Learning Session #1“Staying Alive”

“Engaging Patients and Communities In Order to Improve Care of Patients Living with Diabetes and High Blood Pressure”

October 22, 20159AM – 4PM

Hilton Garden Inn, Freeport

Maine Chronic Disease Improvement Collaborative

(CDIC)

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https://www.youtube.com/watch?v=8KhNzHL5kKw

Speaker Disclosures:The speakers today do not have any relevant financial relationships with the

manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

This project is supported by contract with the Maine Center for Disease Control & Prevention and is funded by a federal grant (US

CDC grant award DP13-1305).

Some Maine Quality Counts staff working on CDIC have funding for part of their salaries for the Chronic Pain Collaborative 2 Project (CPC2) which is

funded by a grant by the Pfizer Foundation’s Independent Grants for Learning and Change (IL&C) which funds the time of QC Staff and Consultants.

Welcome our Participating Practices:

• Dover Foxcroft Family Medicine

• Ellsworth Internal Medicine

• Lincoln Medical Partners Family Medicine – Damariscotta

• Sebasticook Family Doctors

• York County Community Action – Nasson Health Care

• York Family Practice

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Welcome to our Project Partners:• Maine Quality Counts: Project Leadership, QI

coaching, PCMH expertise

• Maine Centers for Disease Control & Prevention (ME CDC): Grantee and Partner

• Partnerships for Health: Evaluation Partner

• QC Health Improvement Partnership Leadership (QCHIP) Group and Community Partners: Operational guidance, advice and direction

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CDIC Project Team:Peer Consultants:

• Dr. Peter Emery• Dr. John Devlin• Rhonda Selvin, NPEvaluation Team-Partnerships for Health:• Michele MitchellCDC:• Holly Richards• Nathan Morse• Ashley Lauze

Project Staff:• Lisa Letourneau, MD, MPH• Amy Belisle, MD, Interim Director• Chris Beaudette, MS, Project Manager• Wendy Rodrigue, Administrative

Coordinator • QI Specialists:

– Josh Farr– Sue Butts-Dion– Kim Gardner– Amanda Bannister

• Kellie Slate Vitcavage, Consumer and Community Engagement Program Manager

Today’s Agenda:• Understand a Population Based Health Approach to Managing

Chronic Disease and Quality Improvement Methodology• Get to the Heart of the Matter: How do we include Patients,

Consumers, Families, and Communities in this Work?• Breakout: Patient/Consumers & Community Partners• Understand the Standards of Care for Diabetes and

Hypertension• Look at the Referral Process for Diabetes Education• Highlight the Work in NH to Prevent and Control Hypertension• Develop a 90 day plan• Connect Primary Care Practices with the Community by

Testing Messages from National work on Diabetes & Hypertension

The Importance of Focusing on Chronic Disease Improvement:

• 33% of people in Maine have hypertension, 39% have high cholesterol, and 23% of all deaths in Maine are attributed to heart disease

• 11% of Mainers have pre-diabetes/diabetes, putting them at 2-4 times greater risk for heart disease

• Chronic Disease is the number one cause of death, accounting for 32% of mortalities in Maine in 2010.

• Despite their hard work, primary care practices face many challenges in helping their patients meet treatment goals for diabetes and heart disease

• New studies suggest we need to have even better blood pressure control

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How can we work together to improve outcomes with patients living with

Chronic Diseases?Work Together: Learn from each other in the project to improve systems and test changes and use a team based approach to care

Improve Quality Metrics: Understand national metrics and goals around diabetes and hypertension care including metrics with CMS PQRS reporting, medical home and ACOs

Engage Consumers, Patients and Community Partners: Enhance how we are including them as partners in our improvement work and focus on shared decision making

Optimize Existing Work: Build on the work of the PCMH/Health Homes, Behavioral Health Homes, Community Care Teams, Care Coordination, healthcare organizations and community organizations

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What Matters Most when Leading and Sustaining QI Efforts?

• Leadership Matters• Teams Matter• Data Matter• Relationships Matters• Patient and Family Stories Matter• Fun Matters

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Leaders Matter:

• Need to identify vocal leaders at the local and health system level

• Need to understand why the project is important

• Need to be willing to confront resistance to change

• Need to be trusted by their teams• Need to help formulate a sustainability plan

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• Team-based care: teamwork and attitude are critical to quality improvement

• Work to include the tools from Team STEPPS training in your work

• Make sure you include everyone from the front office staff, nurses, medical assistants, providers, billers/coders, etc.

• Use everyone to their highest ability• Develop better ways to communicate: you cannot build a team or

change behavior by email edicts• Develop clear goals, workflows, and training to guide the work• Decide how you will spread your work to everyone involved in

health care delivery at your office• Look at quality improvement support available to your practices• Think about building interprofessional and interdisciplinary teams

Teams Matter:

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• “Clean Data and Committed Peers”= Physician Change*• Clean Data is composed of reliable data streams and

analytics; the translation of information into knowledge*• In order for practices to use data to drive improvement,

they need to trust the data• Need to align data/QI measures with reimbursement

*(Source: Dr. Jay Want, Owner/Consultant, WantHealthcare, “HealthCare Reform: Managing Directionally Correct Chaos, 7/23/2013 Presentation”)

Data Matters: Using Data to Create

Champions of Change:

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Data: Key Component of theModel for Improvement:

Model for Improvement

Associates in Process Improvement 14

High Level Aim & Goals:2015 Aim Statement: By June 2016:

• improve the care of patients with hypertension by up to 10% in order to reach an overarching goal of >75% of patients having adequate control of their blood pressure (<140/90) (NQF 18)

• and reduce by up to 10% the percentage of patients with DM (type 1 & type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done in order to reach an overarching goal of <15%. (NQF 59)

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High Level Aim & Goals:Goals:• Do previsit planning for > 90% of patients with diabetes and hypertension

• Recognize social determinants of health for > 90% of patients that may impact health outcomes

• Work with patients on shared decision making so that > 90% will identify goals for their health and feel that there has been collaboration with their practice team

• 90% of patients with diabetes with HbA1c >9 who have not previously completed diabetes self-management education program will be referred to CDE or DSMT program

• 90% of patients will have documented in their chart if they have had signs of overtreatment (hypotension or hypoglycemia)

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What changes can we make?

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In order to make changes look at Your Office Workflows:

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Try to standardize your workflow to align with national/state

algorithms

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Protocol for Controlling Hypertension in AdultsMillion Hearts® HTN Algorithm

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• Screen patient if age > 45 OR • Patient is overweight (BMI > 25) and has at least 1 of additional risk factor

YES NO

RESULTS

TREATMENT

NORMAL PRE-DIABETES RANGE DIABETES RANGE

REFERRAL TO COMMUNITY RESOURCES

REFERRAL TO NDPP &/OR COMMUNITY RESOURCES

REFERRAL TO DSMT

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NO MEDICAL TREATMENT

TREATMENT – REFER TO COMMUNITY RESOURCES

NORMAL PRE-DIABETES RANGE DIABETES RANGEReferral to Community

ResourcesReferral to National Diabetes Prevention Program (NDPP) &/or Community Resources

Referral to Diabetes Self Management Training

(DSMT)

• Community Health & Counseling Services-Bangor

• Eastern Area Agency on Aging• Healthy Acadia-Ellsworth• Maine Coast Memorial Hospital-Ellsworth• Maine General Medical Ctr – Augusta &

Waterville Campus• St. Joseph Diabetes & Nutrition Center-

Bangor• Spectrum Generations Area Agency on

Aging-Augusta

• Eastern Maine Medical Center-Bangor

• Lincoln Health Diabetes & Nutrition Program-Damariscotta

• Maine Coast Memorial Hospital-Ellsworth

• Maine General Medical Center – Augusta & Waterville Campus

• Mayo Regional Hospital-Dover-Foxcroft

• Mount Desert Island Hospital-Bar Harbor

• St. Joseph Hospital-Bangor• York Hospital-York (Living Well

Center)

Kennebec Valley YMCA-Augusta (includes membership)

Relationships Matter: Building Teams

• Building relationships takes time• Need to include patients/consumers and community

groups• Need to develop a common language for projects

that is understood by patients and practice staff• Sometimes relationships are challenged by issues at

the system level that need to addressed • Spreading and sustaining changes depends on

relationships

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Patients and Family Stories Matter:

• Include consumers and families in your QI work

• Make it easy for consumers and families to get consistent health care following national guidelines in your office and in the community

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Starting the Conversations with Patients, Consumers and

Communities: • How Do We Get the Care We Need to Lead Healthier Lives

Million HeartsEveryone with Diabetes CountsPrevent Diabetes STAT

• Reduce Unnecessary CareChoosing Wisely

• Include Trauma Informed Care Recognizing Adversity

Resiliency

Relational Health

• Engage Patients in Health Care Decisions25

MONTHLY REQUIRED PATIENT INFORMATION

GOAL

Information from Patients: Patients will complete the CollaboRATE Survey Tool questions. We hope to do this with a tablet at check out.

Practices will have 20-25 patients a month complete the CollaboRATE Survey Tool at checkout.

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Additional Questions to Better Understand Social Determinants of Health and Build Relational Health:• Do you have one person in your family or in the

community to provide you with assistance if needed? • Do you have any financial, social, or physical barriers

and/or facilitators to achieving better health? • Can you identify at least one goal that is important to

you about why you want to achieve better health?

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TeamSTEPPS in 10…….

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TeamSTEPPS in 10…..• Handouts with TeamSTEPPS tools to be introduced monthly, as a “tool of

the month” • October’s One-Page TeamSTEPPS Core Tools by Dr. Dora Anne Mills at UNE

http://www.mainequalitycounts.org/image_upload/TeamSTEPPS%20Abbreviated%20Tools3.pdf

• St. Louis University (SLU) Online TeamSTEPPS Module: The Essentialshttp://familymedicine.slu.edu/uploads/lectora/STEPPSmodules/Essentials/index.html

• Monthly Team Exercises – Paper Chain http://www.mainequalitycounts.org/image_upload/Team%20Exercise%20-%20Paper%20Chain%2012.pdf

• For more information on the TeamSTEPPS program please visit http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/primarycare/

• To order TeamSTEPPS pocket guides: http://teamstepps.ahrq.gov/abouttoolsmaterials.htm

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Paper Chain:

• Each team will get a packet• Make the longest paper chain that

you can in 2 minutes• There is no talking• No same colors can touch

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Debrief the ExerciseDEBRIEF Reviewing the Team’s Performance: Informal information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors

Was communication clear?Were roles and responsibilities understood?Was situation awareness maintained?Was workload distribution equitable? Was task assistance requested or offered? Were errors made or avoided? Were resources available?What went well? What should improve?

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Paper Chain:

• Use 2 minutes to brief• Each team will get a packet• Make the longest paper chain that you

can in 2 minutes• There is no talking• Put your dominant arm behind your back• No same colors can touch

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Key Components of the Brief• Sharing the Plan: Short session prior to start to share the plan,

discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes

• Brief Checklist: Who is on the team? Do all members understand and agree upon goals? Are roles and responsibilities understood? What is our plan of care? What is the staff and provider’s availability throughout the

shift? How is workload shared among team members?What resources are available?

GATHERING REFLECTIONS &NEXT STEPS:

Amy Belisle, MD

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Upcoming Events:

Webinar: December 17th 12-1 PM

Webinar: February 25th, 2016 12-1 PM

Learning Session #2: March 17th, 2016

9-4 PM Maple Hill Farm, Hallowell

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CME Certificates:• CME disclosure: The speakers today do not have any relevant financial

relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. Some QC staff do have funding for another project, The Chronic Pain Collaborative 2 Project which is funded by a grant by the Pfizer Foundation’s Independent Grants for Learning and Change (IL&C).

• CME will be available for participants

• We do not have separate nursing CEUs- but you can get a CME certificate.

• A CME evaluation survey will sent after the learning session via email.

• Please complete the survey via Survey Monkey within 1 week

• A CME certificate will be emailed within 1 month of completion of the survey

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Chronic Disease Improvement Collaborative 2 (CDIC)

We welcome your comments and questions!

CDIC website:www.mainequalitycounts.org/CDIC

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Project Team:MAINE QUALITY COUNTS:

Amy Belisle, MD - Program DirectorAbelisle@mainequalitycounts.org

Chris Beaudette - Interim Project Managercbeaudette@mainequalitycounts.org

Kellie Slate Vitcavage - Senior Project Manager of Consumer & Community EngagementKSlateVitcavage@mainequalitycounts.org

Sue Butts Dion - Quality Improvement Advisorsbutts@maine.rr.com

Josh Farr - Quality Improvement SpecialistJFarr@mainequalitycounts.org

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MAINE CDC:

Nate Morse, CHES, TTS-CProgram CoordinatorNathan.Morse@maine.gov

Holly Richards, MPH, CHESCardiovascular Health CoordinatorHolly.Richards@maine.gov

Ashley Lauzé, MPH, CPhTHypertension & Diabetes SpecialistAshley.Lauze@maine.gov