1. Diabetes Program Improvement Project
September 20, 2017
Gail Dougherty, Diabetes Program Development Project Manager
Valeria Mallett, Registered Dietitian

2. Agenda The Data – Current State Program Goals
Qualitative data for program design
Key new program components
Approach
Pilot
Timeline

3. The Data – Current State (July 2017)
Number of patients had a visit in the last 12 months = 36,465
Of the 36,465 patients, 3691 patients have diabetes (A1c >6.6)
Number of Patients with Hemoglobin A1c >9 = 1170
Number of Patients to reach 19% target = 468
 Clinic
VG Rate: A1c>9.0
# of Pts with DM
VG Average
31.7%
3691
VGB
31.2%
957
VGC
30.5%
717
VGH
34.7%
1009
VGN
28.6%
154
VGYC
30.7%
787
Goal
19.0%
 3691
# of Pts A1c>9.0
1170
299
219
350 44
242
702
# of Pts to Target
468
117 82
158 14 92
 Ethnicity
% of DM patients
Hispanic
59%
Caucasian
26%
Asian 3%
African American 1%
Other
Unknown
10%
Total
100%
 Gender
% of DM patients
Women
56%
Men
44%
Total
100%

4. Program Goals
Reduce # of patients with out-of-control DM (A1c >9) by increasing patient engagement in DM Services
Non-clinical measure: Increase “CareSTEPs” (encounters/touches) with each DM patient as a surrogate measure of patient engagement
Number of DM pts + number of times for each of the following:
Attending DM Education (seeing Alison, Valeria)
Visits with BHP, CHW, MH, CPS, MSW, HRS
Meaningful contacts with care team (Provider, RN)
Attending support group and self-management programs
Clinical measure: % of Diabetic Patients with A1c > 9.0
STEP = services that engage patient

5. Qualitative Data Gathering – the numbers
Staff Interviews
Interviews conducted – 43
People interviewed – 133
Groups
# Interviews
Teams 14
One-on-ones 26
External groups 3
Patient Surveys
Total Respondents
178
English
129
72%
Spanish 49
28%
Women
101
57%
Men 77
43%
Patient Focus Groups
Total Participants 41
English sessions 21
Spanish sessions 20

6. “When patients engage in services provided …
Staff Interview Summary
What’s Working Well
What’s NOT Working Well
DM Education classes
Clinical Pharmacists
Team-based approach
Nurses & MA’s
Behavioral health
Self-management groups
#1 - Patient Readiness 
Patients not engaged, can't/won't spend effort to work on DM
Not enough classes or groups
Lack of clear pathways for patients
Tracking & charting
Behavioral health – unclear differentiation from Mental Health
“When patients engage in services provided …
we see improvements.”

7. Patient Input Summary Confirms: New approaches / broaden use:
Variety of services & resources still needed
Patients don’t absorb much at once. Repetition, references, reminders required
Best days/time of day – weekday morning & evening, Saturday morning & mid- day
New approaches / broaden use:
Positive approach – Patients need encouragement & hope – they can do this!
Smaller steps, slower but steadier progress
Weekly groups for motivation, life skills, food knowledge & skills
Incentives to attend groups & DM appts
Online resources

8. Key Program Components – Phase 1
Expanded Diabetes Education
Valeria Mallett
Registered Dietitian
Trilingual English,
Spanish, Portuguese
Alison Reta
PharmD, CDE
Bilingual English,
Spanish
Twice as many classes
Twice as many individual slots
New expertise
New services on the way
Basic Diabetes class
Nutrition classes
Learning about Insulin
1:1 appointments

9. Key Program Components – Phase 2
Behavioral Health
DM Self-Management Programs
“Diabetes Health Counselor”
“Navigator” to clinic services
Assesses emotional state, addresses barriers to change
Assesses patient’s readiness to manage health
Recommends next steps – psychosocial help,
DM education,
DM self-management group
Living Well with Chronic Conditions,
Tomando Control de Su Salud
Diabetes Support Group
A Tu Salud
Groups meet weekly for several wks
Life skills – decision making, goal setting, communications
Lifestyle changes for diabetes management – food choices, movement, medications, stress reduction

10. New VG Paradigm for Every Patient Interaction
Approach
New VG Paradigm for Every Patient Interaction
Goal:
Make It Count
Staff:
I have time for you
Patients:
Respect Me
Know Me
Teach Me
Show Me
Respect Me – Positive & Optimistic, conveying that they can be successful
Encourage rather than scolding or shaming
Empower them – meet people where they are, give choices, “what works for you”
Realistic, small changes – what patients can do and will do
Acknowledge successes, no matter how small
Team notes:
Verbiage - does “nutritionist” sound less like “you need to go on a diet” than “dietitian” does? “RD Nutritionist” -
Rather than objective 3rd person (“help patients”), use direct “help you”?
Speaker notes:
Input from Providence:
Shifting to be realistic - what patients can do and will do
Present initially that there are a lot of tools, find what works for you
Try to meet people where they are rather than give everyone the same info

11. New VG Paradigm for Every Patient Interaction
Pilot
New VG Paradigm for Every Patient Interaction
Goal:
Make It Count
Staff:
I have time for you
Patients:
Respect Me
Know Me
Teach Me
Show Me
Psychosocial Issues
Community Health Worker
Behavioral Health Provider
Mental Health Provider
Diabetes & Nutrition Education
Teach Me
Wellness Options
VG Wellness Center(s)
Community Offerings
Diabetes
Self-Management Programs
Show Me
PCP or RN Visit
Behavioral Health Provider /
“Diabetes Health Counselor”
Know Me
Team notes:
Verbiage - does “nutritionist” sound less like “you need to go on a diet” than “dietitian” does? “RD Nutritionist” -
Rather than objective 3rd person (“help patients”), use direct “help you”?
Speaker notes:
Input from Providence:
Shifting to be realistic - what patients can do and will do
Present initially that there are a lot of tools, find what works for you
Try to meet people where they are rather than give everyone the same info

12. DM Program Development Timeline
Year
2017
2018
Month
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Phase 1 – Expand DM Education
Design Program Phase 2
Pilot New Program
Phase 2
Roll out Phase 2 to all Sites
Design Program Phase 3
Pilot & Roll Out Phase 3
Roll out new
DM Ed schedule
Today
Finalize Program Elements - Phase 2
Trng
1 Team
Modify,Train
Pilot at 1 Site (VGH)
Analyze, Modify
Train & Support Teams
Roll Out to 2 Teams per month
VGB
VGYC
VGB
VGYC
VGC
VGN
Phase 3 Elements
Phase 3 Process Details
Pilot at 1 Site (TBD)
Analyze, Modify, Train
Roll Out to Additional Teams