Delivery Design “ an improvement model of diabetes care” a project funded by the Robert Wood Johnson Foundation East Carolina University/Bertie Memorial Hospital East Carolina Health-Bertie All-County Health Services Paul Bray, MA., Skip Cummings, Pharm.D., Jolynn Harrell, RN

Keys to Delivery Design Education with coaching (E-C) is the primary tool used to achieve patient self- management E-C is delivered by an advanced skilled non-physician clinical staff E-C is delivered at the time of the (primary care provider) PCP visit The physician’s and (Educator/coach) EC form a care team The physician’s leadership is very important to the team’s success Nurses and front desk support staff play important and expanded roles There are 6 Steps to the delivery design; 4 steps PCP visit redesigned and 2 steps education-coaching

Step 1: Monthly QI (Quality Improvement) Team Meetings Team reviews 3-5 evidence-based clinic panel outcome indicators including A1C & BP, Team initiates corrective PDSA (Plan, Do, Study, Act) cycles Team reports outcomes quarterly to board of directors, or governing body

Clinical Measures Reviewed in QI Meetings Phase I NCQA= National Committee For Quality Assurance Targets: stretch goals for practices to work toward; -benchmark goals = NCQA Quality Compass Diabetes Patient CountN/A HbA1C Management: Poor Control greater than 9%< 5% Blood Pressure Management : <130/80> 70% LDL Cholesterol Management: <100 mg/dl> 70% Diabetic Eye Exam> 80% Medical Attention for Nephropathy> 90% Influenza Vaccination> 75% Aspirin for DM patients over 40> 85% Lipid Test Documentation> 90% HbA1C Documentation> 90% Statin for DM patients over 40> 70% Tobacco Use Assessment> 80% Tobacco Cessation Intervention> 80%

Step 2: Nurse schedules all patients through standing orders for E-C & Labs Standing Orders 1. E-C with initial Dx of DM 2. E-C at minimum every 12 months 3. E-C visit asap for A1c >8 4. A1c q 3 months 5. Eye exam report every12 months 6. Lipid panel q 12 months 7. Shoes off every provider visit

Nurse scheduling of education based on clinic calendar 1.Same day if EC is on-site 2.Schedule EC for same day if follow-up PC visit is within 30 days 3.If follow-up is not within 30 days, schedule a brief PC visit and EC same day 4.Empowerment of nurse to expedite urgent EC visits (A1c>8.0, TRG >300, BP> 150/90, BS>200, open wound, or combination) Nurse linking EC, PCP & Doctor 1.Coordinates PCP introduction of EC to patient 2.Coordinates PCP brief visit to E-C session 3.Coordinates E-C during exam room waiting times

Step 3: Support staff scheduling follow up and tracking Follow-up appointments scheduled as directed by PCP or EC 1. New diagnosis, 3-4 visits focused on key self-management objectives 2. Follow-up visit scheduled for key learning objectives (i.e. glucose testing, insulin management and bs goals) 3. New start insulin/medication or changes in insulin/medication dose follow up within 2 weeks 4. Visits follow-up 8

Support Staff ( front desk, etc.) calls and reminds all patients one day before visits 1.Support staff calls and re-schedules all no-shows 2.EC calls patient after two no-shows Educator-coach empowered to re- schedule

Step 4: Team consultations for most patients Hall-way brief case conferences Brief visit by PCP in education Brief visit by EC in exam rooms Physician will ask “what is the clinical goal & SM goal?” Any team member is encouraged to schedule case conference for difficult or puzzling patient at monthly QI meeting Educator-coach empowered to recommend medication-insulin (depending on skill)

Step 5: Focused 1 st E-C Visit 1. Use short intake summary questionnaire form 2. Chart consulted: confirm diagnosis, medications, labs, A1C, consult progress notes 3. Seek quick understanding of issues & barriers; clarify why a medication may not be working, determine patient’s knowledge base, literacy, length of diabetes, ability to test blood sugars 4. Clarify blood sugar goals, basic nutrition knowledge, basic survival skill knowledge 5. Key inquiry: what did you eat in last 24 hours, how did it affect blood sugars? 6. Check office meter against patient’s meter: Do they have a glucometer and are they competent in its use, are supplies affordable, do they understand how to use results?

Step 5: 1st Visit (con’t) 7. Standard 1 st visit self-management goal: Check blood sugars as prescribed, return to next scheduled DM visit with log and meter; Begin to understand how portions of carbohydrates and activity impact bs results. Always have return visit in mind. Proceed to check-out, for scheduling of next appointment --or add E-C visit to next physician appointment. 8. Encourage next visit to be with care-partner 9. At end of first visit: Patient should believe they can have control over their diabetes and they should have some definition of blood glucose – and how numbers impact health 10. Final words to patient ALWAYS, “what is your diabetes goal today?”

Step 5: 1 st visit (con’t) 11. Seek out physician for 2 minute hall-way consultation 12. Provide “introduction to diabetes” hand-out, provide score sheet to record bs Information gathered in the 1 st visit is entered into EMR forms. These forms can then report the progress a patient is making in diabetes management both to the patient and the health care team. The following two screen shot slides are reproductions of the clinic’s EMR diabetes forms (in Centricity EMR).

Step 6: Follow-up 2 nd to 4 th to ongoing visits At least monthly visit until blood sugars stable Prioritize key ADA (American Diabetes Association) curriculum issues that are preventing diabetes management Order of modules – based on intake assessment – most problematic or crucial to least problematic.

Step 6: 2 nd visit and on (con’t) Work towards education in each ADA curriculum module 1. Disease of DM, A1C, BS goals, Basic meal planning 2. Nutrition and Carbohydrate Counting 3. Nutrition and Heart Disease 4. Weight loss 5. Exercise 6. Dealing with diabetes, living with life style changes, psychological impact 7. Self management and complications of diabetes 8. Medications and monitoring 9. Problem Solving

Step 6: 2 nd visit and on (con’t) End each session with self-management goal (SMG), begin each session with review of SMG, review of blood sugars, challenges faced in self management. Implement Motivational Interviewing model to enable self-confidence in ability to make healthy change. Screen for Depression Problem solve Eye Exam

Step 6: 2 nd visit and on (con’t) The following PDF files detail the diabetes curriculum used by the EC