1. Welcome!
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2. Focus on Quality Diabetes A1c Uncontrolled and Untested
January 31, 2018
Indiana Primary Health Care Association

3. Agenda Recap of IQIN’s Shared Strengths work group
Review of changes and PDSAs performed during Shared Strengths from health centers
Data overview on diabetes measure
Open Discussion
Clinical Leadership Conference
Health center changes to improve diabetes measure
Future Strategy of Quality Trainings

4. Today’s Objectives
Participants will gain an understanding of the range of activities that your peers are using to improve diabetes outcomes.
Identify one new strategy to try to improve diabetes outcomes.

5. Past Model: Shared Strengths
Two Pillars used to drive quality improvement
Transparency
Collaboration
Met once per month
Alternated between two distinct groups:
Leadership Group: Responsible for strategy, direction
Data/QI Group: Discussed data and workflows
Intention: Share best practices and introduce interventions not yet implemented

6. Possible Interventions
Group Visits
CHWs
Outreach
Case management
Standing Orders
Gaps in care process
These are from June F2F Meeting

7. PDSAs
Each heath center chose an intervention and implemented it as a PDSA Cycle
PDSA examples:
Patient Navigators/Care Coordinators
Diabetes Pathways Program
Point-of-Care Testing
Care Guidelines
Follow-up protocol
Next, we’ll dive into some success stories.

8. Riggs Community Health Center
POC Testing- PDSA
What were your plans for change?
Decrease the number of diabetic patients with no A1c result for the testing period
Who was the target population?
Adult diabetic patients seen in our Adult/Internal Med department
What team of people were responsible?
Medical Assistants, Nurses, Unit Managers
Who monitored the data and measured progress?
Quality (me)

9. Riggs Community Health Center
If not completed, what phase of the PDSA are you in?
Phase 3 and holding at the moment, we have lots of projects going on and had some staff turnover that has made going to Phase 4 difficult

10. Riggs Community Health Center
What are some outcomes to date?
We decreased our untested number of diabetics slightly and increased our overall percentage of diabetics with A1c testing done at least 1x in the last year to 88% (1184 diabetics)
82% in 2015 (1026 diabetics)
86% in 2016 (1106 diabetics)
We found that most of the patients staff were doing POC on were compliant with lab draws and already had an A1c on file
This led to a procedure change
We found that doing POC was not cost effective for our self-pay patients; it is better for them to have labs drawn under our agreement with Labcorp if they need other testing.

11. Riggs Community Health Center
Next Steps:
We are working on Pre-Visit planning that will include reaching out patients prior to appointments to come in for labs. We don’t seem to have any continuity to this process currently, some providers have them come before, others wait until the day of the visit.

12. Questions?

13. Patient Care Coordinators Role in Diabetic Populations
NorthShore Health Centers
January 29, 2018

14. Patient Care Coordinator Role
Implemented Patient Care Coordinator program beginning in June 2016
“The Patient Care Coordinator is responsible for facilitating patient care services while aligning with Patient-Centered Medical Home (PCMH). The ultimate goal of the position is to improve access to care, quality of care, and patient outcomes through the self-care process.”
AADE Diabetes Paraprofessional Course

15. Target Populations Diabetic Population New Diabetics
ER Utilizers
Diabetics
Hypertension
Uninsured/Homeless and Depression
Referrals from Care Team
Diabetic Population
New Diabetics
Diabetics Referred by Provider
Diabetic Patients with an HbA1c > 9

16. Patient Care Coordinator Process
In collaboration with the care team, assess and manage the health needs of the patient
Follow up with patients in the program to address their needs, continuously updating personalized health plans and engaging and empowering patients

17. Outcomes and Next Steps
Quality Team and Patient Care Coordinators collaboration
Continuous follow-up with patients
Next Steps:
Improving documentation
Widening population

18. PDSAs on Diabetes- Other Centers Progress
What were your plans for change?
Who was the target population?
What team of people were responsible?
Who monitored the data and measured progress?
If not completed, what phase of PDSA are you in?
What are some outcomes to date and next steps?

19. Azara Users
Diabetes Data review

20. Diabetes A1c <9 or Untested (NQF 0059) : Trailing Year
*Rate represents 12 health centers with data in Azara DRVS

21. Diabetes A1c <9 or Untested (NQF 0059): Trailing Year
*Rates reflect patients seen within the current month and the previous 12 months who had a qualifying visit and had a A1c of 9 or greater or did not have a A1c test

22. Diabetes A1c >9 ONLY

23. Diabetes Untested ONLY

24. Interactive Dashboard View

25. Open discussion

26. Open Discussion POLL Clinical Leadership Conference attendance?
Diabetes breakout attendance?
Did you use/follow-up any of the following?
Huddles
Community health workers
Rooming cards
Other highlights

27. Open Discussion POLL
Are you working on diabetes measures as a part of your quality improvement plan?
How many track diabetes measures regularly? How often?
Monthly, quarterly, annually…

28. Open Discussion- Diabetes Improvements/Changes
What are you doing specifically to improve diabetes?
What were your biggest challenges/lessons learned?
What worked well/successes?
What Population Health Management tools are utilized to manage diabetic patients (e.g. Registries)?
What questions do you have for the group on how to improve this measure?

29. Future Structure and strategy for quality trainings and initiatives at IPHCA
Moving Forward

30. FQHCs & Look-Alikes

31. PCA & IQIN Collaboration
Changing HRSA focus
Practical challenges
Health center feedback
Workplans

32. Quality/Performance Improvement Strategy: Rationale
Coordinate Activities
Leverage Resources
Streamline Engagement
Reduce Participation Burden

33. Alignment of Goals HRSA PCA Goals HRSA HCCN Goals
Clinical Quality Improvement
↑ health outcomes and disparities: diabetes and colorectal cancer screening
↑ 5 Healthy People 2020 Goals
Operational Performance Improvement
↑ Health centers w/ costs < national average
↑ Value, efficiency, effectiveness
PCMH
↑ PCMH recognition and advancement
↑ PCMH recognition
Data Quality
↑ UDS EHR reporting on all patients for all clinical measures

34. Roles Data Engagement Framework PCA & IQIN staff Advisory group
Health centers
Roles
Common measurements
Streamlined quarterly monitoring
Needs assessment
Coordinated tracking and evaluation
Data
Predictable monthly webinar engagement
Focus on topics
Combined training and peer learning model
Supplemental engagements
Engagement
Please reach out to IPHCA if interested by Feb. 7th

35. Next Steps ECRI Diabetes CME Online Offering Scheduled to meet monthly
- Starting in March (2nd Wed. of month)
Any other last minute items, updates, announcements….