Chronic Disease Management

Quality Improvement Project

Mackenzie Family Health Clinic

Aim: To further improve the care of patients with chronic diseases,90% of

patients with one or more chronic diseases will have an annual, planned

appointment and will be provided with a care plan and/or discussion of self

management goals.

Patients over 18 in Mackenzie who attend the clinic and have one or more chronic diseases.

The qualifying chronic conditions are based on the GPSC guidelines for complex and chronic disease care.

DiabetesCongestive heart failure COPDHypertension Co-morbidity - patients with two of more chronic diseases

Chronic renal failure with eGFR values consistently less than 60

Chronic respiratory condition Cerebrovascular disease Ischemic heart disease, excluding the acute phase of

myocardial infarct Chronic neurodegenerative diseases Chronic liver disease with evidence of hepatic

dysfunction

Scope and Boundaries

Are we prepare

d?

A Sense of Urgency!

Primary Health Care Charter : a collaborative approach

42% of primary care physicians report

not having adequate time to spend with

their patients

Primary care physicians in a 15 min visit can no longer meet

what patients need or deserve.

Bodenheimer, Building Teams in Primary Care: Lessons Learned,

chcf.org, 2007

Bodenheimer, Building Teams in Primary Care: Lessons Learned, chcf.org, 2007

Evidence shows an increase in patients

with multiple agendas and a decrease in time

and availability with the physician

Bodenheimer, Building Teams in Primary Care: Lessons Learned, chcf.org, 2007

50% of patients leave the visit

without understanding

what advice their physician gave

Bodenheimer, Building Teams in Primary Care: Lessons Learned, chcf.org, 2007

No wonder many

preventative services go undone and many patients

with chronic disease are poorly controlled.

WHAT CAN BE DONE?

• The creation of high-functioning primary care teams

• Systematic, planned care for people with chronic conditions

• Improve Access

• Group Medical Appointments

Chronic Disease Registry Management Process Map

Systematic, planned care for people with chronic conditions

Helps care providers target care to meet patient needs

Facilitates other practice improvements, such as group visits and patient self-management

Improves professional satisfaction

Increases likelihood of follow-up for patients who need it. Targets hard-to-reach patients.

Prevents complications through proactive treatment

Increases patient satisfaction

Primary Care

Teams

Tasks that are now performed by non-physician team members

Obtaining point of care measurements

Updating the Electronic Medical Record

Advising patients to go to the lab prior to their appointment

Advising patients to bring their medications for reconciliation

Monitoring and updating patient registries

Organizing Group Medical Appointments

Managing quality improvement initiatives in the office

Managing and encouraging patients to book annual appointments

Primary Care

Teams

Tasks that will be performed by non-physician team members

Develop Educational Materials Notify and review lab results with the patient

under care provider’s direction. Assist with the development of Self

Management Skills Implement smoking cessation intervention Manage standing orders and complete

standing Lab requisitions

Total Number of Patients in the EMR 4784 Total Number of Patients Identified with Complex or Chronic Diseases 552 (11.5%)

47% of these patients have more than one chronic disease

HTN 79.7%

DM 33.9% COPD 10.9%

CKD 10.7%

ISCH 9.2% CBVD 4.2%

CHF 3.1% RESP 3.3% NEURO 2.5%

LIVER 0.7%

552 pa-tients

440 187 60 59 51 23 17 18 14 4

25

75

125

175

225

275

325

375

425

475

No. of Patents Identified with Complex or Chronic Diseases in the MacKenzie Health Centre

# o

f P

ati

ents

CL 0.374

UCL 0.437

0%

10%

20%

30%

40%

50%

60%

70%

31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-DecJanuarly to December 2011

% of Planned Visits for Patients with Chronic Diseases

On December 31, 2011, 58% of patients identified with chronic diseases had

attended the clinic for a planned chronic disease appointment.

CL 0.536UCL 0.601

0%10%20%30%40%50%60%70%80%90%

100%

26-Apr 6-May 24-May 31-May 20-Jun 8-Jul 11-Aug 8-Sep 27-Sep 31-Oct 30-Nov 31-Dec

April 2011 to December 2011

Number of Patients with Chronic Diseases on the Recall List

As of December 30, 2011, 77% of the patients with chronic diseases were on a recall list for their

annual planed care.

As of December 31, 2011, 73.5% of patients with

diabetes had a foot exam

documented in the EMR.

As of December 31, 2011, 71.9%

had their HgbA1c

checked in the past six months.

CL 0.712

UCL 0.813

50%

55%

60%

65%

70%

75%

80%

85%

30-Jan Feb-29 29-Mar 30-Apr 30-May 30-Jun 30-Jul 30-Aug 30-Sep 30-Oct 30-Nov 30-DecJanuary to December 2011

% of Diabetic Patients with HGBA1c in past 6 mos

CL 0.537

UCL 0.648

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-DecJanuary to December 2011

% of Diabetic Patients with an Annual Foot Exam

As of December 31, 62.5% of the patients with COPD had an

exacerbation plan.

Of 231 patients who had Diabetes and/or COPD, there were

127 visits to the

emergency room

CL 0.078

0%

2%

4%

6%

8%

10%

12%

14%

29-Mar 30-Apr 30-May 30-Jun 30-Jul 30-Aug 30-Sep 30-Oct 30-Nov 31-Dec

% of Diabetic and COPD Patient Visits to ER from April to December 2011

47

19 1816

1411

86 5 5 4 3 3 3 2 1 1

resp injury skin musc GI other syncope blood sugar

BP renal urinary cardio cerebr MH Gland post op seizure

Visits to the ER from March - December 2011

Will managing patients with

chronic disease in a more proactive

way, lead to fewer patients

visiting the ER for acute or crisis conditions?

Are appointments available to meet the demand for care?

Office efficiency has been demonstrated to build capacity in

primary care offices and improve the quality of life for practitioners.

31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec

No Show 54 52 69 54 75 122 88 121 78 96 130 85

18

38

58

78

98

118

138

# of

Pati

ents

who

did

not

show

for t

heir

appo

intm

ent

Total No Show Appointments

Does displaying data on the walls

for the care providers to see

make a difference?

Interview with Dr. David Abbott:

“The reports on the wall are inspirational. It made a difference to my work. I seem to have an antennae now for when I care for patients. I am looking for gaps in care…”

“I became enthusiastic which surprised even me”

“There were many little things that were changed that amounted to major changes in how we look after patients”

Feedback

Displaying data on the wall for the

patients to be

informed, activated

and empowere

d.

Patient Surveys:

• Most people felt their experience at the clinic was excellent or good.

• Some patients do not know what the plan is for their care…were not asked about their beliefs or ideas

did not know they should be booking a yearly exam.

Feedback

MOA Surveys:

• MOAs feel confident in their jobs and their workload.

• They feel part of a team working for the good of the patients

• They rated patient care very high.

Feedback

Indications That Improvements Made In This

Clinic Will Continue• This community is focusing on improving the integration of health services

• The Primary Health Care Developer is working on an improvement charter to improve access

• The care providers will be engaged in the Chronic Disease Module and Group Medical Visit Module of the Practice Support Program.

• The leadership is continuing to encourage site visits and is supporting the improvement work.

Indications That Improvements Made In This

Clinic Will Continue• The clinic staff are keen to take more training, including patient self-management, and the leadership has built time into their day for this training.

• A third permanent doctor is expected to arrive which will create stability with patient care.

• The clinic staff and physicians are keen to organize a group medical appointment for people with chronic diseases.