Development-Knowledge Transfer

Survey results over time: • Recognition of CCGC name was 49-50% in 2002 moving up to 74%

by 2003

• Ranking of most useful guidelines:2002: Diabetes, Depression, Asthma2003: Colorectal, Pediatric Immunizations, Diabetes2009 (May): Asthma, Gestational Diabetes, SBIRT

• Sustained interest in having CCGC continue to:– Develop guidelines– Convene stakeholders– Help practices prepare for systems change

EVALUATE

Guideline Uptake

Survey published in Critical Pathways in Cardiology (June, 2008)

Guideline use before and after dissemination: rates varied between 42.9% and 51.2%

Implementation-systems integration

Rapid Improvement Activity (RIA)

Fit Now Results:

By 12 months participants had lost, on average 11.3 pounds when compared to baseline weight (p<.01, 95% CI: 4.3;18.4 pounds) which corresponds to a 5.6% loss of original body weight. Changes between 6 and 12 months were not significant.

TOTAL ENROLLMENT REFERRALSCURRENT ENROLLMENT

REFERRALS County

2 1 Adams

67 37 Garfield

0 0 Lincoln

0 0Larimer

30 16 Alamosa

35 23Alamosa

8 4 Summit

4 1 Weld

14 10 Kiowa

0 0 Baca

Fit Now Colorado RIA Sites by County: Referrals/Enrollment92 Patients enrolled

SBIRT Colorado Progress to Date

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

Pneumococcal Immunization Rates

Inpatient Pneumococcal Vaccination Rates

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q32005

Q4 Q12006

Q2 Q3 Q4 Q12007

Q2 Q3 Q4 Q12008

Q2

% U

TD

Patients 65+ Diabetes 19-64 y.o. COPD 19-64 y.o.

Pneumococcal Immunization RatesCommunity Health Service Pneumococcal Vaccination

Rates

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q32005

Q4 Q12006

Q2 Q3 Q4 Q12007

Q2 Q3 Q4 Q12008

Q2

% U

TD

Ages 65+ Ages 19-65 Diabetes Ages 19-64 COPD

CCGC Tobacco Program

June 9, 2009

Co-Directors:

• Alison Long, MPH

• Michele Patarino, MBA, MSHA

Project Managers:

• Debbie Dion

• Emily Gingerich

CCGC Tobacco Team

Tobacco Program Overview

Show Me The Data

Intervention Participation QuitLine Self Report

Chart Audit/ registry or

EMRAdditional

data

CMEX

TRIAX X X

TRIA with IPIP X X X X

Mini-grantsX X X X

Grantsx x X X X

Tobacco Program Provider Participation

6www.coloradoguidelines.org/tobacco

Grants to Healthcare Organizations

Grants to Healthcare Organizations

MedSouth

8www.coloradoguidelines.org/tobacco

Grants to Healthcare Organizations

Intervention Participation QuitLine Self Report

Chart Audit/ registry or

EMRAdditional

data

CMEX

TRIAX X X

TRIA with IPIP X X X X

Mini-grantsX X X X

Grantsx x X X X

Tobacco Rapid Improvement Activity(TRIA)

TRIA’s

Examples of Practice Changes Following the TRIA

WHAT WHO HOWASK about tobacco status Intake nurse or MA •Intake form – add “Do you use

tobacco?”•Add Tobacco Use tab in EMR•Amend vital sign stamp to include smoking status

ADVISE to quit RN, NP, PA, MD Provider is prompted to advise patient to quit b/c of chart documentation or b/c QL fax form is on chart

REFER for help RN, NP, PA, MD or staff cessation specialist

QuitLine referral materials (brochures, fax forms, prescription pads) are available in exam rooms

Tobacco Rapid Improvement Activity (TRIA)

Intervention Participation QuitLine Self Report

Chart Audit/ registry or

EMRAdditional

data

CMEX

TRIAX X X

TRIA with IPIP X X X X

Mini-grantsX X X X

Grantsx x X X X

TRIA Results

Average Goals Implemented per Practice Within 6 Weeks

66%

34% ImplementedGoals

NotImplemented

15www.coloradoguidelines.org/tobacco

Practice TRIA Goals

97%

3% Implemented atLeast One Goal

NotImplemented

Asthma Patient Tobacco Measures

33%

61%52%

68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ask Pre Ask Post CounselPre

CounselPost

IPIP Tobacco Measures

Diabetes Patient Tobacco Measures

62%

79%

66%73%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ask Pre Ask Post CounselPre

CounselPost

Additional Data Source: Colorado QuitLine

QuitLine Fax Referrals from CCGC Grantee & TRIA Practices

0

20

40

60

80

100

120

140

160

180

200

Jun-

06

Aug

-06

Oct

-06

Dec

-06

Feb

-07

Apr

-07

Jun-

07

Aug

-07

Oct

-07

Dec

-07

Feb

-08

Apr

-08

Jun-

08

Aug

-08

Oct

-08

Dec

-08

Feb

-09

Apr

-09

month

# o

f re

ferr

als

Referrals

28%

36%

0%

10%

20%

30%

40%

Coaching w/o NRT Coaching w/NRT

Colorado QuitLine Success Rates

1-800-Quit-Now

RIA Flyers

Questions?

VISIT: www.coloradoguidelines.org/tobacco

Email: tobaccoinfo@coloradoguidelines.org

CALL: 720/297-1681

Boulder, Coloradohttp://sprucestreetinternalmedicine.com

Hillary Browne, MD, FACP

• ColoradoPractice Coaches: Debbie Barnett & Deb Maltby

• Improving Diabetes Care• Start date: January 2007• Number of diabetes patients in the registry:

~250

Description of Practice• Boulder, Colorado• 3500-4000 active patients,

5% Medicare• 3.5 full time equivalent providers• Aim: to provide excellent,

comprehensive diabetes care; NCQA certification

• Staff: Manager, Phone receptionist, 2 front office, 4 MAs, 4 file clerks, part time dietician.

• Quality improvement team: 1 front office, 1 back office (MA), office manager, 2 providers, QI coach

Data collection

• Reach My Doctor (RMD): portal with diabetes and asthma registries

• Special features we use: – Care plan/flow sheet– labs automatically populate flow sheets– email reminders– labs can be emailed with our comments– patients can view their care plans

Planned care at Spruce Street …how it works

• Registry • Protocols

– Patient makes appointment and DM goes on the schedule– File clerk pulls the chart (red dot) and prints the flow sheet– MA notes that patient has DM and removes patient’s shoes– If annual sensory exam is due, she performs and

documents the exam– Visit with provider focuses on flow sheet, which is given to

patient at the end of the appointment– Self-management goals and reminder

Retinal Exams

6/07 to 5/08 6/08 to 5/09

Adopting a clinical protocol: overcoming provider insulin resistance!

• Registry enabled us to clearly identify patients with hgb AICs > 9

• Leading to a conscious decision to relearn insulin regimens to achieve better glycemic control

• MAs now trained to teach patients to administer insulin and monitor blood sugars

Spruce Street Internal MedicineA1c > 9

6/07 to 5/08 5/08 to 4/09

Spruce Street Internal MedicineA1c < 7

6/07 to 5/08 5/08 to 4/09

Spruce Street Internal MedicineBP < 130/80

6/07 to 5/08 5/08 to 4/09

Spruce Street Internal MedicineBP < 140/90

6/07 to 5/08 5/08 to 4/09

Spruce Street Internal MedicineLDL < 100

6/07 to 5/08 5/08 to 4/09

Spruce Street Internal MedicineKidney Assessment

6/07 to 5/08

6/07 to 5/08 6/08 to 5/09

Spruce Street Internal MedicineFlu Vaccine

6/07 to 5/08 6/08 to 5/09

Spruce Street Internal MedicineFoot Exams

6/07 to 5/08 6/08 to 5/09

Sustainable improvement

• Routine protocols with immediate correction if not followed

• Staff feels responsible and integral to successful patient outcomes

• Patients develop stronger connections with ancillary staff

• Ultimate outcome is improved satisfaction for patients and staff

Next steps

• Focus on high-risk patients (hgbAiC > 9)• Challenge ourselves to attain goals on

individual diabetes measures. • Asthma registry initiated• Move forward with plan include COPD and

heart/stroke• Coordinate timely office follow up after

hospitalization to prevent readmission.

Thank you

• To all of our providers and staff for their exceptional performance

• And to Allyson Gottsman, Associate Director, and Marjie Grazi Harbrecht, MD, Medical/Executive Director of the Colorado Clinical Guidelines Collaborative

LDL in control

Chet CedarsLone Tree Family Practice

Lone Tree Family Practice

• Two physicians and two nurse practitioners One physician spends ½ time in clinical work and ½ time in practice management. One nurse practitioner spends ½ time clinical work and ½ time as Care Manager. (three FTE)

• Use Allscripts/Misys EMR with imbedded orders in Preventive Health Module based on sex, age and diagnosis.

• Query Reports to pull patient lists based on Dx and other clinical data.

Patients with 1 LDL in last 12 months

Pct of DM patients w ith >=1 LDLs

0

20

40

60

80

100

LDL < 100Pct of DM patients w ith latest LDL <100

0

20

40

60

80

100

System that Underpins Performance

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

To improve timely LDL measurements:

• Print list of patients with LDL >100– Mailing labels for outreach

• Last LDL date and value available at time of service

• Informal provider consensus regarding how often to measure assists with consistent messaging to patients

Interventions to Help Patients Achieve LDL Target

• Lab values auto imported to diabetes tab, including LDL

• Informal consensus among providers regarding management

• Aggressive follow up • Print out of trends from PHP registry• Guidelines and targets shared with patients • Provider directed self management strategy• Some assistance with DAPs for Rx as needed

Sustaining Activities when at Target

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

Appropriate Follow Up

• Aggressive follow up encouraged

• Patients engaged in progress toward goal

• Patients recognize ongoing follow up essential for optimal outcomes

Still working on…

• Strategy to get patients in based on last date of LDL

• More data points auto populated for diabetes care parameters

• Continuing process to eliminate double data entry

• Documentation of self management goals

Improving Performance in Improving Performance in Practice - Evaluation DataPractice - Evaluation Data

June, 2009June, 2009

Perry DickinsonPerry Dickinson

ElementsElements• Registry data – performance measures• Assessment of Diabetes Management

(clinician survey)• Patient data from trial practices• Qualitative data from practice interviews• Chart audit data for trial practices –

coming soon• In slides: ** means p<.01, * means p<.05,

+ means nearing significance

Diabetes Process MeasuresDiabetes Process Measures

0

10

20

30

40

50

60

70

Eye** Renal+ Aspirin** Feet** Flu shot*

Diabetes Outcome MeasuresDiabetes Outcome Measures

0

10

20

30

40

50

60

70

A1c >9+ LDL <130+ LDL <100 BP <140/90 BP <130/80

Asthma MeasuresAsthma Measures

0

10

20

30

40

50

60

70

80

90

Symptoms ICS Actionplan

Smokingasked*

Smokingcounsel+

Patient MeasuresPatient Measures• Only those 11 practices involved in the

randomized clinical trial• Patients recruited from a list of diabetic

patients provided by practice • Same patients at baseline, 9, 18 months• 244 patients at baseline, 235 at 9 months• 18 month f/u data soon!• Patient self report regarding various

aspects of their diabetes care

Checked in Past 12 MonthsChecked in Past 12 Months

0

10

20

30

40

50

60

70

80

90

100

A1c* Eyes Feet* Lipids* Renal*

Baseline 9 months

Overall Diabetes Process of CareOverall Diabetes Process of Care

0

1

2

3

4

5

6

7

8

Total* Process* SMS

Baseline 9 months

• Process – A1c, urinary protein, cholesterol, eye exam, foot exam done over past year

• SMS – Self-Management Support - Dietary counseling, goal setting, home glucose monitoring dealt with over past year

• Total = checks + PSMS

Clinician SurveyClinician Survey

• Assessment of Clinician Diabetes Management (ACDM) – designed to measure the level of implementation of elements of the Chronic Care Model

• 42 practices; 181 clinicians at baseline, 80 post-intervention

ACDMACDM

0

10

20

30

40

50

60

70

80

90

Teams** SMS** Info Sys** QI**

Qualitative DataQualitative Data

• Interviews of key informants (lead physician, practice manager, key staff) from 8 IPIP practices regarding issues around their diabetes improvement efforts through IPIP

• All practices had engaged to the point of reporting measures

• Qualitative interviews of the trial practices are in progress

Practices InterviewedPractices Interviewed

• Six from Denver metropolitan area, one from Pueblo, and one from Colorado Springs

• Ranged from three to seven clinicians,• Three belonged to an IPA in the Denver

area, two to other IPAs, and three were independent

• Primarily family medicine, with one internal medicine

Clinical ChangesClinical Changes• Practices all implemented mechanisms to identify

and track their patients with diabetes • Most used flow sheets to assist with data

management and point of care decision support –key in organizing care

• Virtually all developed a distinguished “diabetic visit”- helped focus visit activities

• Most expanded MAs’ activities, including screening questions, assessment and performance of needed labs or services

• Many developed patient recall systems to bring patients in when visits and services were due.

BarriersBarriers

• The major barrier was time

• Substantial financial costs – mostly personnel

• Insufficient staff

• “It is hard to have more than one person in the practice trained and up to speed on doing this, and they tend to be upwardly mobile.”

• Staff and clinician turnover an issue

• Problems getting information from consultants

IT BarriersIT Barriers

• Duplication of effort in data entry a huge issue, especially in practices with EHR

• Lack of ability to enter data once and have it show up in the appropriate places for administrative, clinical, and quality data reporting and use

• Often easier for practices without an EHR to implement a registry

• Practices with paper charts - charts not always available, time spent tracking them down.

BenefitsBenefits

• Improved quality of care• “Power of having better data for managing patients.” • Possibility of financial benefit through bonuses, pay-

for-performance, higher coding, group visits, and bringing patients in for services

• Improved organization and efficiency of work flow• Improved morale for clinicians • Greatly improved staff satisfaction • Staff more engaged and invested in the practice -felt

like they were more an important part of patient care

Colorado April 2008 v March 2009

0

10

20

30

40

50

60

70

80

90

100D

MP

ctA

1C

Ab

ove

9

DM

Pct

A1

CU

nd

er7

DM

Pct

Asp

irin

DM

Pct

BP

Be

low

13

0

DM

Pct

BP

Be

low

14

0

DM

Pct

Eye

Exa

m

DM

Pct

Eye

Re

f

DM

Pct

Flu

Va

cc

DM

Pct

Fo

otE

xam

DM

Pct

LD

LU

nd

er1

00

DM

Pct

LD

LU

nd

er1

30

DM

Pct

Mic

roa

lb

DM

Pct

Sm

okC

ess

DM

Pct

To

ba

cco

Qu

ery

DM

Pct

With

A1

C

DM

Pct

With

LD

L

DM

Pct

SM

Go

al

DM

Pct

Sta

tin

DM

Pct

Ace

Arb

DM

Pct

Pts

Pn

eu

mo

0

10

20

30

40

50

60

70

80

90

100

DM

Pct

A1

CA

bove

9

DM

Pct

A1

CU

nder

7

DM

Pct

Asp

irin

DM

Pct

BP

Be

low

130

DM

Pct

BP

Be

low

140

DM

Pct

Eye

Exa

m

DM

Pct

Eye

Ref

DM

Pct

Flu

Va

cc

DM

Pct

Fo

otE

xam

DM

Pct

LDLU

nder

100

DM

Pct

LDLU

nder

130

DM

Pct

Mic

roal

b

DM

Pct

Sm

okC

ess

DM

Pct

To

bacc

oQ

uer

y

DM

Pct

With

A1C

DM

Pct

With

LD

L

DM

Pct

SM

Goa

l

DM

Pct

Sta

tin

DM

Pct

Ace

Arb

DM

Pct

Pts

Pn

eum

o

0

10

20

30

40

50

60

70

80

90

100

DM

Pct

A1C

Abo

ve9

DM

Pct

A1C

Und

er7

DM

Pct

Asp

irin

DM

Pct

BP

Bel

ow13

0

DM

Pct

BP

Bel

ow14

0

DM

Pct

Eye

Exa

m

DM

Pct

Eye

Ref

DM

Pct

Flu

Vac

c

DM

Pct

Foo

tExa

m

DM

Pct

LDLU

nder

100

DM

Pct

LDLU

nder

130

DM

Pct

Mic

roal

b

DM

Pct

Sm

okC

ess

DM

Pct

Tob

acco

Que

ry

DM

Pct

With

A1C

DM

Pct

With

LDL

DM

Pct

SM

Goa

l

DM

Pct

Sta

tin

DM

Pct

Ace

Arb

DM

Pct

Pts

Pne

umo

Measures reported – March 2008

Measures reported – April 2009