1. Housekeeping Tips Microphones will be muted by the host Please note the audio and video controls in the top left corner If you would like to ask questions during the question and answer session, please type them in the chat box at the bottom right hand of your screen as pictured below Audio & Video controls Chat Box

2. Using Data to Drive Quality in Diabetes Care This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity.

3. Faculty Disclosure In compliance with ACCME Guidelines, I hereby declare: I do not have financial or other relationships with the manufacturer(s) of any commercial services(s) discussed in this educational activity. Name: Kristine McVea, MD, MPH Title: Chief Medical Officer Disclaimer The information provided at this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

4. AAFP Credit This activity has been reviewed and is acceptable for up to __1__ (Prescribed or Elective) credit by the American Academy of Family Physicians. The AAFP invites comments on any activity that has been approved for AAFP CME credit. Please forward your comments on the quality of this activity to cmecomment@aafp.org. cmecomment@aafp.org At the conclusion of this activity, participants should be able to: Participants will learn how to link their strategic plan to data driven initiatives at the department and individual clinician and staff level. Participants will understand how to make data meaningful and motivating to all members of their diabetes team. Participants will learn how to analyze data on their diabetic patients to determine who to target for more intensive intervention given limited resources.

5. Where I Practice Free Clinic 7 total staff No resources 9 Sites Exponential Growth 58% Uninsured

6. Every Site is Unique and Challenging! If we can do it, you can do it!

7. The Golden Thread Alignment of Purpose from Strategic Vision through Execution at the Individual Level Department Dashboards Strategic Plan Individual Report Cards Employee Performance

8. Our Strategic Plan Identifying Clinical Quality as a Priority for the Organization

9. Prioritizing and Defining Quality At Department Level Yearly Provider/Nursing/Support Staff Retreat  Review Data, Discuss in Small Groups – Everyone Participates!  Nominate Potential Focus Areas  Vote on SMALL, Do-Able Number Subsequent Bi-Weekly Meetings  Determine Measures of Success, Goals  Define Action Plans  Review Progress Everyone Understands the Organizational Goal and Interprets What that Means for the Department

10. Clinician Dashboard

11. Dashboard Detail DEFINITION: Numerator: Number of patients in the denominator whose last systolic blood pressure measurement was less than 140 mm Hg and whose diastolic blood pressure was less than 90 mm Hg. Denominator: Patients between 18 - 85 who have been diagnosed as hypertensive prior to June 30 of the measurement year and have been seen twice during the reporting year. Action Plan: Clinical Pharmacy BP Checks Provider Rechecks BP if High

12. Clinician Report Cards

13. Sharing Clinical Performance Considerable Variation Among Providers Within Same Practice Identify Best Practices Within Your Organization Accelerates Learning 1. A1C Last 6 Months- Harry Diaz (96%), Kelly Houfek (88%), Hans Dethlefs (87%) 2. Hypertension Controlled- Kelly Houfek (75%), Leah Jorgensen (74%), 2 Providers at 67% Michelle Christensen, Kris McVea 3. LEAP- Kelly Houfek (80%), Stephanie Hall (77%), and Ledy Davidson (76%) 4. LDL in Last Year- Kelly Houfek (93%), Eloise Poyner (86%), Vicki Bangert (83%) 5. Microalbumin- Kelly Houfek (91%), Vicki Bangert (86%), and 2 Providers at 82% Don Allison and Stephanie Hall 6. Optometry- 2 Providers at 74% Don Allison and Stephanie Hall, Hans Dethlefs (69%)

14. A1C Last 6 Months- Harry Diaz (96%), Kelly Houfek (88%), Hans Dethlefs (87%) Hypertension Controlled- Kelly Houfek (75%), Leah Jorgensen (74%), 2 Providers at 67% Michelle Christensen, Kris McVea LEAP- Kelly Houfek (80%), Stephanie Hall (77%), and Ledy Davidson (76%) LDL in Last Year- Kelly Houfek (93%), Eloise Poyner (86%), Vicki Bangert (83%) Microalbumin- Kelly Houfek (91%), Vicki Bangert (86%), and 2 Providers at 82% Don Allison and Stephanie Hall Optometry- 2 Providers at 74% Don Allison and Stephanie Hall, Hans Dethlefs (69%) Sharing Clinical Performance Considerable Variation Among Providers Within Same Practice Identify Best Practices Within Your Organization Accelerates Learning

15. Examples of OneWorld Best Practices for HbA1c > 9 Schedule monthly follow up visits until < 9 Be Aggressive about med & insulin titration  Almost everyone at this level needs Insulin – Talk about it NOW  Titrate Insulin up by 10% Do not rely on BS values to titrate Insulin Self Titration of Long Acting Insulin (1 unit/day for am BS > 140) “Just Try it for One Week” Approach to Insulin Same Provider Every Time, but Take Care of Business if you Cross Cover! Praise Patients Whenever Possible

16. Using Report Cards For Other Staff Nursing Staff – LEAP Exams Health Assistants – Retinal Photos Diabetic Educators – Diabetic Huddles on Time All Staff Members Understand How Their Personal Performance Contributes to Organizational Goals

17. The Golden Thread Alignment of Purpose from Strategic Vision through Execution at the Individual Level Department Dashboards Strategic Plan Individual Report Cards Employee Performance

18. Using Data to Characterize Your Population

19. Using Population Data To Prioritize 1750 Patients with Diabetes 298 Patients with HbA1c ≥ 9% 530 Patients on Insulin That’s a lot of patients! How should the Diabetic Educators and Case Manager spend their time?

20. Diabetic Educator Approach Focused on Insulin Users only Called monthly Over 10 attempts to call some patients per month Controlled Diabetics loved it, but no insulin changes made Time wasted on unmotivated patients Patients in control got most resources

21. Case Manager Approach Patients Not Seen for > 120 days Started with the letter “A” each month Sometimes got thru “L” Called from 8-9:00 am Often pulled to answer phones “Lost to follow up” patients appeared each month Lists run only monthly – needed to consult EMR before calling Oh Boy – Not effective on so many levels.

22. Using Data to Prioritize Resources Diabetic Educators focus on “At Risk” patients  New Diagnosis  New start Insulin  Active Insulin titration  Out of Control or HbA1c > 8 MOTIVATED PATIENTS ONLY  Instituted “Diabetic Huddles” with providers quarterly to determine intensity of contact

23. Case Manager Monthly, then Daily Report – Real Time Work Adequate time to Manage Population Contacted by Phone (different times/days) followed by Post Cards Protocol for Inactivating “Lost to Follow Up” patients Developed “Supervision” Reports for Oversight of Population Management

25. Case Manager Empowered Given “Carte Blanche” to offer appointments, financial assistance, medications, transportation – Whatever it Takes! Case Manager offered:  Appointment with PCP  Anytime – even evening appointment not usually scheduled  Free Visit  Free Meds  Transportation

26. Failed! Patients still “NO SHOWED” their appointments If you are working harder than your patient, something is wrong

27. Characterizing our Population Chart review of DM patients out of control:  25% New Diagnosis or Working on Control  25% Not Motivated  50% Not Engaged, Not Reachable MOTIVATION, not Education, Resources were the Key!

28. Our Response Training for Diabetic Educators, Providers, Case Managers in Motivational Interviewing Resource: http://www.chcf.org/publications/2006/08/video-with- techniques-for-effective-patient-selfmanagement

29. Characterizing Your Population “It seems like physicians are being more aggressive with insulin use in our practice compared to midlevels providers. “ Using insulin earlier made a difference! Midlevels needed educational support to feel confident with Insulin Insulin Use% HbA1c < 9 Midlevels25%80% Physicians45%85%

30. Diabetes Population Data Better Prioritize Resources Coordinate Care Identify Staff Training Needs Chart Reviews or EMR Reports Can Both Provide Valuable Information Looking Beyond the UDS Can Yield Valuable and Surprising Information

32. CME Credit Survey This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity. The following disciplines are qualified to receive credit for this webinar: MD, DO, NP, & PA. Nurses can receive a certificate of attendance. If you are seeking credit for this webinar training, please click the following link from your computer now: CLICK HERE for CME Credit Survey

33. Announcements Best Practice Story Contest - CLICK HERE This webinar series was funded by Bristol-Myers Squibb Foundation Partnership for Diabetes Health Equity.