by seven family medicine practices during three year-long diabetes quality improvement Collaboratories led by the California Academy of Family Physicians

New Directions in Diabetes Care Advisory Committee Bo Greaves, MD, Chair

Private Practice, Santa Rosa Past President, California Academy of Family Physicians (CAFP)

Members Asma Jafri, MD Michael Potter, MD Elizabeth Kalve, MD Ada Marin, MD Dana Ware, MD Yeva Johnson, MD Jerry Penso, MD Ted Ganiats, MD Larry Dardick, MD Ana Perez, APRN Bruce Bagley, MD Deborah Johnson Alan Glaseroff, MD Edward O’Neil, PhD Sophia Chang, MD Albert Chan, MD Jose Arevalo, MD Cathy Coleman, RN

Contents Glossary................................................................. 1 Introduction........................................................... 2 New Directions in Diabetes Care Data.................. 4

Riverside County Regional Medical Center, Moreno Valley University of California, San Francisco Kaiser Permanente, Woodland Hills Private Practice, San Diego Private Practice, Chester Northwest Community Clinic, San Francisco Sharp HealthCare, San Diego University of California, San Diego Private Practice, Santa Monica Kaiser Permanente, Oakland American Academy of Family Physicians, Leawood, KS Dartmouth College, Hanover, NH Private Practice, Eureka UCSF Center for the Health Professions, San Francisco California Healthcare Foundation, Oakland Palo Alto Medical Foundation, Palo Alto California Latino Medical Association, Sacramento Lumetra Healthcare Solutions, San Francisco

Acknowledgments Thanks to all of the family physicians, medical assistants, nurse practitioners and other office staff who made New Directions in Diabetes Care a success for practices and patients. The work of CAFP staff and former staff Sandra Newman, MPH, Jane Cho, Leah Newkirk and Susan Hogeland, CAE in the preparation of this document is acknowledged and appreciated, as is the work of consultant Catherine Direen. CAFP also wishes to thank Bo Greaves, MD for chairing the NDDC project over four years and Shelly Rodrigues, CAE for her support of the project. Finally, CAFP wishes to thank The Physicians Foundation for Health Systems Excellence and the CAFP Foundation for their support of the project and this document.

Ada Marin, MD, MPH Metro Family Physicians Medical Group; San Diego, CA.............................. 6 Craig Endo, MD Grace Medical Group of the Valley, Inc.; Pomona, CA...................................... 10 Isaac Kim, MD Merced Faculty Associates; Atwater, CA......................................................... 14 Susan Glockner, MD North Coast Family Medical Group; Encinitas, CA........................................... 18 Craig Johnson, MD Sierra Spring Family Wellness Center; Pasadena, CA.......................... 22 Sumana Reddy, MD and Danielle Acton, MD Acacia Family Medical Group; Salinas, CA............................................... 26 Lyman “Bo” Greaves, MD Sutter Medical Foundation of the North Bay, Doyle Park Family Medicine Office; Santa Rosa, CA........................................ 30 Appendix.............................................................. 34

GLOSSARY Aim statement: A written, measurable and time-sensitive statement of the expected results of an improvement process. DocSite: A Web-based registry. CAFP does not endorse any registry product but arranged for free two-year licenses to be offered to all Collaboratory participants and physicians in their offices thanks to an in-kind contribution from GlaxoSmithKline. Flow sheet: A comprehensive form to keep all information regarding management of a patient’s chronic condition, e.g., diabetes flow sheet. A flow sheet prevents staff and physicians from having to search through a patient record or look in several places for the information needed for care management. Registry: A patient registry is a system for capturing, managing and providing access to condition-specific information for individuals and groups of patients. A registry is used to support organized care management for a list of patients with the condition(s) being tracked, e.g., diabetes. Registries can be compiled in a simple paper format, computer-based freeware, or purchased software programs or subscriptions. At a minimum, a registry would contain patients’ names and contact information; ideally it would also include pertinent clinical information for each patient.

Small Tests of Change: CAFP uses the term “Small Tests of Change” (STOCs) to describe a structured trial of process change. Drawn from the Shewhart Cycle, this effort includes: • Plan - Planning the change; • Do - Implementing the change and observing what happens; • Study - Analyzing the trial results; and • Act - Taking next steps based on the analysis. This cycle naturally leads to the Plan step of a subsequent cycle. The process then is repeated in rapid cycles to continuously test a change to determine if it is an improvement. Spread: The intentional and methodical expansion of the number and types of people, units or organizations using the improvements. Standing order: A written document containing rules, policies, procedures, regulations and orders for the conduct of patient care in specific clinical situations. Team huddle: A practice a care team uses to improve communication. To conduct a “huddle,” the care team assembles at a predetermined time each day to look at the schedule and anticipate the needs of patients visiting the clinic that day. Visit Planner™ sheet: A feature of the DocSite registry, a Visit Planner™ provides a complete picture of a patient’s condition based on relevant clinical information compared with evidence-based guidelines.

new directions in diabetes care: promising Practices

INTRODUCTION New Directions in Diabetes Care (NDDC) was a three-year initiative led by the California Academy of Family Physicians (CAFP) to assist family physicians in improving care for their patients with diabetes and to introduce concepts of practice redesign and chronic care management. In NDDC, three successive cohorts of solo and small family medicine practices participated in a 12-month collaborative (called a “Collaboratory” in NDDC) modeled after the Institute for Healthcare Improvement (IHI) Breakthrough Series. The project ran from the fall of 2005 through the fall of 2008. Teams included family physicians and staff from solo and small practices (two to eight physicians) throughout California. The chart below presents basic team data including the number of practices recruited, rollovers (those that participated in subsequent Collaboratories) and those that dropped out. This document summarizes the content of interviews with principals from seven practices that participated in NDDC and includes their aim statement goals. It outlines not only “best practices” – what worked – but also what did not work and what could not be sustained and why. CAFP developed this report to inform the work of others engaged in quality improvement and to help policy makers understand the challenges and barriers to improvement in small practices.

Category

Collaboratory 1 (2005-06) (C1)

Collaboratory 2 (2006-07) (C2)

Collaboratory 3 (2007-08) (C3)

Total

Total number of teams

Number of physician participants

Number of other participants in team

Number of rollover teams

N/A

Number of recruited teams

Number of teams that dropped out

Collaboratory Work

Methodology

Purpose

• Completion of pre-work assignments, including a practice profile, staff satisfaction surveys and an aim statement prior to the first learning session.

CAFP staff interviewed physicians and staff at seven practices that had participated in at least one of the three Collaboratories. The goal of the meetings was to understand from both physician and team member perspectives what led to improvements in workflow, patient self-management and team-based care, as well as the practices’ successes or challenges in sustaining these efforts. The key question was, “How did they do it?”

This monograph focuses on the experiences of solo and small primary care practices in adopting patient registries, improving workflow, implementing team-based care, incorporating patient self-management, redesigning visits to focus on planned care, implementing group visits, and much more. It also describes promising practices achieved during NDDC.

• Collection of baseline and follow-up chart review data of measures related to care for patients with diabetes (e.g., A1c, blood pressure, lipids, etc.). • Attendance at one day-long, in-person learning session that included a project overview, an introduction to using practical tools for quality improvement (QI) and an explanation of how to incorporate QI and chronic disease management into practice redesign. • Attendance at a series of highly structured learning sessions with expert faculty. The first Collaboratory consisted of four five-hour virtual sessions (webinars). Based on feedback from C2 participants, CAFP changed the five-hour sessions to three-hour sessions for C3. The teams also met in monthly one-hour conference calls addressing clinical or redesign topics. • Participation in team coaching calls monthly in which CAFP staff answered questions, updated participants about other teams’ progress and assisted practices in finding resources. On these calls, CAFP staff also tracked completion of Small Tests of Change (STOCs), also known as the Plan, Do, Study, Act (PDSA) cycle.

CAFP used the same interview questionnaire for each site visit (see Appendix), but interviews were open-ended. Practices were provided with the questionnaire in advance; some submitted written responses. CAFP requested interviews with all team members involved in the project. Some practices were able to accommodate this request; others chose to have the physician provide most, if not all, of the information. In some cases, supplemental interviews were conducted with other members of the practice team. Whenever possible, interviews were recorded. In addition, CAFP asked for any materials (e.g., exam room signs, flow sheets and patient education materials) developed or improved as a result of the project. CAFP also asked to observe how office practices and workflow had changed as a result of the team’s participation in the Collaboratory.

Over the course of this three-year initiative, CAFP heard many anecdotal reports about barriers to practice redesign, including staff turnover, technology adoption challenges, office relocations and other problems. Each practice explained its efforts to overcome these challenges. CAFP concludes that although practices can be creative in managing challenges, the payment and contracting landscape continues to test many small and solo primary care practices. In addition, practices are in varying stages of technology adoption and the cost and complexity of technology are formidable barriers for small practices that already operate on thin profit margins. Nonetheless, physicians and staff are enthusiastic about improving the quality of care they provide; given appropriate training and support, they can redesign their practices and make vast improvements in the management of chronic diseases such as diabetes.

• Work in participants’ medical practices to test STOCs and, when improvements resulted, using practice redesign to achieve aim statement goals. Analysis of clinical and redesign data at the end of C2 showed that a number of practices had achieved a range of accomplishments (Note: the following do not contain results from C3). These included: • Increasing the percentage of patients with diabetes screened for eye exams from 29 percent to 75 percent (Grace Medical Group of the Valley, Inc.). • Increasing the percentage of patients with diabetes screened for foot exams from six percent to 29 percent (Merced Faculty Associates). • Increasing the percentage of patients with diabetes with a microalbuminuria test performed from 29 percent to 78 percent (Sierra Spring Family Wellness Center).

… they can redesign their practices and make vast improvements in the management of chronic diseases…

• Increasing the percentage of patients with diabetes with self-glucose counseling from 11 percent to 63 percent (Doyle Park Family Medicine Office). • Increasing the percentage of patients with diabetes screened for depression from 26 percent to 92 percent (Grace Medical Group of the Valley, Inc.).

2 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

NEW DIRECTIONS IN DIABETES CARE DATA To begin the Collaboratory process, CAFP asked each team to gather benchmark data by reviewing randomly selected charts of 35 patients with diabetes. Data then were entered into CAFPâ&#x20AC;&#x2122;s online data collection platform, ceCity, using National Committee for Quality Assurance (NCQA) and other diabetes and comorbidity measures recommended by CAFPâ&#x20AC;&#x2122;s NDDC Advisory Committee. Quality measures for populations, in addition to individual patients, are important for any QI effort and for informing decisions about service delivery design.

Collaboratory 2

Collaboratory 1 Data Point

Aggregate Baseline

Aggregate Follow-Up

National Benchmark

A1c (average)

7.54

7.39

LDL (average)

99.63

95.44

<100

Microalbuminuria

47%

69%

>50%

Foot Exam Performed

39%

68%

>80%

Eye Exam Performed

39%

56%

>60%

Depression Screening Performed

20%

52%

>50%

At the end of each Collaboratory, teams again reviewed randomly selected charts (for patients with diabetes who had been seen during the course of the Collaboratory). The tables below show aggregate data for all three NDDC cohorts. In C2, CAFP began to include nutrition, foot care and physical activity counseling measures in the group data report because of the significance of these counseling measures in managing diabetes. While the data collected are valuable, the collection process posed challenges. Data entry errors occurred, but the system did not allow data deletion, so incorrect data remained in the system. Another technological limitation was the inability to distinguish data for each cohort. All data flowed into an aggregate pool. This meant that when C2 practices viewed the data, the pool included data from C1, and when C3 viewed the data, the pool included data from C1 and C2. Individual practice data, however, were not affected. Finally, some practices participated in more than one Collaboratory, which may have affected the aggregate data pool.

4 new directions in diabetes care: promising Practices

Collaboratory 3

Data Point

Aggregate Baseline

Aggregate Follow-Up

National Goal or Benchmark

Data Point

Aggregate Baseline

Aggregate Follow-Up

National Goal or Benchmark

A1c (average)

7.4

7.34

A1c (average)

7.39

7.27

Microalbuminuria

52%

66%

>50%

Microalbuminuria

56%

68%

>50%

Foot Exam Performed

37%

59%

>80%

Foot Exam Performed

41%

59%

>80%

Eye Exam Performed

39%

52%

>60%

Eye Exam Performed

42%

54%

>60%

Depression Screening Performed

30%

42%

>50%

Depression Screening Performed

32%

44%

>50%

Influenza Vaccine Administered*

25%

41%

73%

Influenza Vaccine Administered*

29%

50%

73%

Pneumovax Administered*

23%

40%

66%

Pneumovax Administered*

25%

46%

66%

Self-Glucose Monitoring Results

45%

63%

50% noninsulin 97% insulin

Self-Glucose Monitoring Results

48%

64%

50% noninsulin 97% insulin

Nutrition Counseling Provided

52%

71%

Not available

Nutrition Counseling Provided

55%

70%

Not available

Foot Care Counseling Provided

34%

52%

Not available

Hypo/Hyperglycemia Counseling Provided

31%

40%

Not available

Physical Activity Counseling Provided

51%

63%

Not available

Physical Activity Counseling Provided

53%

63%

Not available

* Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health promotion: Behavior Risk Factor Surveillance System (2001)

new directions in diabetes care: promising Practices

Aim Statement: Metro Family submitted the following aim statement for its 2005-06 work: • Fifty percent of patients will have had a documented dilated eye exam done in the previous 12 months. • Sixty percent of patients will have had a documented monofilament test (foot exam) done in the previous 12 months.

Practice: Metro Family Physicians Medical Group (Metro Family) Location: San Diego, CA Physician Leader: Ada Marin, MD, MPH Team Members: Christine Eros, MD; Olga Vera, Medical Assistant; Tammy Duong, Medical Assistant Participating Year: Collaboratory 1

Data Report

Data Point

Metro Family Baseline Data

Metro Family Follow-up Data

National Benchmark

A1c (average)

6.74

6.59

LDL (average)

83.14

81.54

<100

Microalbuminuria

80%

89%

>50%

Foot Exam Performed

34%

86%

>80%

Eye Exam Performed

23%

66%

>60%

Depression Screening Performed

26%

>50%

Sustainable Changes and EMR Adoption Ada Marin, MD, MPH is co-owner of Metro Family, a private family medicine practice with a 20-person staff. She credits her participation in NDDC with improving patient care and increasing her practice’s income. By taking small steps, such as expanding medical assistants’ knowledge and participation in patient care, and large steps, including moving to an electronic medical record (EMR), Dr. Marin led a successful practice transformation. Metro Family made a series of improvements during and after the Collaboratory. The most significant were technology adoption and workflow changes. Prior to the Collaboratory, the group had been working to set the stage for EMR implementation. The practice’s goal of implementing this technology was part of the impetus to sign up for NDDC. Dr. Marin and Christine Eros, MD, along with medical assistants (MAs) Tammy Duong and Olga Vera, formed a Collaboratory team and developed aim statements.

Practice staff members, primarily MAs, significantly increased their involvement in chronic disease management, particularly in the improvement of workflow in the subspecialty referral process, performance of foot exams and coordination of lab data. They also created a customized template for Centricity Logician, their EMR. Using these tools, Dr. Marin pre-loaded patient visit information to optimize the team’s use of time in the face-to-face patient encounter. Metro Family also achieved significant improvement in its clinical measures and chart documentation. Based on physicians’ anecdotal reports, patient satisfaction also increased. In addition, the focus on chronic disease management brought public recognition to the practice. Dr. Marin was featured in 2007 in The San Diego Union-Tribune, for example, for her efforts in QI and diabetes care. In their CAFP interviews, team members expressed their belief that new patients were eager to make appointments with Dr. Marin because of the positive publicity the practice received. Also based on anecdotal reports, established patients appreciated the changes in care. A number of patients noted the increase in testing (e.g., foot exams) and expressed appreciation for more comprehensive care. Before fully transitioning to an EMR, the practice took small steps to track patients with chronic diseases, which made EMR implementation much easier. As part of the diabetes Collaboratory, staff used blue stickers to label all diabetes charts. When Metro Family implemented an EMR, the data transfer was seamless and all patients with diabetes were noted in the system. Loss of data can occur when transitioning to an EMR, but this process ensured that no patient with diabetes was left behind. As part of the process, Dr. Marin also asked the EMR software company to customize templates according to her specifications; the result was an efficient and user-friendly system. Metro Family’s QI goals were sustained by the use of its EMR. Physicians and staff developed the infrastructure to improve office processes and facilitate data-driven improvement work. They first customized the EMR, which has a minimal navigation, tab-oriented design that lets the user categorize information important to the physician and patient. Metro Family chose specific tabs, including one for immunization updates. One drawback of this EMR, however, is the lack of a registry function. Without a registry, the practice can no longer do population management for patients with chronic diseases. Staff initially maintained a paper-based diabetes registry with flow sheets as part of the Collaboratory work, but they disliked the time it took to maintain two systems. Dr. Marin ultimately decided to put maintenance of a registry on hold. The EMR system, however, has been an improvement in most other areas.

6 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Finances and Pay-for-Performance

Office Staff

Spread

Practice Pearls

Dr. Marin believes that participation in the Collaboratory had a direct impact on the practice’s finances. Sixty percent of Metro Family’s patients are in capitated plans. She said that improved management of patients with chronic diseases is a central component of improving the sustainability and profitability of the practice. This shift made sense clinically and Metro Family’s achievements prove Dr. Marin’s belief that a clinically sound practice also can be a profitable one.

“My staff is my backbone,” said Dr. Marin, who takes great pride in her medical team’s capabilities. All of the Metro Family MAs participated in a Diabetes Care Coordinator (DCC) training program, an NDDC resource CAFP provided in collaboration with Lumetra. Staff members uniformly found the program helpful and were excited to implement new techniques with patients. Ms. Vera now discusses diabetes health concerns with patients before the physician steps into the room. She performs glucose control tests, prepares lab slips and discusses dietary issues with patients as well. Prior to NDDC, she was reluctant to provide recommendations because she was concerned that her knowledge base was inadequate. As a certified DCC, she has the confidence to talk with patients about diabetes. In fact, as the first point of contact, Ms. Vera says she feels privileged to answer patient questions. Ms. Duong, currently in nursing school, found the training so helpful that she feels she has an edge over classmates when they discuss diabetes.

Dr. Marin had the opportunity to spread Collaboratory learnings in many ways. The article in The San Diego Union-Tribune was one of the most effective. In 2007, she also was named CAFP’s Family Physician of the Year. She likes to recount her NDDC experiences and successes and has served as a speaker at CAFP annual meetings.

Dr. Marin’s advice to colleagues interested in QI is that it does take time, but the rewards are significant. She devoted a minimum of eight hours every two months to data entry, the most time-consuming activity, and estimates a total of 50 to 60 hours during the Collaboratory year to maintain the paper registry. Her dedication to QI was well worth it, however, because her practice is thriving. NDDC has improved Metro Family’s physician, patient and staff satisfaction.

Metro Family first received pay-for-performance (P4P) money when Dr. Marin participated in Lumetra’s (California’s former Quality Improvement Organization) California Quality Connections (CQC) program in 2005. Under a contract authorized by the Centers for Medicare and Medicaid Services (CMS), Lumetra offered physician practices assistance in selecting, implementing and fully utilizing an EMR throughout the fouryear CQC initiative. Participants also were eligible to apply for a Medicare Care Management Performance (MCMP) demonstration project and receive up to $100,000 annually in P4P funds. The program included training for physicians to learn about the benefits and eligibility requirements of P4P, the required clinical measures and data collection process and how to report and obtain payment. While participating in the Lumetra program, Metro Family worked diligently to document chronic disease care and produce P4P reports through its EMR. The group’s hard work paid off when the practice received the full amount of funds for which it was eligible. This was the first time Metro Family received money from a federal agency for its QI efforts and patient data collection. The practice continues to bring in approximately $100,000 annually from P4P. Most, if not all, of the money earned has gone toward reducing debt incurred when new equipment was purchased for EMR implementation.

One of the most powerful takeaways Dr. Marin likes to share with patients came from an NDDC learning session on motivational interviewing led by William Polonsky, PhD. He asked physicians to name the top cause of blindness and unnecessary amputation. The answer: poorly controlled diabetes. Wellcontrolled diabetes is not a cause of blindness or amputation. This statement was eye-opening for Dr. Marin and, after the session, she asked her staff and patients the same question. She posted Dr. Polonsky’s quote in exam rooms and quizzes every patient with diabetes who walks into her office. She says it is a powerful motivational tool.

Dr. Marin successfully incorporated new diabetes protocols, finding it easier to take small steps than to institute big changes all at once. She decided not to have MAs perform foot exams, for example, and instead asked them to have patients with diabetes remove their shoes and socks at the start of a visit. That small additional step for staff saves time for physicians, improving practice efficiency. Because staff workload is heavy, Dr. Marin often hesitates to ask MAs to perform additional work, which was another reason the practice was unable to maintain the registry of patients with diabetes. She instead entered data into a paper registry herself. Staff members already work hard, she said. Physicians see approximately 30 patients a day; nurse practitioners see between 15 and 20 patients. Nurses are also responsible for phone follow-ups, scheduling appointments and more, all part of the team care concept taught in NDDC.

The practice continues to bring in approximately $100,000 annually from P4P.

8 new directions in diabetes care: promising Practices

…it does take time, but the rewards are significant.

new directions in diabetes care: promising Practices

Aim Statement: Grace Medical submitted the following aim statement for its 2006-07 work: Over the next year, our practice will improve diabetic control and patient compliance by redesigning care and improving self-management education for our patients with diabetes. Goals: • Implement a computerized disease registry of all patients with diabetes. • Design and conduct quarterly group visits.

Practice: Grace Medical Group of the Valley, Inc. (Grace Medical)

• Assess more than 80 percent of patients for neuropathy. • Provide more than 80 percent of patients with a routine foot examination.

Location: Pomona, CA Physician Leader: Craig Endo, MD Team Members: Jennifer Sun, MD; Nikki Pham, Medical Assistant Participating Year: Collaboratory 2

10 new directions in diabetes care: promising Practices

Data Report

Data Point

Grace Medical Baseline Data

Grace Medical Follow-up Data

National Benchmark

A1c (average)

7.35

7.2

Microalbuminuria

57%

94%

>50%

Foot Exams Performed

20%

53%

>80%

Eye Exams Performed

29%

75%

>60%

Depression Screening Performed

26%

92%

>50%

Influenza Vaccine Administered

43%

53%

73%

Pneumovax Administered

51%

56%

66%

Self-Glucose Monitoring Results

49%

94%

50% noninsulin 97% insulin

Nutrition Counseling Provided

83%

92%

Not available

Foot Care Counseling Provided

37%

97%

Not available

Physical Activity Counseling Provided

86%

92%

Not available

Enthusiasm for Diabetes Care Craig Endo, MD was one of the first physicians to sign up for C2. Dr. Endo and colleague Jennifer Sun, MD attended the first learning session and appreciated the innovative topics of practice redesign and use of information technology in the management of patients with diabetes. When they returned to their office, they were eager to share their learnings. Drs. Endo and Sun report that some staff members expressed immediate interest in NDDC because of a personal connection to the disease (e.g., a family member with diabetes) and wanted to learn more about it. After participating in NDDC, Dr. Endo is more proactive when managing diabetes and more dedicated to helping patients reach their clinical goals and live longer, healthier lives. Seeing positive physical and emotional changes in his patients during the Collaboratory year renewed his enthusiasm for managing chronic diseases.

Diabetes Registry Grace Medical achieved its goal of implementing a diabetes registry and has been able to sustain this significant change. Dr. Endo was the driving force behind registry adoption, although actual implementation was accomplished through efforts of the entire care team. Overall, investing in health information technology (HIT) has been a good use of time. Dr. Endo took advantage of the free, two-year DocSite registry license offered by CAFP through NDDC. Compared with the paper flow sheet he had been using, one benefit of the Webbased product is that it facilitates the capture of a wide range of data, such as patient counseling measures, in addition to clinical measures. The registry is so useful that Dr. Endo hopes to begin using it for other chronic diseases. The goal is to add a condition or disease state to the registry each year, beginning with asthma. Prior to using a registry, Grace Medical staff documented patient data using flow sheets. One MA, Nikki.Pham, was the lead for data entry during registry implementation. A fast typist, she took five to seven minutes to enter data for new patients and less than three minutes for established patients. Ms. Pham entered demographic data for more than 340 patients with diabetes in approximately two weeks. Use of the registry facilitated P4P bonus payments and a significant portion of these funds go toward her salary.

new directions in diabetes care: promising Practices

Group Visits

Improvements in Patients’ Health

Small Tests of Change (STOCs)

Dr. Endo’s second redesign goal was to implement group visits with patients. Several staff members were involved in this process. Dr. Endo took the lead in developing the visit agendas. Visits were scheduled for Saturday afternoons and took place at the practice. Between 10 and 15 patients attended each session.

Dr. Endo described the example of a 57-year old male patient, “Mr. B.” His first routine check-up took place after a recent marriage; his wife was present at this visit. Tests showed glucose in his urine, a hemoglobin A1c of 11.2 and a dense cataract in one eye. On his second visit, he had diabetic neuropathy. Mr. B’s situation was so serious that he and Dr. Endo developed an emergency action plan. Dr. Endo monitored and counseled Mr. B regularly, addressing his and his wife’s concerns. When Mr. B became discouraged because he wanted faster results, Dr. Endo reinforced the idea that getting healthy had to be a gradual process. Mr. B’s A1c dropped from 11.2 to 6.7 over six months because of lifestyle improvements, including eliminating fast food from his diet, enrolling in local diabetes education classes, adhering to his medication schedule and consulting an endocrinologist.

The STOCs process has been the starting point for every new workflow idea in this practice. At the beginning of the Collaboratory year, Dr. Endo was extremely motivated to redesign his entire office and his ambitious goals were reflected in the practice’s aim statement.

Two-hour-long visits included a guest speaker (e.g., a diabetes educator or podiatrist) and were moderated by one of the practice’s physicians. Sessions were open to both English and Spanish speakers; a local diabetes educator, fluent in Spanish, attended and interpreted. Dr. Endo’s staff followed the same protocol prior to each group visit: attendees’ charts were pulled, individual Visit Planner™ sheets printed and attendance confirmed with patients via phone call. Group visits included patient registration, vital signs assessment, education and information sessions, and review of individual Visit Planner™ sheets to concretely show patients their progress toward clinical goals, compared with national benchmarks. Each patient encounter was coded as an evaluation and management service. Patients rated the group visits positively and Grace Medical still holds them. Dr. Sun plans to use the same format to address teen obesity or eating disorders.

Cycle Time Measurements Grace Medical conducts patient surveys on a regular basis. After each visit, patients are asked to complete a quick survey that includes questions about cycle time. Cycle time is the length of time in minutes that a patient spends at an office visit. Grace Medical chose to measure the number of minutes it took to sign in and room a patient, with a goal of less than 10 minutes. The group reviews small samples of results periodically.

When the concept of STOCs was introduced to Collaboratory participants at the first learning session, Drs. Endo and Sun reflected on the value of starting small. They believed that to make sustainable workflow changes, work had to be done in manageable steps and analyzed and assessed over time to determine whether changes resulted in practice improvements. Dr. Endo’s analogy for transforming his office was that change is “like training [for] a marathon. It is not a sprint but a slow and steady run.” One change the practice attempted to make, incorporating team huddles, was not sustainable. Although huddles work well in some offices, they did not work for Grace Medical. Instead, monthly staff meetings were found to be effective. These meetings took place in the afternoon and lunch was provided. “Prior to the Collaboratory, staff meetings were sporadic,” said Dr. Endo. “One key thing the Collaboratory has done for us is help our team meet monthly and it has improved the way we work.” Regular staff meetings have helped support innovation as well as staff coordination. For example, a diabetes visit protocol was developed during one meeting. The protocol outlined steps MAs and physicians should take when new or established patients with diabetes visit the practice. Dr. Sun said one benefit of the protocol is that, although each staff person has his or her individual clinical duties, standardized processes ensure accuracy and efficiency. Furthermore, the protocol has been a great resource when training new MAs. Dr. Endo plans to develop additional protocols.

Grace Medical also changed its ophthalmologist referral process. The practice had not been routinely receiving reports from sub-specialists to whom patients had been referred. During the Collaboratory, the practice identified several local ophthalmologists to whom physicians referred patients; the practice continued working with those who consistently provided reports.

Spread Dr. Endo serves as adjunct faculty at a local family medicine residency program, where he enjoys talking to residents about his experiences in QI and encourages colleagues and students to participate in QI programs. He believes that while change is peer-driven, improvement must also be data-driven. He credits NDDC as a strong motivating factor that helped him think of creative ways to manage care for his patients with chronic diseases.

Mr. B’s A1c dropped from 11.2 to 6.7 over a six-month period because of lifestyle improvements…

…transforming his office was...“like training for a marathon. It is not a sprint but a slow and steady run.”

12 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Aim Statement: Merced submitted the following aim statement for its 2006-07 work: Through our participation in NDDC, our practice will implement improved care of our patients with diabetes. Our goals are to: • Hold regular team meetings to discuss progress. • See a rate of more than 75 percent of our patients with diabetes with SBP (systolic blood pressure) at less than 140. • Establish a Diabetes Care Coordinator in our practice.

Practice: Merced Faculty Associates (Merced) Location: Atwater, CA Physician Leader: Isaac Kim, MD Team Members: Cindy Coberley, Office Manager; Mary Club, Medical Assistant Participating Year: Collaboratory 2

• Maintain a registry, which will contain more than 30 percent of our patients with diabetes.

Data Report

Data Point

Merced Baseline Data

Merced Follow-up Data

National Benchmark

A1c (average)

6.85

6.78

Microalbuminuria

43%

31%

>50%

Foot Exams Performed

29%

>80%

Eye Exams Performed

23%

51%

>60%

Depression Screening Performed

31%

>50%

Influenza vaccine Administered

17%

26%

73%

Pneumovax Administered

14%

11%

66%

Self-Glucose Monitoring Results

17%

50% noninsulin 97% insulin

Nutrition Counseling Provided

51%

Not available

Foot Care Counseling Provided

14%

11%

Not available

Physical Activity Counseling Provided

20%

Not available

Practice Motivation Prior to participating in NDDC, Merced physicians participated in the American Academy of Family Physicians (AAFP) Measuring, Evaluating, and Translating Research Into Care (METRIC) program. Dr. Kim, the NDDC project lead, attributed the group’s involvement in other QI projects to its earlier participation in METRIC. As part of METRIC, the group completed a practice assessment questionnaire based on data for 10 patients and then received a summary report with peer comparison data and a recommended improvement plan. METRIC helped staff members appreciate the value of continuous data collection. To leverage momentum, they then decided to participate in NDDC. Another incentive was that NDDC was free of charge; METRIC required a nominal fee for each online module. The push to prepare for P4P reporting also contributed to the decision. On a personal level, Dr. Kim’s motivation to serve as a physician champion was based on attending a local Merced conference at which diabetes expert Kwabena Adubofour, MD discussed the value of using chronic disease registries. After the conference, Dr. Kim was convinced that Merced needed to develop a registry to better manage its patients with chronic diseases. He realized, for example, that by using a registry, his practice could better track patients – especially those not adhering to medical advice – and more closely supervise care.

Isaac Kim, MD credits participation in NDDC with implementing a flow sheet and patient registry to improve chronic disease care. With the help of talented support staff, Merced gained confidence to participate in performance improvement projects. (Note: After a provider became seriously ill, NDDC implementation was delayed and follow-up data above were entered into the ceCity database before many of the workflow changes were implemented.)

14 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Registry Implementation

Flow Sheets

Staff Satisfaction

Financial Incentives

The successful implementation of a registry depended substantially on the contributions of a skilled and motivated staff person. Dr. Kim initially asked an MA who was not comfortable with technology to do some of the data entry; this was not an effective solution. A part-time MA in the Medical Records Department, Mary Club, then expressed interest in the project and her attention to detail and typing skills contributed to her success. “It is important to find the right person with the aptitude and interest in doing computer work,” Dr. Kim explained, “rather than simply appointing someone to do it. We had to identify a reliable person and challenge her to incorporate the new work as part of her daily routine.”

Dr. Kim implemented a diabetes flow sheet and registry at the same time. The first task was to choose a flow sheet that everyone agreed on. There were several to choose from, but the group came to consensus during a staff meeting. Once the flow sheet was selected, MAs were asked to attach one to the chart of every patient with diabetes before a visit. This was not done consistently, however, because it differed from the standard workflow. Based on this feedback, Dr. Kim requested that Medical Records staff perform this task and that was effective. He noted that, in retrospect, the switch made sense because Medical Records already had a system for pulling patient charts, similar to an assembly line process, and adding a flow sheet and Visit Planner™ sheet was relatively simple.

Staff members acknowledged that Dr. Kim enjoys taking on new projects. He recognized, however, the added responsibilities required to accomplish these goals. To get staff support for NDDC, he was honest and up front about the additional time the project would require. He also provided as much context as he could and held a meeting to request staff participation. Office manager Cindy Coberley recalled how Dr. Kim’s motivation to help patients with diabetes inspired her and said she was humbled that the physician was asking staff for help. Staff members did not find the new work difficult and felt good knowing their efforts would directly improve patient care.

Merced’s implementation of a registry and flow sheet prepared it for P4P because the practice had already gathered much of its diabetes data during NDDC. In fact, additional data gathering was minimal. When staff created P4P reports for other chronic diseases, the diabetes reports were noticeably better. Dr. Kim foresees clinical reporting as a future mandate in the medical profession and highly recommends that his colleagues implement technology to automate data gathering. After NDDC, Merced participated in the MCMP project described in Dr. Ada Marin’s profile. Ms. Club was the designated data-entry specialist for this project as well. Her success with NDDC gave the group confidence to participate in subsequent performance improvement projects.

Merced established a protocol for using its registry system. Several days before a patient visit, the Medical Records Department pulls patients’ charts. If diabetes is noted as a diagnosis, a Visit Planner™ sheet is printed and placed on top of the chart to ensure visibility. A sheet is placed on the chart of every patient with diabetes, even if diabetes is not the patient’s chief complaint at the time of that visit.

Ms. Coberley reported that the NDDC affected everyone in the practice. She works closely with the MAs and noticed their increased consistency in routinely asking patients with diabetes to remove shoes and socks at the start of each visit. Even staff members who typically would not have been connected to patient care learned about diabetes management. Medical Records Department staff, for example, now knows what a “DM” code means, what a flow sheet is and why it is significant.

This system was inspired by a Collaboratory seminar, Planned Care, led by Michael Zimmerman, MD, an NDDC faculty member and participant. During the first C2 learning session, Dr. Zimmerman explained how he uses a Visit Planner™ sheet as a tickler system in his practice. Merced was able to track 100 percent of its patients with diabetes in the registry. On a quarterly basis, the staff has been pulling reports of patients who are not doing well and contacting patients not yet scheduled for a follow-up visit.

“ It is important to find the right person with the aptitude and interest in doing computer work.”

…staff members did not find it difficult and felt good knowing their efforts would directly improve patient care.

16 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Aim Statement: North Coast submitted the following aim statement for its 2006-07 work: North Coast will redesign our system to maximize the health care of our patients with diabetes in a cost-effective manner. Using NDDC, we will become the model of exemplary diabetes management for primary care in our Independent Physicians Association (IPA) targeting the following measures: • Seventy percent of our patients with diabetes will have an LDL less than 130.

Practice: North Coast Family Medical Group (North Coast) Location: Encinitas, CA Physician Leader: Susan Glockner, MD Team Member: Lisa Haggerty, Information Systems Specialist Participating Year: Collaboratory 2

• Eighty percent of our patients with diabetes will have documented foot exams. • Sixty percent of our patients with diabetes will have had documented ophthalmologic exams in the past year. • Ninety percent of our patients with diabetes will be in a diabetes registry. • Seventy percent of our diabetic visits will be documented with a diabetes template. • Ten percent of our patients with diabetes will have attended at least one group visit for diabetes care. • After October 1, 2007, we will make plans to do a similar process for another chronic disease (such as asthma). • Physician time needed to manage patients with diabetes will not increase and the group’s profit-loss ratio will not worsen as a result of our intervention.

Susan Glockner, MD was grateful to have a staff member, information systems specialist Lisa Haggerty, co-lead NDDC at North Coast. Together, they encouraged their group to work on improving the quality of care for patients with diabetes. Graphs and data were essential factors in motivating staff.

Technology Dr. Glockner read about the second NDDC cohort in CAFP’s biweekly e-newsletter, Academy in Action, and asked staff members if they were interested in participating. Ms. Haggerty immediately expressed interest in the project; she and Dr. Glockner became project leads. Ms. Haggerty was drawn to the data component of the Collaboratory and eager to use a registry as a tool to analyze patients as populations. Prior to NDDC, the practice had already downloaded free registry software, the Chronic Disease Electronic Management System (CDEMS), a Microsoft Access database application. North Coast already had an EMR, e-ClinicalWorks (eCW), and began using both systems concurrently. North Coast later attempted to sync CDEMS with its EMR but the merge was unsuccessful. When North Coast’s EMR vendor gave notification that an upcoming version of the software would include a registry function, the group discontinued CDEMS and waited for the upgrade. North Coast then implemented eCW’s full registry and began grouping its patients by disease diagnoses, deceased patients, outliers and other categories.

Data Report

18 new directions in diabetes care: promising Practices

Data Point

North Coast Baseline Data

North Coast Follow-up Data

National Benchmark

A1c (average)

6.83

6.91

Microalbuminuria

57%

51%

>50%

Foot Exams Performed

31%

51%

>80%

Eye Exams Performed

40%

37%

>60%

Depression Screening Performed

26%

43%

>50%

Influenza Vaccine Administered

17%

23%

73%

Pneumovax Administered

66%

Self-Glucose Monitoring Results

47%

37%

50% noninsulin 97% insulin

Nutrition Counseling Provided

74%

66%

Not available

Foot Care Counseling Provided

29%

46%

Not available

Physical Activity Counseling Provided

69%

60%

Not available

Because of their NDDC participation, North Coast physicians became better at documenting encounters with patients with diabetes. Previously, for example, they sometimes advised patients to visit an ophthalmologist but did not document the referral. Physicians also at times provided paper referrals to patients but had no process to determine whether patients made or kept appointments. One of North Coast’s former MAs, Cesar Ayala-Rodriguez, MD, proposed an imaging system in the EMR that would document, with just one click, whether an ophthalmology referral was provided and, with another click, whether the exam was completed. This customization was easy to do. Dr. Ayala-Rodriguez is a physician from Mexico who briefly worked at North Coast as an MA and is now a medical resident in New York. Dr. Glockner and Ms. Haggerty feel lucky that he championed innovation during his time with the group. Also as a result of participating in NDDC and better documenting its diabetes population, North Coast felt prepared to work on P4P and the CMS Physician Quality Reporting Initiative. The office manager served as project lead for both. The practice began with diabetes and used NDDC learnings to manage other chronic diseases as well.

new directions in diabetes care: promising Practices

Engaging Staff Communication was essential in engaging the rest of the North Coast staff. When Dr. Glockner and Ms. Haggerty introduced NDDC at a meeting, staff members were reluctant to take on a new project and concerned that they did not have enough time for the additional workload. Dr. Glockner and Ms. Haggerty explained the project in detail and the work that would be required. The goal was to create a list of every patient with diabetes in the practice. They believed this work would not be overwhelming or unreasonable; the practice had a relatively small population of approximately 500 patients with diabetes. Dr. Glockner also provided an overview of the diabetes assessment form they planned to use to document clinical measures and held shorter follow-up meetings to address other questions. Physicians and staff met the following week for a progress report. At the meeting, Ms. Haggerty presented a graph showing the number of diabetes visit forms each physician/ MA team had completed. Results were displayed in the meeting room and staff reviewed each team’s progress. A week later, the number of documented diabetes visits had decreased, so Dr. Glockner called a staff meeting to reinforce the importance of documenting every patient with diabetes, every visit. The graph reminded staff to stay motivated and consistent. Staff meetings were also educational. During one meeting, Dr. Glockner included a question and answer session on diabetes. Staff shared personal experiences and physicians discussed treatment options. The meeting became an open forum and diabetes care became a more personalized issue for the team. Staff members actively contributed and brainstormed creative ways to remind themselves to follow the diabetes protocol. One person suggested making “Got diabetes?” note cards and placing them in every room. The following week, the performance graph showed staff working at peak levels. Each week, Dr. Glockner rewarded the top-performing MA with a Starbucks gift card, a low-cost reward that proved to be an effective form of recognition and an excellent motivator.

Because the performance graphs were so effective with MAs, Dr. Glockner and Ms. Haggerty decided to use the same method with North Coast physicians for ophthalmology referrals. The graph displayed the number of ophthalmology referrals each provider gave to patients with diabetes and the group formally recognized and congratulated the provider with the highest rate of documented ophthalmology referrals. Fostering good-spirited competition, the physicians held team huddles with their MAs to develop action plans before each patient visit. Staff members worked hard and, in Dr. Glockner’s opinion, with a great attitude. Data transparency was crucial to the success of the project and even the group’s shareholders began to notice NDDC’s value.

Patient Satisfaction A customized Health Practitioner Index (HPI) code was created for diabetes in the practice EMR system and the names of all patients with diabetes were flagged in yellow, with the color prominently displayed on the front page of every patient’s profile. When a patient came in one day with a complaint of knee pain, Dr. Glockner pulled the patient’s chart, which was coded bright yellow, indicating that the patient had diabetes. The patient had recently returned from Easter vacation and her lab results were off the charts from her holiday diet. During the visit, she and Dr. Glockner mostly discussed nutrition, diet and exercise and other health-related issues. Dr. Glockner addressed the patient’s knee pain, but the remaining 20 minutes of the visit were devoted to diabetes education. The patient was pleased with the visit because diabetes was something she meant to discuss with her doctor, but never did. Knee pain was the initial reason for the visit, but when Dr. Glockner noted the yellow flag on the patient’s chart, she knew she also had to address the issue of diabetes.

Sustaining the Gains STOCs The rewards of P4P were the staff’s main incentive to continue QI efforts. The clinical measures focused on during NDDC were also P4P reporting measures. A physician in the practice commented that “MAs are documenting diabetes measures at every visit. This has been so very helpful and I do not see them dropping the habit.” Other MAs said that the diabetes protocol, among other wellness visit protocols, made their jobs easier.

Office Hurdles To participate in QI projects, North Coast must obtain the support of upper management. Staff members are open to new projects, but asking for their time and for them to take on additional responsibilities requires prior approval from the practice’s shareholders. With NDDC, no staff members had to work late or be paid overtime. The practice’s IPA, however, made it financially unfeasible for North Coast to work on P4P because funds were distributed among practices based on their relative size, as measured by number of patients, and not based on documented performance improvements. The IPA recognized performance but did not distinguish the practices making improvements. When shareholders do not see direct financial reward, it is difficult to justify staff time dedicated to QI work. This demonstrates the challenges of external factors, such as financial incentives.

North Coast’s successful redesign changes began with STOCs. One was finding a better way to track ophthalmology referrals. This was easy because Dr. Glockner met directly with the ophthalmologist to whom she frequently refers her patients to figure out a way they could both obtain accurate patient data. The ophthalmologist agreed to create a list of Dr. Glockner’s referrals, note whether those patients came in and, if they did, follow up with a report. Both parties maintained an ongoing list for cross-referencing. When there were inconsistencies, staff could easily go back to the list to locate an error or send another reminder to the patient. Referral relationships with sub-specialists are valuable and need to be cultivated, Dr. Glockner said. Practice Pearls Dr. Glockner was motivated to work on QI, but understands the time and dedication it takes. During the first Collaboratory she was a full shareholder and did not have time to devote to a QI project. When CAFP recruited for C2, however, she was planning to retire and work part-time. With a new schedule, she was able to devote time to NDDC and practice redesign. In her view, a full-time provider may have difficulty managing a QI project, especially when work volume is high. “If you have a life outside of medicine, it is hard to find the time to do another project, but the financial and staff payoff are rewarding,” she said. It was also helpful to have Ms. Haggerty manage the project and involve staff as much as possible to ensure the success of NDDC and improve patient care.

One staff member suggested placing “Got diabetes?” note cards in every room.

“…the financial and staff payoff are rewarding.”

20 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Aim Statement: Sierra Spring submitted the following aim statement for its 2006-07 work: Sierra Spring will redesign our system by using the following measures from the NDDC change package: • More than 40 percent of our patients with diabetes will have an A1c of 7.0 or less. • More than 35 percent of our patients with diabetes will have a blood pressure of less than 130/80. • We will design and launch group visits.

Practice: Sierra Spring Family Wellness Center (Sierra Spring) Location: Pasadena, CA Physician Leader: Craig Johnson, MD Team Members: Sheyla Perez, Office Manager; Marisela Dominguez, Medical Assistant Participating Year: Collaboratory 2

• We will implement a patient registry for patients with diabetes.

Data Report

Data Point

Sierra Spring Baseline Data

Sierra Spring Follow-up Data

National Benchmark

A1c (average)

8.19

7.88

Microalbuminuria

29%

78%

>50%

Foot Exams Performed

23%

69%

>80%

Eye Exams Performed

29%

61%

>60%

Depression Screening Performed

31%

>50%

Influenza Vaccine Administered

58%

73%

Pneumovax Administered

11%

44%

66%

Self-Glucose Monitoring Results

14%

64%

50% noninsulin 97% insulin

Nutrition Counseling Provided

23%

81%

Not available

Foot Care Counseling Provided

14%

36%

Not available

Physical Activity Counseling Provided

17%

78%

Not available

Implementing Change Dr. Johnson believes that to improve chronic disease management, change must be approached systematically. While participating in NDDC, he moved from focusing solely on individual care to managing his entire population of patients with diabetes and worked to ensure that the population met national benchmarks. Seeing improvement in the data report over the course of a year, Dr. Johnson was confident that his work was effective. He created a tickler system to identify patients with diabetes and began using a flow sheet. These minor redesign changes produced significant clinical results; the practice saw an almost threefold improvement from its baseline measures. Sierra Spring was a fairly new practice, established in 2004. It had two full-time physicians and used a paper records system. Dr. Johnson asked his MAs to identify charts for patients with diabetes and label each one with a bright pink sticker, which served as a tickler system for staff. When nurses saw the sticker, they were prompted to perform foot exams and blood sugar tests and capture data on body mass index, weight and blood pressure. Once the patient entered the exam room, the sticker then served as a reminder to the physician. This is an example of a small change that was easy to implement and made a great impact. Dr. Johnson focused heavily on increasing the number of flu shots and pneumococcal vaccines and created standing orders for these shots. The idea came from a Collaboratory learning session in which University of California, San Francisco faculty member Hali Hammer, MD described her experience creating similar protocols at a hospital. Dr. Johnson reviewed standing order templates Dr. Hammer presented and created several orders for his office. They were implemented and standardized during the Collaboratory year.

Working in a small practice gave Craig Johnson, MD the flexibility to more easily implement workflow changes. The practice redesign efforts paid off. Sierra Spring’s clinical achievements were substantial and the practice will only continue to improve as Dr. Johnson works to transform the practice, one step at a time.

22 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Group Visits

Registry and Flow Sheets

Office Staff

Flexibility

Another redesign goal was to develop and implement group visits. Dr. Johnson combined two small exam rooms to create a larger office space for group visits and advertised this new service by word-of-mouth and brochures. Front office staff also informed patients of the visits and posted information on the practice’s website.

Sierra Spring took advantage of the free two-year DocSite registry license and asked a volunteer to enter data. Once data were submitted and reports pulled, Dr. Johnson’s numbers showed a strong trend toward improvement.

One challenge at Sierra Spring was staff turnover. At the time of the Collaboratory, one MA was about to take a pregnancy leave and another left to attend nursing school. Another challenge was implementing written protocols. Dr. Johnson says his staff appears to know everything without having anything written on paper. Therefore, the practice found it challenging to transform work processes into written protocols.

Dr. Johnson appreciates the flexibility of working in a small family practice where many of the systems changes were implemented fairly quickly. Larger medical groups may sometimes encounter bureaucratic barriers to even small changes, but he gets minimal resistance when testing new ideas. His staff is supportive and easily adapts to new work roles, which encourages him to try new things to improve patient care and increase workflow efficiency.

Dr. Johnson chose 12 topics to cover in monthly group visits. He wanted the sessions to be interactive and build peer-to-peer relationships. He created PowerPoint presentations and pulled materials from the Family Medicine Digital Resources Library, a service of the Society of Teachers of Family Medicine. The Digital Resources Library provided an abundance of diabetes and other presentation materials, handouts and curricula posted by educators. Dr. Johnson also used tools and resources available on CAFP’s Diabetes Resource Center to learn how to run a group visit. After developing a curriculum, he launched the visits. At the beginning of each group visit, he reviewed each patient’s vitals and then presented the day’s educational topic. Sessions concluded with individual patient-physician time. The group visits were initially successful, but subsequently posed certain challenges. Three patients who attended the first session and a fourth who attended later visits had dynamic personalities and bonded immediately. Initial visits went well and participants were extremely motivated and supportive of one another, even outside the group setting. When two patients eventually had a personal conflict, however, the group disbanded. Dr. Johnson found it difficult to moderate such an intense group; for this reason, he is hesitant to run another one.

Dr. Johnson is humbled by his clinical achievements. As is the case for many physicians, his diabetes baseline measures were lower than he thought they would be. “Once you see the numbers in front of you, there is no turning from it,” he said. His immediate impulse was to work to improve the numbers. The registry produces a clinical measures report on which a blue line denotes a practice’s patient indicators and a red line denotes national standards, where patient results should be. The color-coded graphs “helped keep [me] accountable to make sure what needed to be done got done,” he said. The technology was helpful and the visuals helped him to focus on the clinical measures that needed the most work. Once the registry was in place, it was easier to use flow sheets. Dr. Johnson transferred most of the clinical measures from the registry to a customized flow sheet. He had not previously considered inserting an option for depression screening or a monofilament exam, so using DocSite’s template made the original flow sheet a better one. Unfortunately, Sierra Spring could not afford the system once the free license expired.

In hindsight, that type of visit resembled more of a mini-group visit. Instead of organizing a large group visit, in which not all patients attend every week, or seeing two or three patients with diabetes in separate 20-minute visits, the physician in a mini-visit sees two or three patients with diabetes together. A two-patient mini-group visit is scheduled for 40 minutes. This innovative model is something Dr. Johnson would like to try in the future. If a physician has the capacity to conduct larger group visits, they can be an efficient way of providing care to multiple patients with the same condition.

Despite minor challenges, Dr. Johnson values his team and is grateful for his staff’s support. MA Marisela Dominguez assisted with much of the office redesign and was key in organizing group visits. She attended every group visit, labeled diabetes charts, and also trained other MAs to perform blood glucose tests.

The biggest obstacles for Sierra Spring are time and money. For physicians like Dr. Johnson, traveling for even one day can be impossible because he generally cannot afford to be away from his office with the resulting loss of revenue. Every patient visit contributes to the practice’s viability and financial stability; a day away from the office means fewer patients seen. He did take the leap, however, and attended the first in-person NDDC meeting. In retrospect, he believes he would not have caught the QI “bug” had he not attended the meeting, which led to his participation in C2.

His staff is supportive and can easily adapt to new work roles. This flexibility encourages him to try new things to improve patient care and increase workflow efficiency.

“ Once you see the numbers in front of you, there is no turning from (them).”

24 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Aim Statement: Acacia submitted the following aim statement for its 2006-07 work: • Fewer than 20 percent of our patients will have an A1c over 8.0. • Acacia will establish a registry for patients with diabetes and have 70 percent of our patients who receive care at our Salinas office entered into the registry.

Practice: Acacia Family Medical Group (Acacia) Location: Salinas, CA Physician Leaders: Sumana Reddy, MD and Danielle Acton, MD Team Members: Titia Clouse, Medical Assistant; Maggie Acosta, Medical Assistant Participating Year: Collaboratory 2

• Acacia will revise our diabetes flow sheet and train our MAs to input data. Our goal is to have 50 percent of our patients with diabetes on a current flow sheet.

Data Report

Data Point

Acacia Medical Baseline Data

Acacia Medical Follow-up Data

National Benchmark

A1c (average)

7.7

6.84

Microalbuminuria

51%

40%

>50%

Foot Exams Performed

11%

20%

>80%

Eye Exams Performed

34%

49%

>60%

Depression Screening Performed

26%

57%

>50%

Influenza Vaccine Administered

26%

54%

73%

Pneumovax Administered

34%

51%

66%

Self-Glucose Monitoring Results

54%

43%

50% noninsulin 97% insulin

Nutrition Counseling Provided

54%

83%

Not available

Foot Care Counseling Provided

29%

69%

Not available

Physical Activity Counseling Provided

43%

71%

Not available

Acacia met the clinical goals in its aim statement, but was not able to set up the infrastructure to sustain the redesign goals. Struggles with staff turnover and office changes during the Collaboratory year left Sumana Reddy, MD with limited time and capacity to address QI efforts and practice redesign.

Challenges of a Small Family Practice Dr. Reddy considers the NDDC year a challenging but successful one. Staff turnover was just one challenge her small family practice faced, but it was probably the most disruptive. Shortly after she brought two of her staff members to the first NDDC learning session in Oakland, for example, one left the group. In 2006, Acacia was a small practice in its 11th year of operation. Dr. Reddy remembers having to do much “soul searching” to figure out her next steps. There were financial challenges: the practice had only recently begun paying off its start-up debt and she was putting much of her salary back into the practice. It was challenging to focus on QI when the office’s financial viability was at stake. Overhead was high and payment from health plans was low. Dr. Reddy ultimately decided to downsize across the board, in both staff and space, and realized she should have done so years before.

Improving Processes Developing and using an improved flow sheet was the easiest and most effective way for Acacia to improve care of patients with diabetes. The practice had been using the same health plan diabetes flow sheet since 1998. When Acacia joined NDDC in 2006, flow sheets were discussed and evaluated during the first learning session. Dr. Reddy realized several elements were missing from her flow sheet compared to her colleagues’ and decided to improve it. She chose a new flow sheet and asked each clinician to contribute and make adjustments. After revisions were made, she held a staff meeting to introduce the sheet and train staff. The new sheet asked for so much information, however, that most staff had trouble completing it. Danielle Acton, MD then developed a simpler template, which staff unanimously agreed to use. Another redesign change the practice undertook was creating a system to ensure foot exams were done. The group decided to ask patients to take off shoes and socks before the physician entered the exam room. A short note was written on the foot exam measure on the flow sheet to remind MAs to make the request part of their routine.

The outcome data from Acacia’s clinical measures, however, were positive. Even enthusiastic and committed practices like Acacia face significant challenges in practice redesign. Dr. Reddy overcame many practice management challenges related to running a small family practice during her participation in the Collaboratory and now works with a high-performing team and a satisfied patient population.

26 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Staff Reorganization and Operations

Patient Experience

MA Titia Clouse attended the first learning session with Dr. Reddy and was responsible for overseeing staff assisting with NDDC work. She noticed early on that staff members were eager to learn to use a diabetes registry and enthusiastic about taking on a new project. They labeled each diabetes chart with a purple sticker and, after entering the patient’s information in the registry, labeled the chart again with a red sticker. The DocSite registry, however, could not interface with the practice’s EMR system. Furthermore, two employees left that year and there were not enough staff members to focus on QI activities. Ms. Clouse could no longer serve as the project lead because she had to take on the duties of those who left.

Dr. Reddy’s staff meets monthly, holds a team huddle daily and emails frequently. The group also conducts bimonthly patient satisfaction surveys. With a recent move back to a larger office space, the practice also changed its phone system based on patient feedback to include a bilingual feature. Dr. Reddy is serious about patient surveys and works hard to enhance the patient experience and accommodate patients’ requests. She also likes to share her Collaboratory experience with patients. After one NDDC learning session focused on motivational interviewing (MI), for instance, Dr. Reddy asked patients if she could practice MI techniques with them. She says her MI skills improved because she practiced them, and believes her patients would attest to this improvement. Dr. Reddy encourages colleagues to make the small changes necessary to improve workflow. “We can’t take the risk not to work on quality measures,” she said. “It is better to be proactive. One can be easily intimidated by the changes that need to be made in order to address QI, but it is possible to start small. Physicians need to be brave and try different things.”

“ We can’t take the risk not to work on quality measures. It is better to be proactive. One can be easily intimidated by the changes that need to be made in order to address quality improvement, but it is possible to start small. Physicians need to be brave and try different things.”

28 new directions in diabetes care: promising Practices

new directions in diabetes care: promising Practices

Aim Statement: Doyle Park submitted the following aim statement for its 2007-08 work:

Team Building

• By the end of the Collaboratory year, the average A1c will be equal to or less than 7.2 percent (the previous year’s baseline chart audit was 7.6 percent).

Bo Greaves, MD chaired CAFP’s NDDC Advisory Committee and his practice, Doyle Park, participated in all three Collaboratories. Through the course of the Collaboratory years, he and MA Aleem Emerson made a number of workflow changes and worked closely on building team-based care. Together, the care team developed a template for planned diabetes visits to promote easy and efficient documentation. When a patient with diabetes walks into the office, Ms. Emerson completes much of the clinical information on the diabetes flow sheet, including recording the patient’s most recent ophthalmology exam, and performs a foot exam. Every visit of a patient with diabetes is clearly noted on the office’s scheduling system by front office staff, so Ms. Emerson is reminded to use the established protocol. Work done in advance improves the work of other team members, particularly Dr. Greaves.

• By the end of the Collaboratory year, more than 60 percent of patients will have an annual eye exam with an ophthalmologist (the previous year’s baseline chart audit was 37 percent).

Practice: Doyle Park Family Medicine Office (Doyle Park) (now known as Sutter Medical Foundation of the North Bay) Location: Santa Rosa, CA Physician Leader: Lyman “Bo” Greaves, MD Team Member: Aleem Emerson, Medical Assistant Participating Year: Collaboratory 1, 2, 3

• Design and implement group visits. • Expand MAs’ role in team care. We would like to empower our MAs and have them more involved with patients. They will enter more information before an appointment so it will take less time during the visit and increase patient/provider time. They will request information from patients regarding eye exams and foot exams. They will get comfortable entering labs and be more detailed in their notes when in the exam room. Doyle Park will hold monthly lectures for the MAs to expand their knowledge about diabetes and chronic care illnesses.

Data Report

30 new directions in diabetes care: promising Practices

Data Point

Doyle Park Baseline Data

Doyle Park Follow-up Data

National Benchmark

A1c (average)

7.04

6.55

Microalbuminuria

66%

74%

>50%

Foot Exams Performed

34%

57%

>80%

Eye Exams Performed

40%

>60%

Depression Screening Performed

23%

14%

>50%

Influenza Vaccine Administered

71%

73%

Pneumovax Administered

23%

66%

Self-Glucose Monitoring Results

57%

83%

50% noninsulin 97% insulin

Nutrition Counseling Provided

46%

80%

Not available

Foot Care Counseling Provided

17%

57%

Not available

Physical Activity Counseling Provided

54%

71%

Not available

Dr. Greaves and Ms. Emerson practice as a team and chose to make small, incremental changes to their routine, changes not limited to diabetes-related work. One NDDC learning session, for example, addressed redesigning workspace to facilitate faster patient flow and improve team communication and overall performance. After that session, Dr. Greaves and Ms. Emerson decided to work in close proximity and now work at the same station. The office redesign has worked out very well for both of them and improved many aspects of their work. They communicate with one another frequently and work closely throughout the busy clinic day.

new directions in diabetes care: promising Practices

Challenges

Relocation and the Genesis of a Care Team

Improving Patient Care

Reflection

The team’s main challenge has been spreading lessons learned to other practice members. Although workflow changes made their professional lives easier, for instance, others in the practice have been reluctant to change. Some physicians prefer to work in the privacy and quiet of their offices and some staff members prefer to work at their own stations. Various patterns can be difficult to alter and physical constraints in the office layout prohibit rearrangement of furniture. Dr. Greaves and Ms. Emerson continue to set an example for other team members, however, and hope to inspire them to redesign with efficiencies in mind.

Doyle Park, a three-practice independent group of family physicians in the Santa Rosa area, included Rohnert Park, Cherry Street and Santa Rosa offices. During the third Collaboratory, the medical group closed the Rohnert Park office for financial reasons. After the Santa Rosa office lost four physicians to the Permanente Medical Group and was unable to replace them, the original medical group was unsustainable, so the Rohnert Park and Cherry Street offices joined Sutter Medical Foundation of the North Bay.

Dr. Greaves shared several instances in which patients were positively affected by his participation in the Collaboratory. He believes, for example, that he has learned more about MI and how to incorporate discussions about behavioral change with his patients with diabetes. He also has learned to be an active listener. Many patients are shocked to learn of their diabetes diagnosis. Dr. Greaves works hard to reassure patients that diabetes is a manageable disease and they do have control over it. He described one patient who, at an initial visit, had an A1c of 11; the patient came back six months later with a much-improved A1c of six or seven. Dr. Greaves reports that several patients have described the diabetes diagnosis as one of the best things that ever happened to them because it motivated them to take control of their lifestyles and health behaviors. Being a part of these life-changing events in his patients’ lives has been a major highlight for Dr. Greaves and renews his dedication to improving diabetes care.

NDDC has been a positive experience for Dr. Greaves. He believes it improved the way he works in a team. One reason he chose the field of family medicine was the teamwork involved in patient care. Working on an even playing field with his office staff is gratifying. He and his staff believe that coming to work just for the sake of working is quite unsatisfying; they prefer to work in a dynamic environment where team players are actively trying to identify problems and solve them.

Dr. Greaves was very passionate about NDDC, but he initially encountered resistance when he introduced the project to his team. Most staff members, including his MA, were hesitant. He was serious about taking on a QI project and was looking for a different level of cooperation and teamwork, one that involved undertaking several STOCs. He and Ms. Emerson had to improve their method of communication to allow for constructive criticism and suggestions. Working closely with Ms. Emerson, Dr. Greaves realized “the importance of honesty, respect and clearly identifying roles and responsibilities.” More importantly, he realized that to communicate effectively, dialogue must come from a place of caring about the practice and with no intention to hurt anyone.

Some patients at Cherry Street had no designated primary care physician and instead saw any available physician. As the two remaining offices merged and then joined Sutter, there were significant discussions with physicians who were already part of the Sutter network and wanted to make practice redesign changes with their new partners. Physician leaders agreed on the common goals of identifying their patients and designating a physician to manage each patient’s care. The physicians thought this would be an effective way to manage their patient populations and improve the quality of care. The larger goal was to offer patients open access scheduling. To provide open access, physicians had to identify their patients and begin measuring their panels. They decided to work on this goal incrementally. The practice included four family physicians, three nurse practitioners and office staff; they divided themselves into smaller care teams. Dr. Greaves served as leader of his care team, working with one nurse practitioner and two MAs. Each care team was responsible for developing its own unique work processes and managing its patient panel. The front office staff scheduled appointments so that at least 90 percent of patients were seen by their respective care teams. The physician leaders of each team met monthly to discuss teams, provide updates and troubleshoot when necessary. The new system initially posed challenges. Care team members often were double-booked with patient appointments, for example. In other instances, front office staff hesitated to offer appointments with a non-designated care team because they were working so hard to match patients with designated providers. Overall, however, members of the practice enjoy working in smaller care units and this substantial change in the organization of the practice has proven effective.

32 new directions in diabetes care: promising Practices

Spread on a County Level One of Dr. Greaves’ many notable accomplishments is his participation in the development of the Sonoma County Patient Centered Medical Home (PCMH) Collaborative. He says NDDC was a springboard for this work. Dr. Greaves serves as co-chair of a community task force that developed Sonoma County’s Health Action Priorities. The county’s Board of Supervisors came together in 2008 to develop and implement a community-wide effort to redesign care focusing on the PCMH model. Health and business leaders spent approximately six months analyzing county health care issues and systems and concluded that every patient deserves access to a medical home. That led to the launch of a collaborative designed to help practices transition into a PCMH. The collaborative has garnered a great deal of local media attention. Nine practices are participating and Dr. Greaves consulted CAFP staff on numerous occasions in the development process.

Dr. Greaves describes QI as a rewarding experience. He explained how important it is for each practice to identify and clearly articulate the problems in a practice and understand why these problems need solving. He also believes it is important to analyze how a group intends to measure the outcome of an STOC to ensure that any changes are actually working. He advises that any project a practice takes on be consistent with its larger strategic plan. To accomplish his practice redesign and QI goals, Dr. Greaves had to identify key stakeholders in his practice and/or the community and clearly state the group’s values and why the team needed to work on QI. To get support and focus on improvements or open access, for example, he had to define words like “quality” and “access” in concrete ways that made sense to stakeholders. All of these small steps and the STOCs Doyle Park tested helped the practice move in a direction aligned with the team’s values and strategic plan. Looking at the bigger picture, Dr. Greaves notes the importance of developing a health care system that supports physicians’ QI efforts. He believes that his practice, like many in California, is working hard to make change in the context of a health care system that does not always support that change. He expresses a commitment to influence public policy to create a health care system that supports quality of care improvements.

new directions in diabetes care: promising Practices

Appendix: CAFP Interview Guide New Directions in Diabetes Care Interview Guide

1. It has been several months since your participation in New Directions in Diabetes Care. How has your office practice changed as a result of the project? How has it changed since the project ended in September? 2. How have you and your staff continued your efforts in quality improvement? 3. As a graduate of the NDDC Collaboratory, what steps have led to the sustainability of your results? 4. Tell us about an instance in which your involvement in the Collaboratory positively affected an outcome for one of your patients. 5. You were able to implement a chronic disease registry for your patients with diabetes during the Collaboratory. What is the status of the registry? 6. How has the involvement of your staff in achieving quality excellence changed since participation in the Collaboratory? What effect has staff turnover had on you and your team, if any? 7. How have you “spread” the Collaboratory learnings? 8. How has the Collaboratory affected your and your staff’s satisfaction levels? How has it affected your patients’ satisfaction with the care you provide? Have you measured that? 9. What advice/pearl would you offer to your colleagues who want to redesign their offices and/or take on a quality improvement project but have concerns about doing so? 10. If you could do the Collaboratory project all over again, what would you do differently? In retrospect, what information/knowledge would have been helpful to have to achieve better results? 11. Have there been unexpected changes related to your work in the Collaboratory? 12. Are there changes to your workflow that you can demonstrate for us?

34 new directions in diabetes care: promising Practices