1. Provider Tips and Toolsets Rural Quality Program Conference Office of Rural Health Policy Health Resources Services Administration September 2, 2009 Kathy Reims, MD Chief Medical Officer CSI Solutions, LLC Clinical Assistant Professor, UCHSC Eugene Maynard, MD Rural Quality Project Participant Benson Area Medical Center Benson, NC I do not have any relevant financial relationships to disclose

2. Objectives Provide practical tools and tips to improve performance on OHRP CVD measures ◦ General approach ◦ Hypertension and Lipid control ◦ Integrated Smoking Cessation Toolkit

3. Tools to Improve Performance Patient Factors Care Team Factors System Factors

4. Patient Factors Awareness* Education* Commitment to Care Plan ◦ Patient confidence in managing condition* ◦ Side effects ◦ Practical considerations ◦ Psychosocial impacts*

5. Assist Patients with Care Plans Self-Management supports* Proactive follow up* Care Team is accessible DAP programs Pay attention to medication regimens Medication reconciliation Screen for literacy*, depression*, substance abuse

6. Care Team Factors Evidence-based care* Planned Care ◦ POS prompts and reminders* Protocols ◦ Trained Staff* ◦ Delegated work* Outreach and proactive follow up* Expand the team: pharmacist, promotora Optimize the team: designated roles or FTE*

7. System Factors Access ◦ Group visits* ◦ Email or Web-based ◦ Convenient, timely appointments Continuity of care Population management* Coordination of care Effective use of technology*

8. Awareness: BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 National Health and Nutrition Examination Survey, Percent II 1976–80 II (Phase 1) 1988–91 II (Phase 2) 1991–941999–2000 Awareness 51736870 Treatment 31555459 Control 10292734 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

9. Awareness: Guidelines

10. Patient Education http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/dash_brief.pdf

11. Education and Patient Reminders: BP Wallet Card

12. BP Wallet Card

13. Education and Patient Reminders: National Cholesterol Education Program http://www.nhlbi.nih.gov/health/public/heart/chol/wyntk.pdf

14. HTN & Lipid Patient Education http://www.nhlbi.nih.gov/health/index.htm http://www.americanheart.org/presenter.j html?identifier=1516 http://www.americanheart.org/presenter.j html?identifier=1516 http://familydoctor.org/online/famdocen/h ome/common/heartdisease/risk/092.html http://familydoctor.org/online/famdocen/h ome/common/heartdisease/risk/092.html http://www.webmd.com/heart- disease/guide/heart-disease-prevent http://www.webmd.com/heart- disease/guide/heart-disease-prevent

15. Patient Self Management http://www.ama- assn.org/ama1/pub/upload/mm/ 433/phys_resource_guide.pdf

16. BUBBLE DIAGRAM If you have diabetes, here are some things many individuals try to do for their health. Would you like to set any goals concerning any of them? Blood glucose monitoring Taking medications to help control blood sugar Losing weight Daily foot care Depression  Smoking Skin care Taking insulin Diet

17. Goal Setting Tools www.healthdisparities.net

18. Plan the Visit: Flowsheet Organize key information POS Reminders Share the work Huddles

19. Plan the Visit: Electronic Flow Sheet

20. Delegated Work: Standing Orders

21. Standing Orders

22. Evidence-based care: JNC VII Reference Card

23. JNC VII Reference Card, side 2

24. Evidenced-based Care ATP III Palm Interactive Guideline Tool http://hp2010.nhlbihin.net/atpiii/atp3palm. htm http://hp2010.nhlbihin.net/atpiii/atp3palm. htm CVD Risk Calculator http://hp2010.nhlbihin.net/atpiii/calculator. asp http://hp2010.nhlbihin.net/atpiii/calculator. asp ATP III At-a-Glance Desk Reference http://www.nhlbi.nih.gov/guidelines/choles terol/dskref.htm http://www.nhlbi.nih.gov/guidelines/choles terol/dskref.htm

25. Staff Training: Lunch and Learns JNC VII Slide Set http://hp2010.nhlbihin.net/nhbpep_slds/m enu.htm http://hp2010.nhlbihin.net/nhbpep_slds/m enu.htm AAFP Ask and Act Program http://www.aafp.org/online/en/home/clinic al/publichealth/tobacco/toolkit.html http://www.aafp.org/online/en/home/clinic al/publichealth/tobacco/toolkit.html ATP III Slide Set http://hp2010.nhlbihin.net/ncep_slds/men u.htm http://hp2010.nhlbihin.net/ncep_slds/men u.htm

26. Staff Training: Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency Improve your patient communication skills Increase your awareness and knowledge of the three main factors that affect your communication with patients Implement patient-centered communication practices

27. Optimize your Team: Case Manager Role Plans and integrates care for people with diabetes and other chronic diseases Liaison with other community resources Provide good documentation in patient record, all patient contact attempts, and all telephone and written communication with patients Log in binder the appointment date/time/location; check off if the letter was sent, phone call made, films requested Reviews charts for what is needed (with help of other team members) Coordinate with other team members Help with referrals and links to community resources as needed Helps counsel around self-management goals

28. Optimize your Team: Outreach Log

29. Manage your Population: use your data

30. Health Literacy Screen Newest Vital Sign http://www.pfizerhealthliteracy.com /pdf/FH_vitalsigns_040605.pdf

31. Depression Screening http://www.commonwealthfund.org/usr_doc/PHQ2.pdf PHQ -9 http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/

32. Why Process Map? Creates a visual snapshot of the current flow of the process Allows you to “see” opportunities for improvement Facilitates identification of process variations, duplications and waste Adds a discipline to improvement Allows involvement of all key players

33. Patient given order for fasting lipids RN enters patient name and date into log (in lab) Returned results are processed by lab staff and results entered into log Lab gives results to PCP PCP orders follow up visit Lipids at target? Results notification mailed Yes No RN schedules appointment But what about….?

34. Patient given order for fasting lipids RN enters patient name and date into log (in lab) Lab gives results to PCP. PCP orders follow up visit. Lipids at target? Results notification mailed Yes No Log checked q 2 weeks for follow up phone calls needed Returned results are processed by lab staff and results entered into log RN schedules appointment and places reminder in tickler file Front desk checks tickler and reports no-show appointment to RN Gaps addressed: 1.Follow up for Lipid results that have not been returned 2.Ability to track if patient received timely follow up on elevated lipids.

35. Smoking Cessation Toolkit An Integrated Approach