IMPROVING DIABETES AND HYPERTENSIONNOVEMBER 2014 – JUNE 2015 PILOT

Maine Chronic Disease Improvement Collaborative (CDIC)

Learning Session #1

House-Keeping

Remote access with Pines, Presque IsleTone for the day: Conversational Needs / Norms / Requests from group?

Agenda

Welcome and Introductions Setting the Stage for team-based improvement

Key Drivers #1 & #2: Standardizing Care throughout your Team Optimizing your Registry

Sticky Issues & Common ChallengesTeam Time & Cross-PollinationNext Steps

Maine Quality Counts Staff : Your Resources

Sue Butts-Dion, Improvement Advisor

Louise Morang Quality Coach

Josh Farr – QI Specialist

Change is Personal AND It Takes a Village!

Holly Richards & Nathan Morse

CDC Statewide Efforts

Rhonda Selvin

Setting the contextTeam-Based

Improvement

Why Us? Why Now?

How will WE know we’ve succeeded?

Michelle Mitchell, Partnerships for HealthContext of the Evaluation workInvitation to participate in initial interviews

Welcome

Our Patients Live with Chronic Disease‘Tis the Season…

Naples Family PracticeYork Family Practice

Midcoast Brunswick Family PracticeCapeheart Community Health Center

(PCHC)Pines Presque Isle

CDIC Participating Teams

What we’ve learned from you (Baseline Assessment) Payment model important to improvement (but not imperative!) Wide variation exists throughout any given practice

Decision Support (protocols, patient education) Pre-Visit Planning Identifying patients most at risk

Standards begin with engaging everyone on improvement

Data helps drive this engagement

Setting the Stage

Setting the Stage

Where you all are so far…

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Environment CDIC Scope

Setting the Stage

Current Strengths

High Performers to learn from

Community Linkages

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Education ToolsBehavior ChangeEngaging all Team Members

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GuidelinesProtocolsOptimizing Team-Roles

Setting the Stage

What you’ve told us (your Top Three Things)

1. If we can engage all members of our staff…2. If we could standardize risk assessment tools…3. If we could better educate our patients…

1. Education Materials 2. Patient Goals & Action Plans3. Shared Care Plans throughout the Team

4. “….WHILE SUPPORTING WORK-LIFE BALANCE!”

A Team

So, Improvement Requires …

So, Improvement Requires …

Data

Rhythm!

So, Improvement Requires…

Aim

Measure

Change Idea

CDIC Aim Structure

Measures Global Aims Specific Aims

Let your Aims Drive your Change Ideas

Let your Aims Drive your Change Ideas

Standard Care Processes

 

 Clinical Guidelines / Protocols

 

Medical Team composition 

Technology Use

 Communication (e.g., referral standards)

Community Resources

Optimize Registry

 Embedded Guidelines on EMR 

 Clinical Decision Support Tools (e.g., alerts & reminders) accessible to all team members 

 Access to Labs/Tests across setting/system 

 Ability to ID Populations 

 ID sub-populations 

 Stratify based on complexity, severity, CM services

 Capture/Track outcomes by provider 

 Access to clinical information by practice-based and community-based members (CCT) 

 Ability to get data for improvement from registry (e.g., run charts) 

What are Your Aims?

On a scale of 1 (clueless) to 10 (ready to roll):What will you work to improve?How will you measure improvement?What small test will you start with?

Optional slides to follow…Use as needed

Guidelines / Protocols

Medical Team Composition

Team-based care, including: Expanded nursing/MA protocols Standing Orders Health Coaches, Care Coordinators, Navigators

Technology Use

Utilize EMR for action plans.Inter-connected EMR systems for coordination

of care (incl. e-consults with specialists).Use biometric devices (digital scale, BP

monitoring, etc.)

Communication

HuddlesTime for Improvement MeetingsStaff training that maximizes scopes of practice

for all practice staffImprove coordination between primary care

provider and hospital

Community Resources

Partnerships with community organizations (e.g., YMCA and pharmacies for lifestyle changes education, counseling and support)

Identify areas resources that support on-gong self-management support. (e.g., Diabetes Self-Management Support (DSMS) planning).