December 2012 Webinar Good News from PA SPREAD Data Review Helping Patients Lead Healthy New Year

Good News, Good Cheers! ABIM Part IV MOC Credits ABFM Part IV MOC Credits 20 CME Credits Through AAFP (for Physicians and RNs) The second change concept is about how we work together.

Approval Processes CME credits restricted to Learning Session and webinar attendees who have been active in planning, implementing, monitoring PDSAs and clinical performance improvement. Part IV Maintenance of Certification (MOC): Restricted to physicians who are engaged in 12 months of quality improvement via PA SPREAD. Must complete short PA SPREAD form in May to describe engagement in PDSAs, team meetings, performance improvement. Forms will be reviewed by PA SPREAD team and practice facilitators.

Let’s do some seasonal sharing! Data Review Let’s do some seasonal sharing! The second change concept is about how we work together.

Good Sign: Steady Denominators

Trend Still Creeping Wrong Way

Keep the Momentum Going!

Sharing on A1C Control Cornerstone: Providers reviewing patient lists to see who is out of range. Eastbrook: Reviewing clinical protocols. General Internal Medicine: Notifying overdue patients and getting them in for visits; using EMR reminder system to identify unmet needs. Hamilton: Calling in patients with A1C >12; Medication Adherence system Mountville: New Patient Navigator position to track patient services due. Sandrowicz: Review of A1C>7 patients => started insulin on some, need to intensify treatment for others.

Super Strategies Identifying outlier patients and getting them in for planned care. Addressing clinical inertia – medication intensification Helping patient set self-management goals and address barriers to self-care.

Watch Sustainability of Changes

Sharing on BP Control Manor: Physicians tasked to identify strategies to lower BPs. Hamilton: Provider champion presentation on medication intensification.

Sharing on BP Control Warren: Nice BP control improvement trend. Oil Valley: Nice BP control improvement trend. Warren Oil Valley

Still a Gap to Close

LDL Control Sharing Nice LDL control improvement trends: Mountville Oyster Point Manor

What’s Working So Well Here?

Nephropathy Control Sharing Hamilton: Revisited order sets with providers. Semeyn FMC: Increased urine tests by distributing urine cups at front desk during sign-in. Nice improvement trends: Eastbrook General Internal Medicine

Key Part of Planned Care

Evidence of Planned Care Meeting many evidence-based guidelines: All improving!

Strategies for Planned Care Pre-visit planning to identify gaps in care, huddles: Hamilton Reminder system in EMR flags gaps in care: Manor and General Internal Medicine. Population alerts to identify all diabetes patients (even for sick visits): Mountville, Oyster Point. Copies of diabetic registry at MA work stations: Carlisle. Standing orders: Eastbrook.

Foot Exam Sharing Carlisle: Staff training on foot exams, monofilament testing. Cornerstone: Handout to nurses on proper foot exams. Oil Valley: Physician carried monofilament in pocket.

Good Progress on Hard Work

Eye Exam Sharing Semeyn Brookville: Enhance communication with fax back forms to local eye doctors. Mountville: Many diabetes patients not getting retinal eye exams; Letters to major eye practices.

New Starts in New Year

Self-Management Sharing Manor: Flip charts on diet, measures, making the most of your office visit in exam rooms. Cornerstone: Asking patients to choose just one goal to work on. Oyster Point: Providing patient education, self-mgmt tools on patient portal. General Internal Medicine: Goal-setting focus of November team meeting.

Remember the OARS Open-ended questions Affirm Reflective listening Summarize

Open-Ended Questions Tell me how it’s going with taking your insulin? Many people find it challenging to take their insulin daily. How is it going for you? What do you know about diabetes? Tell me about your friends and family that have diabetes. What do you usually eat each day? Tell me what you had to eat yesterday. Tell me about your schedule for taking your medications. What’s the most important thing you can do to control your diabetes? What part of managing your diabetes is most on your mind?

Are We Counting Correctly Now?

Meaningful Use for All Patients!

Documentation Problem?

Cessation Counseling Sharing Cornerstone: Cessation class in collaboration with BC/BS.

January Learning Sessions, Webinar Looking Ahead January Learning Sessions, Webinar The second change concept is about how we work together.

Upcoming Meetings January Learning Sessions January Webinar South Central: Tuesday, January 29 5-9pm, Penn State Hershey Conference Center Northwest: Tuesday, January 22 5-9pm, Cross Creek Resort, Titusville January Webinar Thursday, January 24: 12pm – 1pm Special session for providers with Dr. Bob Gabbay

Always here to help you! South Central – Sharon Adams 814-344-2222, sadams@scpa-ahec.org North West – Patty Stubber 814-217-6029, pstubber@nwpaahec.org

Much happiness and health to you all!