1. Improving Diabetic Care through Implementing Point of Care HbA1C and Utilizing the Care Coordinator in PCMH Josh Strehle, D.O. Jen Kirstein, RN, BSN

2. Disclosures We have no financial relationships with the manufacturer(s) of any commercial products or services discussed in this continuing education activity.

3. Objectives Discuss the stepwise process and difficulties of implementing point of care Hemoglobin A1c in our office Discuss efficient and appropriate referrals to our care coordinator and strategies to improve follow-up Demonstrate the effect of our workflow on Hemoglobin A1cs in our office and present several specific patients successes

4. Iowa Lutheran Family Residency Community Base 6/6/6 University of Iowa affiliated Residents employees of UnityPoint Health Clinic Operations under UnityPoint Clinics

5. Our Patient Population 23 languages –English –Spanish –Burmese –Karen –Nepalese

6. Why Real Time A1c? Chronic Disease Group Health System Metrics

7. Workflow Machine purchase Refine the process Trial of one

8. Workflow Patient Roomed Blood Draw Blood to Lab A1c Resulted Provider Visit

9. Provider Education Monthly Starting July 2014

10. Provider Utilization As of December 2014 Faculty – 100% R3 – 83.3% R2 – 100% R1 – 16.6%

11. Patient Centered Medical Home Went live in September 2012 Key principles based on UnityPoint pilot –Co-location –Huddle –Team Based Care –Population Management –Care Coordination NCQA level 3 certified in July 2013

12. Triple Aim Quality of Care Improving Population Health Lower Cost

13. Population Management High Risk Rising Risk Low Risk Care navigators Chronic care coordination Wraparound services Patient Centered Medical Home Care Coordination Low-acuity access, education E-health

14. Co-location People with different job roles working in a common workspace Why it works –Communication! –Same day access –Care Coordination –Ideal patient care

16. Huddle Once/Twice a day for 15 min Everyone attends Things to talk about –Patient issues/Quality/MU –Scheduling – patients and staff –Process Improvement

17. Team Based Care A cooperatively functioning group that works with the patient toward ideal patient care –Patient, providers, Care Coordinator, Clinical Staff, Patient Service Representatives, Clinic Administrator All are Leaders (no hierarchy), Not competitive, Communication, no front-back office separation

18. What does a Care Coordinator do?  Care Coordination Support patient through transitions in care  Patient education and coaching related to chronic disease self- management Focus on rising risk patient population Support patient and provider in goal attainment  Identify rising risk patients and proactively intervening with the guidance of the provider  Provide information regarding internal and external resources, including community resources

19. Care Coordination Integrated Approach Link patients with community resources –Social Determinants of Health –Referrals Track and support patients Follow up with patients within few days of discharge from emergency room or hospital Care Plans

20. Implementation December 2013 Registered Nurse/BSN –Certified in Chronic Disease Management

21. Referrals to Care Coordination Adult –Asthma, CHF, COPD, Diabetes, Overweight/Obesity, Hypertension, Hyperlipidemia Pediatric –Asthma, Overweight/Obesity

22. Increasing Referrals

23. 2014 251 Referrals into Care Coordination Program Diabetes- 144 Hypertension- 10 Hyperlipidemia- 11 Obesity- 54 RN Program- 7 Pediatric- Asthma- 1 Pediatric- Overweight/Obesity- 24

24. Diabetes Pre-diabetes/Diabetes Referrals –Motivational Interviewing –Goal-Setting –Continuous Follow-up –Completion of Feedback Loop

25. Process Referral from physician made into RN Program –Diagnosis/Need Care Coordinator Outreach –Face to face encounter at office visit –Phone call –Visit Education/Motivational Interviewing

27. Conclusions Team based care combined with point of care testing works Providers will utilize point of care testing Patients will utilize the care coordinator Find a process that works for your office

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