1. IMPROVING DIABETES AND HYPERTENSION NOVEMBER 2014 – JUNE 2015 PILOT Maine Chronic Disease Improvement Collaborative (CDIC) Launch Webinar: November 7, 2015: 8 – 10 AM (866) 740-1260 ; 1120970# www.readytalk.comwww.readytalk.com #1120970 Rhonda Selvin, NP Associate Medical Director, Maine Quality Counts Joanne O’Neil Lafferty, M.Ed. Quality Improvement Specialist, Maine Quality Counts

2. Agenda Welcome and Introductions (45 minutes)  Quality Counts Staff  Practice Teams Project Overview (45 mins)  Setting the Stage  Collaborative Model  Benefits of Participation  Collaborative Overview Next Steps Q & A

3. Maine Quality Counts Staff & Faculty

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

6. Welcome Your name and role (all team members) A little bit about your team (improvement initiatives involved in, etc.) One thing your practice is most proud of One thing you want to learn from the collaborative Six word sentence that describes your teams’ feelings going into this

7. National Front Local Front Chronic disease is the number one cause of death. 32% of mortalities in Maine in 2010 Diabetes rates have risen from 6% to 8.7% in 10 years 92,000 adult residents living with diabetes Why Now?

8. Strong primary care leadership Active participation by Maine practices in Medical Home & Health Home, others… Rural communities increase isolation and the need for support for chronic disease patients Your readiness & willingness! Why Maine?

9. Funder: Maine Centered for Disease Control (CDC)  1305: State Public Health Actions to Prevent & Control Diabetes, Heart Disease & Obesity Project Partners:  Maine Quality Counts: project leadership, practice coaching, PCMH expertise  Maine CDC: grantee and partner  Partnership for Health: evaluation partner About the Project

10. Stakeholder group … strong and growing!  Including:  MMC Diabetes Collaborative  Maine Cardiovascular Health Council  Medical Care Development/Public Health  HealthCentric Advisors Quality Improvement Organization (QIO)  Area Agencies on Aging  Maine Nurse Practitioner Association  Primary care practice and Specialty provider groups

11. Our Goals  Expand knowledge on evidence based, safe, cost effective care  Implement/spread best practices and algorithms across the state  Improve quality, cost and safety  Teach and spread science of quality improvement

12. Leading Improvement  Patients/families  Health  Provider support  Leadership  Teams  Relationships  Data

13. JOANNE O’NEIL LAFFERTY, M.ED. MAINE QUALITY COUNTS, QUALITY IMPROVEMENT SPECIALIST CDIC Collaborative Model

16. Benefits of Participation  Dedicated, on-site improvement coaching support  Learning sessions—all teach all learn  Case conference calls with clinical experts  Virtual learning communities—”share seamlessly and steal shamelessly”  Maintenance of Certification & CME available (contact Joanne for information)

17. Benefits of Participation Dedicated, on-site improvement coaching support A dedicated improvement coach on-site to support you with the program requirements 2 times a month at a time convenient for you Assess current state and support ongoing improvement work Optimize registry to inform improvement Support data collection and reporting Develop team meeting and improvement skills

18. Benefits of Participation Building In-person & virtual Learning Communities  Most of the learning will be virtual, allowing you to stay in your office  Share & network across the state  Access to clinical and quality improvement experts  Access to best practices, tools & templates  A chance to learn, share and spread best practices NovemberDecemberJanuaryFebruaryMarchAprilMayJune Launch Webinar Learning Session 1 Case- Conference Call Practice- based Self- Study Learning Session 2 Case- Conference Call Practice- based Self- Study Case- Conference Call Learning Session 3 (Optional) 11/7/14 8AM- 10AM 12/4/14 9 AM – 3 PM 1/15/15 12:15 – 1:15 Anytime this month 2/26/15 9AM – 3PM 3/19/15 12:15 – 1:15 Anytime this month 5/21/15 12:15 – 1:15 6/18/15 9AM – 3PM

19. Benefits of Participation

20. Additional Benefits of Participation  An easy way to achieve Maintenance of Certification (optional)  CME available (optional) for your staff

21. CDIC Aims 2014-2015 By July, 2015, the CDIC participants will aim to redesign their practices to: Improve blood pressure control of hypertensive patients so that 65% of hypertensive patients have BP<140/90 mm Hg. Improve HbA1c control of diabetic patients so that 80% of diabetic patients whose most recent HbA1c level is <9.0% during the measurement year.

22. How might we meet that Aim?

23. Drivers for Improving Chronic Care

24. Family of Measures Outcome measure Overall measure of success Voice of customer or clinical outcome Process measures How work gets done More sensitive to change Come and go as work changes

25. Our Measures Note: Will vary based on MOC participation Outcome Measures: HTN BP Control (<140/90) (NQF 18) and/or LDL <100 (NQF 0074) DM A1c Control (>9%) (NQF 59) and/or a1c <8% (NQF 0575) Process Measures: Registry UsePopulation Management Pre-Visit Planning Self-Management PlanReferralOthers… Balancing and Structural: Systems Assessment Staffing Patient Satisfaction Time Others??

26. CDIC Evaluation Federally required evaluation. Partnerships For Health is based in Augusta and has been awarded the evaluation contract. Two components of the evaluation – performance measures and qualitative evaluation. Performance measures: Approximately 6 measures Need to be reported beginning/end Partnerships For Health will be available to assist with data collection Qualitative evaluation 1 - 45 minute interview with an administrative leader / manager 1 - 1 hour focus group with staff 3 - 45 minute individual interviews with patients

27. Balancing… Is there any other part of the system that might be influenced by your changes?  Patient Satisfaction  Length of Visit  Finances  Staff Satisfaction Structural  Staffing (turn over)  Educated Care Team

28. How have we learned that we can accelerate change and increase improvements in healthcare? Aim Measure Change Idea

29. Changes Tied to Aim/Measures Measures AimsChange Ideas

30. Next Steps Meet your QI Support! (Onsite) 1.BUILD your team 2.ASSESS your systems and registry 3.CLARIFY your needs for support 1.Measure collection 2.Registry optimization 3.Workflow optimization 4.Others… 4.BRAINSTORM Aims and improvement opportunities 5.ORIENT team to resources

31. How Ready are You? On a scale of 1 (low) – 10 (high) 1.We have are excited to meet with QI Specialist and get started! 2.We can easily pull measures that tell each team how they are doing with Diabetes and Hypertension patients! 3.We have tested things in the past that seem to have gone well! 4.Our team can work with our QI Specialist 2x/month 5.Here’s where we think we might start: __________________________________

32. Contacts Joanne O’Neil Lafferty, M.Ed. jlafferty@mainequalitycounts.org Rhonda Selvin, NP rselvin@mainequalitycounts.org General CDIC Mailbox CDIC@mainequalitycounts.org

33. Questions?