Earl K. Long Medical Center Diabetic Retinal Eye Screening Mary Campos RN, CDE Diabetes Care Manager January 25, 2011

EKL MC Site visit October 2007 But Dr. Butler, even though our eye screens are low, we have data to prove that they are being ordered. I dont care how you get them done, just get them done even if you have to purchase a retinal camera!

Committee Members Diabetes Team Lead- Endocrinologist Diabetes Team Lead- Endocrinologist Chief of Ophthalmology Chief of Ophthalmology Retina Specialist Retina Specialist Disease Management Supervisor Disease Management Supervisor Diabetes Care Manager Diabetes Care Manager Clinic Nurse Managers Clinic Nurse Managers LPN-Retinal Eye Technician LPN-Retinal Eye Technician

Other Services Computer Services Computer Services Diabetes Clinic Administrative Assistant Diabetes Clinic Administrative Assistant Financial Management Analyst Financial Management Analyst Maintenance Department Maintenance Department Ophthalmology Clinic Staff Ophthalmology Clinic Staff Resource Scheduling Supervisor Resource Scheduling Supervisor Runner/Transporter Runner/Transporter Screening Department Screening Department

Determine Roadblocks Data Collection: Data Collection: Is it a referral problem? Is it a referral problem? 80% referred- < 50% scheduled 80% referred- < 50% scheduled Is it an access to service issue? Is it an access to service issue? Ophthalmology Clinic: 17 wks booked Ophthalmology Clinic: 17 wks booked Waiting list: 478 patients Waiting list: 478 patients

Scope of the Problem Below ADA standards at achieving diabetic retinal eye screens Below ADA standards at achieving diabetic retinal eye screens

Scope of the Problem Lack of Access into Ophthalmology Clinic Lack of Access into Ophthalmology Clinic

Formulate Plan of Action Develop a One Stop Shop Program Develop a One Stop Shop Program Observe a Model Program (UMC) Observe a Model Program (UMC) Partner with the Ophthalmology service Partner with the Ophthalmology service Get approval from administration Get approval from administration

Short Term Goals Improve access into the Ophthalmology Clinic Improve access into the Ophthalmology Clinic by eliminating the waiting list by eliminating the waiting list Improve quality of care Improve quality of care by increasing access into the Ophthalmology Clinic by increasing access into the Ophthalmology Clinic Meet HCSD system benchmark in performing yearly retinal eye exams Meet HCSD system benchmark in performing yearly retinal eye exams by increasing screens through retinal photography by increasing screens through retinal photography

Long Term Goal To meet or exceed ADA standards in order to improve patient outcomes To meet or exceed ADA standards in order to improve patient outcomes

Population Served Any ambulatory person with Diabetes Any ambulatory person with Diabetes last retinal exam one year or greater last retinal exam one year or greater no past history of treatable eye disease no past history of treatable eye disease

Expenses One FTE (LPN) One FTE (LPN) Topcon Non Mydriatic Retinal Camera Topcon Non Mydriatic Retinal Camera Non Contact Computerized Tonometer Non Contact Computerized Tonometer power tables included power tables included Warranty, installation, and in-service $95.00 Warranty, installation, and in-service $95.00 $22,895$7,695

Implement the Plan Strategically located the clinic; Strategically located the clinic; Hired staff; Hired staff; Purchased equipment; Purchased equipment; Created a system for walk in; Created a system for walk in; Educated staff on the referral process; and Educated staff on the referral process; and Opened business Opened business

Process Process Phase 1: Phase 1: Walk-in Family Practice Clinic only Walk-in Family Practice Clinic only Phase 2: Phase 2: Opened 4 slots a day for booked appts.- later changed to 12 slots Opened 4 slots a day for booked appts.- later changed to 12 slots scheduled from waiting list scheduled from waiting list rescheduled routine Ophthalmology appts. into Screening Clinic rescheduled routine Ophthalmology appts. into Screening Clinic

Process Process Phase 3: Opened to other clinics Phase 3: Opened to other clinics Diabetes and Diet Clinic Diabetes and Diet Clinic Foot, Wound, and EIC Foot, Wound, and EIC NBR and SBR Clinics NBR and SBR Clinics Phase 4: Opened to remaining clinics Phase 4: Opened to remaining clinics Medicine and SP Clinics Medicine and SP Clinics

Procedure Patient checks in and attended Patient checks in and attended Reports to the Screener Reports to the Screener Visual Acuity Test Visual Acuity Test Tonometer Test to evaluate IOP Tonometer Test to evaluate IOP Retinal Photography- 4 views in each eye Retinal Photography- 4 views in each eye

Procedure After the exam, the screener: After the exam, the screener: Records a brief history, visual acuity, and IOP results Records a brief history, visual acuity, and IOP results Places form in a folder for pick up Places form in a folder for pick up Runner transports documentation forms weekly to the Ophthalmology Clinic Runner transports documentation forms weekly to the Ophthalmology Clinic To be reviewed

Procedure Ophthalmologist: Ophthalmologist: Reads photos via computer Reads photos via computer Records findings and recommendations Records findings and recommendations Schedules Ophthalmology appt if needed Schedules Ophthalmology appt if needed Runner returns forms to screener Runner returns forms to screener Reviewed

Procedure Screener: Screener: Inputs information into the data base Inputs information into the data base Files forms into the medical record Files forms into the medical record

Program Evaluation Screening time from check in to departure Screening time from check in to departure Initially : minute average Initially : minute average After first month: 9-19 min After first month: 9-19 min After 6 months: 8-9 minutes After 6 months: 8-9 minutes

Retinal Eye Screen Clinic Retinal photography Retinal photography opened December 2009 opened December 2009 On-site Clinics Family Practice Diabetes & Diet Foot & Wound EIC CL Off-site Clinics NBR & SBR Specialty Medicine Ophthalmology

Referral Source Referral Source One Stop Shop One Stop Shop Majority of referrals came from clinics located within the same building (Jan-June data) Majority of referrals came from clinics located within the same building (Jan-June data)

Total Screens Performed 1220 within the first nine months 1220 within the first nine months 69% screen only 69% screen only 31% Ophthalmology follow up needed 31% Ophthalmology follow up needed

Program Evaluation: Goal # 1 Improve access into the Ophthalmology Improve access into the Ophthalmology Clinic by eliminating the waiting list Clinic by eliminating the waiting list Goal met within 4 months Goal met within 4 months

Program Evaluation: Goal # 2 Improve quality of care by increasing access into the Ophthalmology Clinic Improve quality of care by increasing access into the Ophthalmology Clinic Goal met within 6 months Goal met within 6 months

Program Evaluation: Goal # 3 Exceed HCSD system average of 43.6% Goal met for the last 3 quarters

Improvement over Time Award criteria met

Program Evaluation: Long Term Goal Achieve ADA standard at obtaining yearly retinal eye screens of 61% Approaching goal

Other Benefits of the Program Early detection and treatment Frees up Ophthalmologist Walk in availability Addresses transportation and scheduling issues Quick procedure Non dilated exam (no driver needed) Academic benefits

Ophthalmologist Feedback Very happy with the success of the program Quality photos being received Able to address diabetic retinopathy and other issues more rapidly

Opportunities for Improvement Cliq input of retinal screen (accomplished in September) Cliq input of retinal screen (accomplished in September) Electronic Medical Records Electronic Medical Records Develop a system for pt feedback regarding results Develop a system for pt feedback regarding results

Keys to our Success Collaborative support from the UMC staff One Stop Shop Clinic location Partnership with our Ophthalmology Program Multi-disciplinary team work

Purr……….. Now… thats better! Six months after instituting the Retinal Eye Screen Program