Diabetes Program Improvement Project September 20, 2017 Gail Dougherty, Diabetes Program Development Project Manager Valeria Mallett, Registered Dietitian

Agenda The Data – Current State Program Goals Qualitative data for program design Key new program components Approach Pilot Timeline

The Data – Current State (July 2017) Number of patients had a visit in the last 12 months = 36,465 Of the 36,465 patients, 3691 patients have diabetes (A1c >6.6) Number of Patients with Hemoglobin A1c >9 = 1170 Number of Patients to reach 19% target = 468  Clinic VG Rate: A1c>9.0 # of Pts with DM VG Average 31.7% 3691 VGB 31.2% 957 VGC 30.5% 717 VGH 34.7% 1009 VGN 28.6% 154 VGYC 30.7% 787 Goal 19.0%  3691 # of Pts A1c>9.0 1170 299 219 350 44 242 702 # of Pts to Target 468 117 82 158 14 92  Ethnicity % of DM patients Hispanic 59% Caucasian 26% Asian 3% African American 1% Other Unknown 10% Total 100%  Gender % of DM patients Women 56% Men 44% Total 100%

Program Goals Reduce # of patients with out-of-control DM (A1c >9) by increasing patient engagement in DM Services Non-clinical measure: Increase “CareSTEPs” (encounters/touches) with each DM patient as a surrogate measure of patient engagement Number of DM pts + number of times for each of the following: Attending DM Education (seeing Alison, Valeria) Visits with BHP, CHW, MH, CPS, MSW, HRS Meaningful contacts with care team (Provider, RN) Attending support group and self-management programs Clinical measure: % of Diabetic Patients with A1c > 9.0 STEP = services that engage patient

Qualitative Data Gathering – the numbers Staff Interviews Interviews conducted – 43 People interviewed – 133 Groups # Interviews Teams 14 One-on-ones 26 External groups 3 Patient Surveys Total Respondents 178 English 129 72% Spanish 49 28% Women 101 57% Men 77 43% Patient Focus Groups Total Participants 41 English sessions 21 Spanish sessions 20

“When patients engage in services provided … Staff Interview Summary What’s Working Well What’s NOT Working Well DM Education classes Clinical Pharmacists Team-based approach Nurses & MA’s Behavioral health Self-management groups #1 - Patient Readiness  Patients not engaged, can't/won't spend effort to work on DM Not enough classes or groups Lack of clear pathways for patients Tracking & charting Behavioral health – unclear differentiation from Mental Health “When patients engage in services provided … we see improvements.”

Patient Input Summary Confirms: New approaches / broaden use: Variety of services & resources still needed Patients don’t absorb much at once. Repetition, references, reminders required Best days/time of day – weekday morning & evening, Saturday morning & mid- day New approaches / broaden use: Positive approach – Patients need encouragement & hope – they can do this! Smaller steps, slower but steadier progress Weekly groups for motivation, life skills, food knowledge & skills Incentives to attend groups & DM appts Online resources

Key Program Components – Phase 1 Expanded Diabetes Education Valeria Mallett Registered Dietitian Trilingual English, Spanish, Portuguese Alison Reta PharmD, CDE Bilingual English, Spanish Twice as many classes Twice as many individual slots New expertise New services on the way Basic Diabetes class Nutrition classes Learning about Insulin 1:1 appointments

Key Program Components – Phase 2 Behavioral Health DM Self-Management Programs “Diabetes Health Counselor” “Navigator” to clinic services Assesses emotional state, addresses barriers to change Assesses patient’s readiness to manage health Recommends next steps – psychosocial help, DM education, DM self-management group Living Well with Chronic Conditions, Tomando Control de Su Salud Diabetes Support Group A Tu Salud Groups meet weekly for several wks Life skills – decision making, goal setting, communications Lifestyle changes for diabetes management – food choices, movement, medications, stress reduction

New VG Paradigm for Every Patient Interaction Approach New VG Paradigm for Every Patient Interaction Goal: Make It Count Staff: I have time for you Patients: Respect Me Know Me Teach Me Show Me Respect Me – Positive & Optimistic, conveying that they can be successful Encourage rather than scolding or shaming Empower them – meet people where they are, give choices, “what works for you” Realistic, small changes – what patients can do and will do Acknowledge successes, no matter how small Team notes: Verbiage - does “nutritionist” sound less like “you need to go on a diet” than “dietitian” does? “RD Nutritionist” - Rather than objective 3rd person (“help patients”), use direct “help you”? Speaker notes: Input from Providence: Shifting to be realistic - what patients can do and will do Present initially that there are a lot of tools, find what works for you Try to meet people where they are rather than give everyone the same info

New VG Paradigm for Every Patient Interaction Pilot New VG Paradigm for Every Patient Interaction Goal: Make It Count Staff: I have time for you Patients: Respect Me Know Me Teach Me Show Me Psychosocial Issues Community Health Worker Behavioral Health Provider Mental Health Provider Diabetes & Nutrition Education Teach Me Wellness Options VG Wellness Center(s) Community Offerings Diabetes Self-Management Programs Show Me PCP or RN Visit Behavioral Health Provider / “Diabetes Health Counselor” Know Me Team notes: Verbiage - does “nutritionist” sound less like “you need to go on a diet” than “dietitian” does? “RD Nutritionist” - Rather than objective 3rd person (“help patients”), use direct “help you”? Speaker notes: Input from Providence: Shifting to be realistic - what patients can do and will do Present initially that there are a lot of tools, find what works for you Try to meet people where they are rather than give everyone the same info

DM Program Development Timeline Year 2017 2018 Month Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Phase 1 – Expand DM Education Design Program Phase 2 Pilot New Program Phase 2 Roll out Phase 2 to all Sites Design Program Phase 3 Pilot & Roll Out Phase 3 Roll out new DM Ed schedule Today Finalize Program Elements - Phase 2 Trng 1 Team Modify,Train Pilot at 1 Site (VGH) Analyze, Modify Train & Support Teams Roll Out to 2 Teams per month VGB VGYC VGB VGYC VGC VGN Phase 3 Elements Phase 3 Process Details Pilot at 1 Site (TBD) Analyze, Modify, Train Roll Out to Additional Teams