1. SC PA Best Practice Sharing

2. Practice 1 PDSA’s Included:  Identifying DM patients prior to and/or at time of visits  Identify who needs Urine Micro Albumin and Eye Exams Prior to visits  Shoes/Socks off at visit, Monofilaments completed if due How did these Impact the Staff/Work Flow:  Secretaries assisted in placing “Prep Sheets” with Encounters when registering  All MA’s trained in Monofilament exams  Referral MA ran reports and placed calls to diabetics to get eye exam info.

3. Diabetic Patients PA Spread REMINDERS HPI entered “ Pt. is a Diabetic ” Have patient take shoes and socks off at every routine visit!!! Monofilament Foot exam completed within the last year??? If no, PERFORM exam today!!! Urine Microalbumin done within the last year??? If no, COLLECT urine sample and send!!! Retinal Eye Exam done within the last year??? If no, enter REFERRAL for diabetic eye exam!!!!

4. Practice 1 Moving Forward…  Pre-Visit Chart Preps  Daily Huddles (Providers, MA, etc…The whole team!)  RN Care Coordination for patients who need “extra care”  “High Risk” Meetings for Complex Patient Care Plans  Expanding the PCMH Module to other Diagnoses and eventually “All Patients”

5. MAJOR CHANGE Implementation of EMR All charts are now electronic with PMR scanned and saved to appropriate folders. All labs, orders, medications, letters and communication notes are in the EMR. OUTCOME Improved continuity of care with greater access for all providers Easier tracking and searching for test/results Ability to set Protocol Template allowing quick look for gaps in care Practice 2

6. MAJOR CHANGE Pre Visit Chart Preparation Health Coach uses EMR to Plan upcoming patient visit. Focus on Diabetic patients. Uses a Needs List Worksheet & completes with Gaps in Care identified. Worksheet is given to MA for review with patient at visit & standing orders to be completed. Physician to be made aware of other orders needed to complete Gaps in Care. OUTCOMES Microalbumin testing increased by 9% A1C Trending down More staff engaging w/pt visit

7. Practice 2 MAJOR CHANGE PCMH Health Coach Pt is referred to Health Coach at time of visit or referral made for teaching which could include diet, exercise and/or insulin titration to target based on standing orders. Continued point of contact for pt. & f/u calls made by PCMH Team. Recognize when further needs or Recourses are needed & assist w/referral. OUTCOMES 70 y/o w/history of DM, HTN, OBESITY and Hyperlipidemia Meet w/health coach, titrated insulin via phone calls & standing orders Date: A1C LDL TRIGLYCERIDES WEIGHT 7/10/12 8.5 127276 307 LBS 3/01/13 6.5 63132 291 LBS

8. Practice 2 MOVING FORWARD: Begin work on Self-management goals. Patient will be given handout that list several types of goals (healthy diet, exercise etc.) and asked to pick one realistic goal for them. High Risk Management: RN Care Coordinator will contact patient to assist with any transitions of care. Regular communication with physicians regarding care of High Risk to include regular meetings for management strategies.

9. Practice 3 Major Change Pre-visit Planning – Huddle Developed a Standard Protocol EMR Monthly Reports HgbA1c > 9.0 LDL > 100 Medication Adherence Hgba1c > 11.0 In House Lab Testing

12. Best Practice Changes Practice 4 Formed a Quality Management Team with a Quality Management Supervisor. – One of the responsibilities is coordinating and performing Pre-Visit Preparations Consists of a check list of orders, reminders, immunizations, results, etc. required to be in the chart based on age, gender and chronic conditions. Pre-Visit Preparations are conducted 24-48 hours prior to all previously scheduled appointments

13. Best Practice Changes Practice 5 Care Guide implementation for chronic conditions – Tool allowing provider to document care plan, goals, self-management abilities, educational material, etc. Diabetes, Asthma, Smoking Patient Recall Registry – Report generated from EHR data indicating patients in need of tests, procedures, immunizations, etc. – Outreach is performed to ensure patient receives appropriate care.

14. Best Practice Changes Practice 6 Created a Patient Navigator Position – Helps complete Pre-Visit Preparation – Reviews Quality Measures Care Guide implementation for chronic conditions Implemented Auto-Fax – Inbound faxing ability – Eliminates the need to scan paper faxes

15. Best Practice Changes Practice 7 Care Guide implementation for chronic conditions Transition of Care (TOC) follow-up – Made/making arrangements with hospital systems to notify site(s) of patient discharge – Implemented TOC Nurse and Office Visit Note Provides structured documentation for nurse phone outreach after discharge and provider office visit follow-up

16. Best Practice Changes Practice 8 Patient Registry – Identified patients with elevated A1C and over due for DM office visit Used this information to outreach to patients via 3 phone calls If no response sent series of 2 letters – Statistics – 32 patients were sent letters, 15 patients scheduled due to receiving the letter(s) » 47% success rate Care Guide implementation for chronic conditions

17. Best Practice Changes Practice 9 Pre-Visit Preparation – Enters reoccurring Reminders for routine and preventative testing Learning how to address the Reminders and over due Orders at time of visit Nurses perform DM Foot Exams – Nurse practitioner worked with nursing staff to teach proper foot exam technique – Nurse enters result into EHR Ensures proper documentation within EHR for reporting purposes

18. Best Practice Changes PAL-Eastbrook Family Health Center Implemented the use of Standing Orders – Protocol for Strep screening – Protocol for A1C blood draw – Protocol for Lipid screening Care Guide implementation for chronic conditions Pre-visit Preparations

19. Best Practice Changes Practice 10 Pre-Visit Preparations by the Quality Management Team – Enters Reminders and Orders to make the most of each visit Quality Team meetings to discuss what is working for each individual site Transition of Care follow-up

20. Best Practice Changes Practice 11 Patient Registry – Outreach to identified patients has evolved into case management Coordinated diabetic learning sessions at Millersville University Involvement with PA SPREAD has prepared the site(s) for PCMH

21. Example Materials Pre-Visit Prep Check List

22. Example Materials Care Guides—Diabetic Care Guide

23. Example Materials Patient Registry for Diabetic Management

24. Example Materials Transition of Care Nurse Note

25. Example Materials Transition of Care Office Visit Note