1. Diabetes Master Clinician Program (DMCP) Edward Shahady MD Helena Karnani MD Florida Academy of Family Physicians St Vincent’s FM Residency Jacksonville FL

2. Background Information (funding) Started in November 2003 by the Florida Academy of Family Physicians Foundation Started in November 2003 by the Florida Academy of Family Physicians Foundation Grants obtained Pfizer $125,000, Blue Cross Blue Shield of Florida $100,000, Nova Nordisk $15,000, Astra Zeneca $10,000 Grants obtained Pfizer $125,000, Blue Cross Blue Shield of Florida $100,000, Nova Nordisk $15,000, Astra Zeneca $10,000 Partner with St Johns, Big Bend and Heartlands Rural Health Networks (some funds for data entry, associate medical directors and travel for medical director) Partner with St Johns, Big Bend and Heartlands Rural Health Networks (some funds for data entry, associate medical directors and travel for medical director)

3. Background Information (Training) Currently have 80 practices, 15,000 patients, 47,000 visits, trained 180 clinicians, 270 office staff Currently have 80 practices, 15,000 patients, 47,000 visits, trained 180 clinicians, 270 office staff Clinician and Staff (MA/LPN) receive initial Training of 4.0 hours followed by monthly emails, visits by assciate med director and two 2 hr follow up sessions over one year. Clinician and Staff (MA/LPN) receive initial Training of 4.0 hours followed by monthly emails, visits by assciate med director and two 2 hr follow up sessions over one year. Training includes Training includes – Evidence Based standards of care – How to use patient reports from diabetes registry – How to use population reports from the registry – How to conduct group visits – Up to date knowledge about diabetes, lipids and hypertension – how to address clinician and patient barriers to standards adherence-clinical inertia

4. Value of DMCP Increased quality of care for diabetics in your practice Increased quality of care for diabetics in your practice Decreased complications and suffering for your patients Decreased complications and suffering for your patients Entry into the Medical Home concept Entry into the Medical Home concept Increased reimbursement for quality of care Increased reimbursement for quality of care Increased prestige through recognition and certification Increased prestige through recognition and certification –Office recognized as a center of diabetes excellence –Clinicians certified as Diabetes Master Clinicians –Staff certified as Diabetes Master Clinician Associates

5. DMCP Diabetes Registry Is internet based-all data and reports on the web Is internet based-all data and reports on the web Research assistant places initial data for all diabetic patients from a Practice into the registry. Research assistant places initial data for all diabetic patients from a Practice into the registry. Staff then keeps up data entry Staff then keeps up data entry Initial training begins once data from practice is entered Initial training begins once data from practice is entered

6. In addition to the registry they are taught how to do group visits.

7. Actual group visit-patients completing first part of medical record.

8. Registry Reports (tools) Point of Care Reports for the Clinician and the Patient- staff gives patient report (team) Point of Care Reports for the Clinician and the Patient- staff gives patient report (team) Population based Reports that identify– Population based Reports that identify– Patients at increased risk because of increased HbA1c, LDL, B/P, Non-HDL, TriglyceridesPatients at increased risk because of increased HbA1c, LDL, B/P, Non-HDL, Triglycerides Patients who do not have documented annual recommendations or daily ASAPatients who do not have documented annual recommendations or daily ASA

9. Saves Clinician 5 minutes

10. Empower the Patient

11. Report compares performance to ADA standards and all other clinics

13. Displays patients with at risk A1c

14. Displays patients that have not had indicated yearly activity or daily ASA

16. ADA Quality Indicator Yearly Cost Savings if indicator achieved HBA1C ≤ 7 $279.00 LDL ≤ 100 $369.00 Syst BP ≤ 130 $474.00 Total yearly savings $1122.00 Towers Perrin actuarial evaluation 2006 Bridges to Excellence 2006 Bridges to Excellence http://www.bridgestoexcellence.org/assets/ Documents/Program_Evaluation_Documents/DCL_analysis1207051.pdf http://www.bridgestoexcellence.org/assets/ Documents/Program_Evaluation_Documents/DCL_analysis1207051.pdf http://www.bridgestoexcellence.org/assets/ Documents/Program_Evaluation_Documents/DCL_analysis1207051.pdf http://www.bridgestoexcellence.org/assets/ Documents/Program_Evaluation_Documents/DCL_analysis1207051.pdf

18. WWW.FAFP.ORG

21. Dr. Karnani will now discuss Team Care and its impact in a Community Hospital Residency Program

22. St Vincent’s Family Practice Residency, Jacksonville, FL Team Work and Diabetes Management St Vincent’s Family Practice Residency, Jacksonville, FL Helena Karnani December 2008

23. The Setting We are a 30 resident FP Program in an urban setting in Jacksonville, FL We are a 30 resident FP Program in an urban setting in Jacksonville, FL 15,000 patients, 150 visits/day 15,000 patients, 150 visits/day All diabetes patients in our practice are entered into the data base All diabetes patients in our practice are entered into the data base Currently > 700 patients with 3006 visits Currently > 700 patients with 3006 visits Each Pt is updated 3-4 times a year Each Pt is updated 3-4 times a year

24. Our Initial Data May 2007 Data showed a large gap between what we assumed and what was actually transpiring

25. Solutions To make changes requires a collaborative, interdisciplinary effort To make changes requires a collaborative, interdisciplinary effort To do this we: To do this we: –Created Teams –There are 4 teams on 2 floors –Team Members from all clinical areas –Initiated Team Meetings

26. Team Meetings Team Meetings Team Based Care is an important part of the Future of Family Medicine Project and the Patient Centered Primary Care Collaborative (PCPCC) Team Based Care is an important part of the Future of Family Medicine Project and the Patient Centered Primary Care Collaborative (PCPCC) Important to train residents to be competent in teamwork as part of the Medical Home Important to train residents to be competent in teamwork as part of the Medical Home Excellent literature discussing how to build effective Teams and run effective meetings Excellent literature discussing how to build effective Teams and run effective meetings

27. Resources TransforMed – Making meetings effective, 8 tips for change management, Leadership excellence TransforMed – Making meetings effective, 8 tips for change management, Leadership excellence STFM – Team Function in the Medical Home STFM – Team Function in the Medical Home FP Management – 3/2006: Creating a high performing clinical team, 4/1999: A Team approach to Quality Improvement FP Management – 3/2006: Creating a high performing clinical team, 4/1999: A Team approach to Quality Improvement

28. Building an Effective team Requires: Clear expectations that teamwork and collaboration are expected Clear expectations that teamwork and collaboration are expected Family Physicians modeling teamwork in their interactions with each other Family Physicians modeling teamwork in their interactions with each other Receptivity to ideas and input from all team members Receptivity to ideas and input from all team members Involving all team members in decision making about team function Involving all team members in decision making about team function Holding regular team meetings and celebrate team success publically Holding regular team meetings and celebrate team success publically

29. Running a Team Meeting Requires: Having a Facilitator/Team leader Having a Facilitator/Team leader Ground Rules Ground Rules Start and end on time Start and end on time Keep it simple, stay on topic, stay organized Keep it simple, stay on topic, stay organized Distribute an agenda prior to the meeting Distribute an agenda prior to the meeting – 3 types of items: Announcements, Discussion Items and Decision Items Consider everyone’s opinions before decisions are made Consider everyone’s opinions before decisions are made Goal is to produce an action report ( who, what, when) and written minutes Goal is to produce an action report ( who, what, when) and written minutes

30. Our Team Meetings Initial planning with team leaders/faculty Initial planning with team leaders/faculty Initial separate meetings with staff, and physicians Initial separate meetings with staff, and physicians Team meetings with all players on a regular basis Team meetings with all players on a regular basis Members of our teams Members of our teams Nurses and MA’s Front Desk Staff Lab Staff Health Care Providers – Faculty, residents, ARNP

31. Our Initial Data May 2007

32. Team Meetings Present the Data Present the Data Education: Reflect on why good diabetes care is important? Education: Reflect on why good diabetes care is important? What are reasonable goals? What are reasonable goals? Brainstorming Brainstorming –Nurses can order shots and labs –Nurses can do foot exams –Templates assist documentation in medical record –Front desk remind pts to come fasting –Use Report Cards to educate patients

34. Nurses template

35. Doctors Template

36. Completed Chart Note

37. Patient Report Card

38. Teams Educating and empowering the Staff Educating and empowering the Staff Educating and empowering the Patients Educating and empowering the Patients Educating and Assisting the Health Care Providers Educating and Assisting the Health Care Providers

39. Impact of Team Work over 8 month period in 140 patients 1.Ordered tests per protocol and 2.Did monofilament exams 3.They gave patients report cards

40. Summary Major improvements have been made Major improvements have been made Don’t know how you are doing unless you measure performance Don’t know how you are doing unless you measure performance Diabetes management takes a team - MA’s very important part of the team Diabetes management takes a team - MA’s very important part of the team Education and participation of all members of the team, including the patient is the key to success. Education and participation of all members of the team, including the patient is the key to success.

41. Questions and Comments