1. IMPROVING DIABETES AND HYPERTENSION NOVEMBER 2014 – JUNE 2015 PILOT Maine Chronic Disease Improvement Collaborative (CDIC) Learning Session #1

2. House-Keeping Remote access with Pines, Presque Isle Tone for the day: Conversational Needs / Norms / Requests from group?

3. Agenda Welcome and Introductions Setting the Stage for team-based improvement Key Drivers #1 & #2:  Standardizing Care throughout your Team  Optimizing your Registry Sticky Issues & Common Challenges Team Time & Cross-Pollination Next Steps

4. Maine Quality Counts Staff : Your Resources Sue Butts-Dion, Improvement Advisor Louise Morang Quality Coach Josh Farr – QI Specialist

5. Change is Personal AND It Takes a Village! Holly Richards & Nathan Morse CDC Statewide Efforts Rhonda Selvin Setting the context Team-Based Improvement Why Us? Why Now?

6. How will WE know we’ve succeeded? Michelle Mitchell, Partnerships for Health Context of the Evaluation work Invitation to participate in initial interviews

7. Welcome Our Patients Live with Chronic Disease ‘Tis the Season…

8. Naples Family Practice York Family Practice Midcoast Brunswick Family Practice Capeheart Community Health Center (PCHC) Pines Presque Isle CDIC Participating Teams

10. What we’ve learned from you (Baseline Assessment)  Payment model important to improvement (but not imperative!)  Wide variation exists throughout any given practice  Decision Support (protocols, patient education)  Pre-Visit Planning  Identifying patients most at risk  Standards begin with engaging everyone on improvement  Data helps drive this engagement Setting the Stage

11. Where you all are so far…

12. CDIC Scope Setting the Stage Current Strengths

13. High Performers to learn from Community Linkages PCHC

14. Opportunities to learn together PCHC Capeheart Midcoast Br Midcoast Brunswick York Pines P.I Pines P.I.

15. Opportunities to learn together PCHC Capeheart Midcoast Br Midcoast Brunswick York Pines P.I Pines P.I. Guidelines Protocols Optimizing Team-Roles

16. Setting the Stage What you’ve told us (your Top Three Things) 1. If we can engage all members of our staff… 2. If we could standardize risk assessment tools… 3. If we could better educate our patients… 1. Education Materials 2. Patient Goals & Action Plans 3. Shared Care Plans throughout the Team 4. “….WHILE SUPPORTING WORK-LIFE BALANCE!”

17. A Team So, Improvement Requires …

18. Data

19. Rhythm! So, Improvement Requires… Aim Measure Change Idea

20. CDIC Aim Structure Measures Global AimsSpecific Aims

21. Let your Aims Drive your Change Ideas

23. Standard Care Processes Clinical Guidelines / Protocols Medical Team composition Technology Use Communication (e.g., referral standards) Community Resources

24. Optimize Registry Embedded Guidelines on EMR Clinical Decision Support Tools (e.g., alerts & reminders) accessible to all team members Access to Labs/Tests across setting/system Ability to ID Populations ID sub-populations Stratify based on complexity, severity, CM services Capture/Track outcomes by provider Access to clinical information by practice-based and community-based members (CCT) Ability to get data for improvement from registry (e.g., run charts)

25. What are Your Aims? On a scale of 1 (clueless) to 10 (ready to roll): What will you work to improve? How will you measure improvement? What small test will you start with?

28. Optional slides to follow… Use as needed

29. Guidelines / Protocols

30. Medical Team Composition Team-based care, including:  Expanded nursing/MA protocols  Standing Orders  Health Coaches, Care Coordinators, Navigators

31. Technology Use Utilize EMR for action plans. Inter-connected EMR systems for coordination of care (incl. e-consults with specialists). Use biometric devices (digital scale, BP monitoring, etc.)

32. Communication Huddles Time for Improvement Meetings Staff training that maximizes scopes of practice for all practice staff Improve coordination between primary care provider and hospital

33. Community Resources Partnerships with community organizations (e.g., YMCA and pharmacies for lifestyle changes education, counseling and support) Identify areas resources that support on-gong self-management support. (e.g., Diabetes Self- Management Support (DSMS) planning).