qin-qio public sharing call slides · 12/13/2018 · 4. ensure all team members understand the ....

QIN-QIO Public Sharing Call:The Basics of Implementing a Successful Continuous Quality Improvement Plan for a DSMT Program

Thursday, December 13, 20183:00-4:30 PM ET

Welcome and Reminders

2

Lindsay KaatzEvent Lead

Susan BrittmanChat Manager

• Please be prepared for sharing and open discussion

• Slides and a recording from today’s session can be found on: https://qioprogram.org/qin-qio-public-sharing-calls-3-part-series

https://qioprogram.org/qin-qio-public-sharing-calls-3-part-series

Purpose

• Audience: Community and healthcare providers, local partners, federal partners, and Quality Improvement Organization (QIO) Program partners (*registration required)

• Purpose: The purpose of this session is to review the basics of implementing a successful continuous quality improvement plan for a DSMT program.

• Expectations: Participants will gain knowledge that is directly applicable to their work in healthcare quality improvement and acquire information that can be easily shared among their own community, organization, or team

• Topics: Topics will be aligned with the CMS Quality Strategy goals

3

Audience Poll

4

Please indicate your profession:• Physician• Registered nurse or nurse practitioner• Pharmacist or pharmacy technician• Dietitian• Quality improvement professional• Healthcare administrator• Other (please specify in chat)

Learning Objectives

• Name the 9 quality pillars of a best practice DSMT program.

• State the 4 things required for CQI effectiveness in a DSMT program.

• State what the 4 letters (i.e., the 4 sequential steps) stand for in the evidence-based CQI model called “P-D-S-A”.

5

Continuing Education Credit

Continuing education credit is available for:• Physicians and Physician Assistants• Registered Nurses and Nurse Practitioners• Dietitians• Pharmacists and Pharmacy Technicians• Certificate of Attendance

6

Method of Participation & Instructions for Claiming CE

• Attend the entire event• Complete the post-event assessment that will pop up at

the conclusion of the event• There is a separate evaluation required for CE linked

within the post-event assessment• Once you submit your CE evaluation, you will be

provided with a certificate to retain for your records• For technical assistance, please email Stacey Davis

([email protected])• If you have questions about this CME/CE activity, please

contact AKH Inc. at [email protected].

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mailto:[email protected]


CE Information

Physicians:This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare, CRW & Associates and Telligen. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

AKH Inc., Advancing Knowledge in Healthcare designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants:NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

Pharmacists:AKH Inc., Advancing Knowledge in Healthcare is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.AKH Inc., Advancing Knowledge in Healthcare approves this knowledge-based activity for 1.5 contact hours (0.15 CEUs). UAN 0077-9999-18-047-L04-P; UAN 0077-9999-18-047-L04-T. Initial Release Date: 12/13/2018

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CE Information, Continued

Registered Nurses:AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.This activity is awarded 1.5 contact hours.

Nurse Practitioners:This activity has been planned and implemented in accordance with the accreditation Standards of the American Association of Nurse

Practitioners (AANP) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare, CRW & Associates and Telligen. AKH Inc., Advancing Knowledge in Healthcare is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 030803This activity is approved for 1.5 contact hour(s) which includes 0 hour(s) of pharmacology. Activity ID #218196

Dietitians:AKH Inc., Advancing Knowledge in Healthcare is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 1.5 continuing professional education units (CPEUs) for completion of this program/material. CDR Accredited Provider #AN008. The focus of this activity is rated Level 2. Learners may submit evaluations of program/materials quality to the CDR at www.cdrnet.org.

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http://www.cdrnet.org/

Disclosure of Financial Relationships & Commercial Support

• The planners and faculty do not have any relevant financial relationships to disclose.

• AKH Inc., CRW & Associates, and Telligen do not have any relevant financial relationships to disclose.

• No commercial support was received for this activity.

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Disclosure of Financial Relationships & Commercial Support

Disclosures:It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whoseproducts or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral toNational Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use and Investigational Product:This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Pleaserefer to the official prescribing information for each product for discussion of approved indications, contraindications, andwarnings.

Disclaimer:This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as ageneral guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or otherprofessional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant's misunderstanding of the content.

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Meet Your Speaker

12

Mary Ann HodorowiczRDN, MBA, CDE, CEC

Mary Ann Hodorowicz Consulting, LLC

Continuous Quality Improvement Plan

for

Diabetes Self-Management

Education and Support Program

Mary Ann Hodorowicz, RDN, MBA, CDE, Certified Endocrinology CoderMary Ann Hodorowicz Consulting, LLC

Mary Ann HodorowiczRDN, MBA, CDE,

CEC

(Certified

Endocrinology

Coder)

Mary Ann Hodorowicz, RDN, MBA, CDE, CEC, is a licensed registered dietitian and certified diabetes educator and earned her MBA with a focus on marketing. She is also a certified endocrinology coder and owns a private practice specializing in corporate clients in Palos Heights, IL. She is a consultant, professional speaker, trainer, and author for the health, food, and pharmaceutical industries in nutrition, wellness, diabetes, and Medicare and private insurance reimbursement. Her clients include healthcare entities, professional membership associations, pharmacies, medical CEU education & training firms, government agencies, food and pharmaceutical companies, academia, and employer groups. She served on the Board of Directors of the American Association of Diabetes Educators from 2013 – 2015, and was the Chair of the Advanced Practice Community of Interest in 2016.

Mary Ann Hodorowicz Consulting, LLC [email protected] 708-359-3864

www.maryannhodorowicz.com

Twitter: @mahodorowicz 14

Learning Objectives

1. Describe Standard 10 of the 2017 National Standards of DSMES as it relates to quality improvement.

2. State the 4 things required for CQI effectiveness.

3. Name the 2 primary goals of a CQI plan for a DSMES program.

4. Name the 9 pillars of a best practice DSMES program.

5. Name the 3 types of nationally recognized quality measures that are key to transforming a DSMES program into a ‘best practice”.

6. 6. Give 1 example of each of the 3 types of quality measures for a best practice DSMES program.

7. 7. State what the 4 letters (i.e., the 4 sequential steps) stand for in the evidence-based CQI model called “P-D-S-A” and describe the steps.

Definition of CQI

• Philosophy and culture of improvement for the patient, practice, and population served

• Encourages health care team members to continuously ask:

− How are we doing?

− Can we do it better…more efficiently?

− Can we be more effective?

− Can we do it faster?

− Can we do it in a more timely way?

CQI in 2017 National Standards of DSMES

Standard 10 of National Standards of DSMES (NSDSMES) is:

“The DSMES services quality coordinator will measure

the impact and effectiveness of the DSMES services

and identify areas for improvement by conducting a

systematic evaluation of process and outcome

data.” 2017 National Standards for Diabetes Self-Management Education and Support, Diabetes Care 2017 Aug; dci170025. https://doi.org/10.2337/dci17-0025

4 Elements Required for CQI Effectiveness

1. Use a formal, evidence-based model for CQI

2. Ensure that patients, families, providers, and care team members are all involved in CQI activities

3. Establish and monitor 3 types of quality measures to routinely evaluate improvement efforts:

• Structure + Process + Outcome

4. Ensure all team members understand the quality measures for success

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The changes involved in patient centered medical home transformation. Prim Care. 2012 Jun;39(2):241-59.

Structure,Process

and OutcomeQuality Measures

OperationsPlan

MarketingPlan

FinancialPlan

ContinuousQuality

ImprovementPlan

Clinical/Teaching

Plan

Preliminary Key

Activitiesand

NSDSMES**National Standards of

DSMES

6 Components

of

DSMES

Business Plan

Why a CQI Plan

Use CQI to Move From Current State to Desired Future State

Plan

Do

Study

Act

CQITeam

+Quality

Measures

Current State

FutureState:

ImprovedPatient Care

Why a CQI Plan, Con’t.

• It assures adherence to all DSMES standards

− This assures quality and consistency of program

from perspective of program’s 4 target markets:

o Patients of providers

o Providers

o Payers

o People in community with diabetes

9 Pillars of Best Practice DSMES Program = The R’s

1. Reputation of quality via AADE accreditation of program

2. Regular use of a DSMES program business plan

3. Robust referrals for DSMES (provider and patient self referrals)

4. Retention of patients in program

5. Related services added to program, per customers’ needs

6. Reimbursement and financial health of program

7. Ratings of patient experience/satisfaction are high

8. Ratios of productivity in educator work hours identified and tracked

9. Routine tracking of structure, process, outcome quality measures

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2 Goals of CQI Plan

1. Meet the needs and wants of our customers …

the target markets …of our DSMES program

• Internal customers

• External customers

Source of image: https://www.stockfreeimages.com/p1/people.html

2 Goals of CQI Plan, Con’t.

Internal customers:

• DSMES team

• Employees of practice setting

• Directors

• Administrators

• Program Stakeholder

Committee

External customers:− Patients

o PWDs and their families

o Patients with pre-diabetes

− Providerso Physicians, DOso NPs, PAs, CNSs

− Payers o Health planso Medicare, Medicaido Employer groups


• External− ADA Education Recognition

Program

− AADE Diabetes Education Accreditation Program

− Centers for Medicare and Medicaid Services (CMS)

− Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

− National Committee on Quality Assurance (NCQA)


2. Meet the needs and wants of customers in a qualitymanner

• We know if we are meeting needs and wants of customers by:

o Measuring the structure, process and outcome

quality measures of DSMES program regularly

o 3 types of quality measures embedded in ALL

the National Standards of DSMES

Mensing, Carolé, et. al, Educators, Publication date unknown. Web. 13 May 2014.http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/general/Narrative.pdf

Maximizing 3 quality measures leads to DSMES program quality!

STRUCTURE PROCESS OUTCOME

= Resource

sof SO*

= Performance

= End Result of

Patient and Provider

Experiences

= Right Tools

= How Tools Used

= End Product

*SO = Sponsoring Organization 28

Source of image:

Heart of CQI: Team + Quality Measures

• CQI projects:

− Are a team effort ….not them or us!

− Focus more on quality measures, and less

on people!

Source of image: https://www.pdclipart.org/thumbnails.php

About Structure Quality Measures

• Related to resources (including capabilities, features) of

DSMES program’s sponsoring organization (SO)

• Examples:

−Data tracking system to track and monitor patient,

program and provider data (number of: visits, referrals,

etc.)

More examples in APPENDIX at end of slide deck

Examples of Structure Quality Measures

− Evidence-based clinical decision support tools:

o Diabetes standards of medical care in diabetes

o Diabetes, hyperlipidemia and HTN nutrition practice guidelines

o AADE7™ Self-Care Behaviors

o 2013 Guideline for the Management of Overweight and Obesity in Adults

About Process Quality Measures

• The way resources are used to deliver DSMES program

• The way program’s activities and procedures are executed

• Ask: does the “way” align 100% with your established:

−Program’s mission, vision and goals?

−Program’s written policies and procedures?

−2017 National Standards of DSMES?

− Insurers’ DSMES reimbursement rules?

−Sponsoring organization’s policies and protocols?

Examples of Process Quality Measures

• Examples:

− Patient contacted within 48 hours of receipt of referral

− No-show patients called within 24--48 hours by educator to inquire about reason and to reschedule

− Educator sends progress note to referring provider within 48 hours

− Scheduled classes start and finish on time

So far, lots to chew on!

34

About Outcome Quality Measures

• End result of what educators do over period of time

• 3 types: patient, provider and program outcomes

• Outcome quality measures and targets are identified by:

− DSMES team

− Benchmarking external data from other DSMES programs

− Studying internal data related to chosen quality measure

Examples of Patient Outcome Quality Measures

• Knowledge of why to or skill/confidence in being able to:

− Eat healthy

− Be active

− Monitor my blood glucose

− Take my medications as ordered

− Use strategies to better cope with having diabetes

− Solve or reduce my diabetes problems

− Reduce my diabetes risks

More examples in APPENDIX at end of slide deck

Examples of Patient Outcome Quality Measures, Con’t.

• Behavior change (AADE7™ Self-Care Behaviors):

− Limit carb foods to 45 g at each of 3 meals

− Walk 20 minutes, 3 times per week

− Monitor blood glucose once day and recording results

− Take my prescription medication as prescribed by provider

− Examine my feet every day


• Clinical:

− Fasting blood glucose

− 2 hour post prandial blood glucose

− A1c

− Blood pressure

− LDL-cholesterol

− HDL-cholesterol

− Weight or BMI

Examples of Patient Outcome Quality Measures, Con’t.Quality of life:• Low energy level

• Pain, discomfort due to diabetes

• Anxiety, worry due to diabetes

• Depression due to diabetes

• ↓ daily activities due to diabetes

• Lost work/school days due to

diabetes

• Relationship problems due to

diabetes

• Blurry vision

• Excessive urination

• Excessive hunger

• Excessive thirst

• Drowsiness/tiredness

• Unintentional weight loss

• Very dry skin

• Blisters

• Cracked or bleeding skin

• Poor sleep at night


Cost savings:• Fewer therapies

• Fewer tests (e.g., laboratory, scans, etc.)

• Less Rx medication

• Less OTC medication

• Fewer emergency room visits

• Fewer hospitalizations

• Fewer intermediate care center visits

• Fewer provider visits

• Fewer visits to specialist providers

Example of Patient Rating Scale for Select Outcome Measures

For a measurement before and afterDSMES program:

Rating for Quality of Life, Knowledge and Skill/Confidence:

1

=

LOW

2 3 4 5 6 7 8 9 10

=

HIGH

Examples of Provider Outcome Quality Measures

• Provider satisfaction with educators, DSMES program and patient outcomes (on surveys)

• Provider testimonials (verbal or on surveys)

• Number of providers’ DSMES initial and follow-up referrals in per year

• Number of new providers who refer to

DSMES program in calendar yearSource of image: https://www.pdclipart.org/thumbnails.php

Examples of Program Outcome Quality Measures

• Patient satisfaction (on variety of queries)

• Patient testimonials (verbal or on surveys)

• Number of patient self-referrals to program

Examples of Program Outcome Quality Measures, Con’t.

• Outcomes that reflect patient attendance and retention in program:

− No. of initial patient visits in calendar year

− No. of follow-up patient visits in calendar year

− Percent of patients who attend all visits in DSMES programs in calendar year

− No. of all patient visits compared to number of provider referrals in calendar year

Just for Fun: Get Rid of the Woodpecker!

4 Step CQI Plan

PLAN − DO – STUDY – ACT

PLAN

A Assess

S Select

K Keep

T Talk

E Explore and Evaluate

A Ascertain

M Make

DO

D Do

O Obtain

Organize

STUDY

A Analyze

I Identify

M Measure

ACT

A Act

C Check

T Target


Now…

real-life example of

the 4 Step CQI Plan in a

DSMES Program


PLANA Assess problems with (or opportunities to

improve) a quality measure: structure, process

or outcome

DSMES team does not think that this

program outcome quality measure is

being met:

“Patient retention in DSMES program is >80%”

PLAN

K Keep the focus more on the problem and less on the people involved

S Specify the exact problem, or opportunity to improve, the quality measure

Problem: Retention of patients in DSMES program

diminishes progressively after 2nd visit to an

average of only 45%

PLANT Team members openly discuss all possible root

causes of the problem

• Group classes held too early in the morning

• Working patients cannot attend morning classes

• Group classes are too long…3 hours

E Explore data needed to study problem: extent of problem; where to get data; when and how to collect data

Data is needed on current program design…

E Explore data

Data is needed on current percent of patients who

attend visits in each DSMES group class:

E Explore data

Data is needed on why patients progressively drop

out of program

• Data will come from new Patient Satisfaction

Survey that educators create

• First, diabetes educators will benchmark other

survey formats before creating own

E Explore data

Diabetes educators:

• Distributed new surveys at each DSMES program

visit during January, February and March

• Called patients who had dropped out to ask

them survey questions on phone

E Explore data…continued:

Diabetes educators:

• Developed tool to track survey results and

aggregate into a summary format

• Studied survey results and responses on questions,

and also patients’ free form comments

E Evaluate data

Data now evaluated from all new surveys:

Question Somewhat Agree %

SomewhatDisagree %

StronglyDisagree

%

Services offered at

convenient times during

the day

20% 30% 35%

Can’t come in morning as work during day: 55 patients

9 am too early: 33 patients

3 hours is too long of class 40 patients

E Evaluate data

Data evaluated from all new surveys was:Question Somewhat

Agree %Somewhat Disagree

%

StronglyDisagree

%

Services offered at

convenient days

during day

80% 10% 8%

Prefer earlier in week instead of Thursdays: 5 patients

A Ascertain all possible actions… change(s)…to reduce problem or improve the quality measure

5 actions being considered:

1. Change group class to Mondays (earlier in wk)

2. Reduce group class time from 3 to 2 hours

3. Change group class time from 9-12 to 10 -12 am

4. Add extra:• 2 hour group class and 1 hour group class

5. Schedule each group class both in morning and in evening

A Ascertain:

• Best action(s)…best changes….to implement

Team decided to implement changes 2 – 5 (not #1)

M Manage every detail of the implementation of the best actions …the changes …i.e., the specific:

• Who, Where, When

Who = Diabetes educators

Where = At primary hospital site only

When = March, April, May

DO

D Do implement the best action(s)…the changes… on a small scale

Diabetes educators implemented changes # 2 -

5 in

April, May and June of same year

O Obtain and organize the new data coming from the changes that are being implemented

Organize the new data in a tracking tool

Coordinator inputted new data into Microsoft Excel™ file

STUDY

A Analyze all the new data…the results of the best actions (the changes)…that were implemented

• Patient retention in each of 5 group classes

increased 40 – 62% (median: 50%)

• Average retention rate increased from 45% to 69%

See new DSMES program design on next slide.

New program design (changes in red) Visit

Type and Order

Number

of Visits

HoursPer Visit

Time of Day

Days of Week

Individual 1 1 am, pm Any day

Group 1 1 11 – 12 noon7 – 8 p

Thurs

Group 1 2 10 – 12 noon6 – 8 p

Thurs

Group 1 2 10 – 12 noon6 – 8 p

Thurs

Group 1 2 10 – 12 noon6 – 8 p

Thurs

Group 1 2 10 – 12 noon6 – 8 p

Thurs

I Identify whether the best actions (the changes) made a difference:

• Was the problem reduced?

• Was there an improvement in the quality measure?

Although the retention rate problem has improved,

rate is still not meeting the quality program

outcome measure of >80%

M Measure the “budget effect” of the new change(s) to determine if financially doable

Increase in salary expense of educator’s extra

hours to teach evening classes is offset by

increased insurance reimbursement due to

patients attending new evening classes

ACT

A Act to implement the best actions…the changes… on a wider scale IF the changes were successful

New program design will remain in effect

C Check your results continuously

Team will continue to:

• Conduct Patient Satisfaction Surveys

• Track and monitor retention of patients in

DSMES program to

meet quality outcome measure of retaining

>80% of patients in

all group classes

T Target the next PDSA cycle IF the best actions… the changes…did NOT reduce problem or improve the quality measure

• Then existing measure remains in place

PDSA cycle will be repeated in order to meet

program outcome measure of >80% retention of

patients in all group visits.

EXTRA APPENDIX

Information For

Your Practice

Examples of DSMES Quality Measures for CQI Projects

Structure

Educators have full access to:

• Quality management director of sponsoring organization

• EHR

• Patient registry

• Electronic data management system (e.g., AADE7™ System)

• Evidence-based DSMES curriculum


Structure

• Decision support tools:

o ADA Diabetes Medical Standards of Care

o AND Online Nutrition Care Manual

o The Art and Science of DSMES book

o AADE website and member benefits

o Chronic Care Model

o Reference books, journals, online subscriptions, websites, listservs, etc.


ProcessWithin required time frames, the educators:

• Complete patients’ initial assessments

• Document patient visits

• Complete progress notes for providers and forward

• Obtain diabetes diagnostic lab for Medicare pts to determine DSMT eligibility

• Patients’ calls/emails returned within 24 hours

• Download CGM data & forward to provider


Process

DSMES program coordinator (or designee):

• Tracks DSMES insurance claims retrospectively each quarter to determine if claims paid, rejected or denied

• For claims denied or rejected:Investigates reason(s) why; seeks to correct any

internal errors causing; and pursues re-billing of

corrected claims within 12 months

• Reviews financial statements each quarter to determine if program is making money, losing money or breaking even


Outcome Quality

Measures for Patients

and/orProgram

• Improved outcomes, or outcomes meet target in specific time frame (e.g., learning outcome >7 on 1-10 scale):

o Learning (knowledge of why)

o Confidence (skill in how)

o Quality of life

o Cost savings

o AADE7™ Self-Care Behaviors


OutcomeQuality

Measuresfor

Patientsand/or

Program

• Outcomes meet goal/target in specific time frame when measured in the aggregate…examples:

oA1c

o FBG

o 2 hour PPG

oDaily foot checks


SatisfactionQuality

OutcomeMeasure

forPatients

Patient satisfaction outcomes meet goal/target…example:

• >75% of queries on satisfaction survey

are rated by patients (at last visit in

program) as excellent, very good or

good and not as fair or poor for all

queries


OutcomeQuality

Measuresfor

Program

• Comparison in each 12 month cycle of:

o Number of initial 1:1 visits

o Number of follow-up 1:1 visits

o Number of initial and follow-up group visits

o Number of patient visits per educator

o Percent of patients completing program

o Number of programs at parent site, community sites

and branch sites

o Percent of DSMES insurance claims paid

o Number of program marketing activities to

providers and community


OutcomeQuality

Measuresfor

Program

• Retention of patients in all program

visits (e.g., >80% of pts complete

program)


OutcomeQuality

MeasuresFor

Providers

• Provider satisfaction outcomes meet

goal/target (e.g., rating of 4 or 5 on 1-5 scale)

for all queries on satisfaction surveys

• Ongoing DSMES referrals from providers

DSMES referrals from new providers in area

• Number of times providers adhered to

educators’ documented recommendation

Now Let’s Look at the

3 Types of Quality

Measures

Imbedded in each of the

6 Components of a

Best Practice

DSMES Business Plan

DSMES Business Plan

Quality Measures

Adherence to 2017

National Standards

of DSMES Plan

Structure Measures

Realization of sponsoring organization (SO) or sponsoring individual for DSMES program

87

DSMES Business Plan

Quality Measures

Adherence to 2017

National Standards

of DSMES Plan

Structure Measures:

Realization of written policies and procedures which indicate how each of the 10 National Standards of DSMES will be adhered to by the sponsoring organization or sponsoring individual

88

DSMES Business Plan

Quality Measures

Adherence to 2017

National Standards

of DSMES Plan

Structure Measures (Standard 1)

Receipt of letter of support from senior administration of sponsoring organization affirming that organization will recognize and support quality DSMES as an integral component of diabetes care

89

DSMES Business Plan

Quality Measures

Adherence to 2017

National Standards

of DSMES Plan


Realization of external stakeholders and experts to promote program quality (aka, Advisory Committee)

90

DSMES Business Plan

Quality Measures

Adherence to 2017

National Standards of DSMES Plan


Realization of program coordinator that is designated to oversee the DSMES program and have oversight responsibility for the planning, implementation, and evaluation of the education services.

• Coordinator is CDE or BC-ADM, or annually accrues 15 hours of CE credits based on program anniversary date

91

DSMES Business Plan

Quality Measures

Adherence to 2017



Realization of instructional staff that includes minimum of RN or RD or RPh with training and experience pertinent to DSMES, or another professional with certification in diabetes care and education, such as a CDE or BC-ADM

92

DSMES Business Plan

Quality Measures

Adherence to 2017

National Standards

of DSMES Plan


Realization of written DSMES curriculum reflecting current evidence and practice guidelines, with criteria for evaluating outcomes, that will serve as the framework for the provision of DSMES

93

DSMES Business Plan

Quality Measures

Adherence to 2017



Realization of DSMES program in order to fulfill the AADE accreditation or ADA recognition requirement that:

• >1 participant completes the DSMES program

• A copy of participant’s de-identified chart demonstrating the complete education process be submitted with initial accreditation or recognition application

94

DSMES Business Plan

Quality Measures

Adherence to 2017


Process Measures (Standard 1)

Realization of the documentation of

• An organizational structure

• Mission statement

• Program goals

95

DSMES Business Plan

Quality Measures

Adherence to 2017



Reliable assessment conducted by provider of the DSMES to identify

• Whom to serve (target population)

• How best to deliver DSMES to that population

• What resources can provide ongoing support for that population

96

DSMES Business Plan

Quality Measures

Adherence to 2017



Realization of DSMES program design that defines the:

• Number of total visits/program

• Number of group and/or individual visits

• Length of time of visits

• Maximum number of pts per visit (if number is limited due to space)

• Locations of the program:

o At sponsoring organization

o At off-site locations97

DSMES Business Plan

Quality Measures

Adherence to 2017



Realization of each participant’s:

• Individualized assessment of the DSMES and support needs by one or more of the instructors and signed by the participant

• Individualized education and support plan focused on behavior change that is collaboratively developed by an instructor and the participant

98

DSMES Business Plan

Quality Measures

Adherence to 2017



Realization of written communication regarding each participant’s individualized education plan, DSMES provided, outcomes achieved and the diabetes self-management support plan with:

• Other health care team members

• Referring provider after each DSMES visit

99

DSMES Business Plan

Quality Measures

Adherence to 2017



Realization of personalized follow-up plan for Diabetes Self Management Support (DSMS) that is reviewed with participant andcommunicated with:

• Other health care team members

• Referring provider

100

DSMES Business Plan

Quality Measures

Adherence to 2017



Realization of instructor documentation of:

• Participant’s written behavioral goals and desired outcomes collaboratively developewith the participant and an instructor

• Interventions to achieve behavioral goals and outcomes

• Follow-up assessment of achievement of behavioral goals and outcomes

d

101

DSMES Business Plan Quality Measures

Adherence to 2017



Realization of the:• Measurement of the effectiveness of the

education and support• Continuous quality improvement activities to

improve any identified gaps in services or service quality, using a systematic review of process and outcome data

• Process for following-up and evaluating the participant’s desired outcome(s)…e.g. clinical, quality of life, satisfaction

102


Adherence to 2017


Process Measures

Reliable assessment conducted by provider of the DSMES to identify

• Referring providers in local area

• People in community who are not patients of referring providers but have diabetes

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DSMES Business Plan

Quality Measures

Adherence to 2017


Structure Measures and Process Measures (Standards 1 -10)

Realization of each “essential element” of Standards 1 through 10

• For complete listing of essential elements for each of the 10 standards, see separate document titled:

ESSENTIAL ELEMENTS CHECKLIST AND INTERPRETIVE GUIDANCEFOR AADE DIABETES EDUCATION ACCREDITATION PROGRAMOR ADA EDUCATION RECOGNITION PROGRAM CERTIFICATION

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DSMES Business Plan

Quality Measures

Adherence to 2017


Outcome Measures (DSMES Program)

Realization of certification of DSMES program as evidenced by:

• Initial AADE accreditation or ADA recognition of program

• Maintenance of accreditation or recognition at each renewal cycle

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Clinical/Teaching Plan

Structure Measures (DSMES Team)

Reliable access to:

• EHR for:

o Lab data

o Providers’ notes

o Diagnoses

o Medications

• Patient registry

• Electronic data management system (e.g., AADE7™ System)

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Structure Measures (DSMES Team)

• Evidence-based DSMES curriculum

• Decision support tools:

o ADA Medical Standards of Care for Diabetes

o AND Online Nutrition Care Manual

o AADE book The Art and Science of DSMES

o Chronic Care Model

o Other reference books, journals, online subscriptions, websites, listservs, etc.

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1 . U.S. Institute of Medicine' s Quality Chasm Report, sev en dimensions of patient-center ed care fo r PWD presented on NDP P information site ; at:http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/patient-centered-interactions/dimensions-of-patient-care.aspx

•

•

•

•

•

•

e

Process Measures (Patient and DSMES Team)

Regularly demonstrated patient-centered car by DSMES team, as evidenced by1:

Respect for pts' values, preferences, an d expressed needs

Coordination and integration of care

Timely and clear communication with pt s

Physical comfort of pts

Involvement of pts’ family and friends

Emotional support of pts: relieving fear an d anxiety, and screening for depression

DSMES Business Plan


Process Measures (Patient and DSMES Team)

Regularly completed clinical processes by DSMES team within required time frames:

• Completion of patient’s initial assessment

• Rendering DSMES program visits

• Documenting patient visits

• Completing progress notes and forwarding to provider within 48 hours

• Downloading CGM data for provider

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Quality Measures


Operations Plan

Structure Measures:

Right DSMES program design to meet needs, wants and expectations of patients and providers:

• Room/space assigned to program

• Number of total visits/program

• Number of group and individual visits/program

• Time frame of each visit in program

• Days and times that visits are scheduled

• Number of programs per year and dates of110


Operations Plan

Structure Measures:

Rendering DSMES program in:

• Other entities (e.g., hospitals w/o program)

• Branch and/or community sites (off-site)

• Employer work sites

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DSMES Business Plan

Quality Measures

Operations Plan

Process Measures (Patient)

Reliable operational processes as evidenced by:

• Patients’ calls/emails returned within 24 hours

• Completion of patient visits attendance sheets

• Maintenance of patient handout inventory• Classroom fully prepared prior to visits• DSMES program schedules completed in

timely fashion and distributed to pts at 1st

visit

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DSMES Business Plan

Quality Measures

Operations Plan

Process Measures (Patient)

• Patient appointment reminder calls made24--48 hours in advance of each visit

• Educators call no-show patients within 24—48 hours to inquire about reason for not keeping appointment and to reschedule

• Training of DSMES team members for functions performed (including CHWs)

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DSMES Business Plan

Quality Measures

Operations Plan

Process Measures (DSMES Team)

• Cross-training of team members to substitute for other roles (in cases of absences)

• Ongoing training to keep up-to-date on all aspects of DSMES

• Clear definition of tasks and of assignment of roles among team members

• Routine communication through regular team meetings and paper and e-information flow 114


Operations Plan

Outcome Measure (Patient)

Retention of patients in DSMES program

Realization of satisfaction ratings on each survey question as excellent, very good or good by >80% of patients who complete surveys

115


Marketing Plan

Structure Measures:

Reliable support from Marketing Dept. or personnel of sponsoring organization

116


Marketing Plan

Process Measures:

Regular use of various, proven-effective promotion and advertising strategies

• Strategies are summarized in acronym S.U.P.E.R. M.A.R.K.E.T.I.N.G. for obtaining

o Provider referrals

o Patient self-referrals

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Quality Marketing Plan Spells: S.U.P.E.R. M.A.R.K.E.T.I.N.G.

Goal:Increase Program Awareness and Value, and Build Trust

In

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S Set up screenings at health fairs, farmers’ markets, malls

U Use social media + patient blogging to promote program

P Pursue free publicity in local newspapers

E Ensure referrals forms are hand-delivered to provider

R Report patient outcomes to providers regularly

M Marketing brochures or slim jimsMailers (single or inside neighborhood ad booklets)

A

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Ads in loca l newspaper s and church bulleti ns Artic le writing for local newspapers

R Radio interviewsReferral forms (branded and Medicare compliant)

K Keeping track of ROI for each marketing activity

E Establishing program as employee wellness initiative

T Television interviews on local cable channe ls Telephone book yellow pages

I Internet website advertising (sponsoring org, LinkedIn, AADE)N No charge presentations at community eventsG Get program logo, tagline, give-away (Diabetes Calendar)


Marketing Plan

Outcome Measures:

Robust Referrals from:

• Providers

• Patient self-referrals

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DSMES Business Plan

Quality Measures

Financial Plan

Structure Measures:

Reliable access to:

• Personnel in Finance/Accounting Dept. of sponsoring organization (bean counters!)

• Personnel in Billing/Coding Dept.

• Timely financial reports related to DSMES program:

o Budget

o Income statement

o Expense report 121

DSMES Business Plan

Quality Measures

Financial Plan

Structure Measures:Realization of:

• How DSMES program structured by administration of sponsoring organization:

o Profit center or cost center

• Expectations of same:

o Break-even?

o Make money?

o OK to lose money (as considered goodwill, community service or loss leader)?

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DSMES Business Plan

Quality Measures

Financial Plan

Structure Measures

• If sponsoring organization or sponsoring individual will bill Medicare for the DSMES, same must:

o Enroll in Medicare Part B as organizational or individual provider

o Be billing Medicare for other services and be reimbursed

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Financial Plan

Process Measures:If billing insurers:

Reimbursement is maximized by the DSMES team insuring that:• All insurer-billable visits billed • All patient co-payments collected• All out-of-pocket payments from uninsured

patients collected• Insurance claims tracked retrospectively for

statuso Action taken on denied/rejected claims

to determine corrective action and re-billing

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DSMES Business Plan

Quality Measures

Financial Plan

Process Measures:

Reliable monitoring by educators of patient financial outcomes…examples:

• Reduction in:

o Medications

o ER visits

o Therapies

o Intermediate care facility visits

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DSMES Business Plan

Quality Measures

Financial Plan

Outcome Measures:

Reimbursement Revenue maximized:

• Claims to health insurers who cover DSMES are reimbursed at maximum rate within 2 months

• 100% of DSMES fees to patients who self pay are collected within 2 months

• 100% of patient co-payments are collected within 2 months

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DSMES Business Plan

Quality Measures

Financial Plan

Outcome Measures:

Reimbursement Revenue maximized:

• Claims to health insurers with DSMES coverage reimbursed at maximum rate within 2 months

• 100% of DSMES fees to patients who self pay collected within 2 months

• 100% of patient co-payments collected within 2 months

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DSMES Business Plan

Quality Measures

Financial Plan

Outcome Measures:

Realization of the sponsoring organization’s financial expectations of DSMES program:

• Make a profit (per methodology used by SO)

• OK to lose money (up to specified amount express as a metric, ratio, etc.)

• OK to break even (per methodology used by SO)

128


Financial Plan

Outcome Measures:

Rates of diabetes educator productivity meet desired targets

Return on investment in educator hours meets desired targets

129


Continuous QualityImprovement Plan

Structure Measures (DSMES Team)Reliable access to:• Quality management/CQI director of

sponsoring organization• EHR for:o Lab datao Providers’ noteso Diagnoseso Medications

• Patient registry• Electronic data management system (e.g.,

AADE7™ System)

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Process Measures (DSMES Team)

Regularly scheduled:

• Performance self-appraisals of DSMES team

• In-service education events for DSMES team within sponsoring organization

• DSMES program’s Advisory Committee meetings

Realization of each team member’s explicitly identified goal for professional development

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Process Measures (CQI Plan Specific)

Regularly completed number of pre-identified CQI projects over set period of time

Regular use of evidence-based steps/protocol for conducting CQI projects…example:

• Plan-Do-Study-Act format

Resolution of identified problems and/or gaps

Realization of improvements in program

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Outcome Measures (Patient)

Realization of patient outcomes:

• Knowledge

• Confidence

• Behavior change

• Quality of life

• Cost-savings

• Satisfaction

Retention of patients in DSMES program

133



Outcome Measures (Provider)

Realization of provider outcomes:

• Satisfaction with DSMES program and educators as evidence by survey responses

• Trust and loyalty in DSMES program and in educators as evidence by survey responses and ongoing and increase in provider referrals

134



Outcome Measures (Program)

Realization of program outcomes:

• Positive responses on satisfaction surveys given to your target markets:

o PWDs

o Providers

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References1. http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/improve-

practice-quality/evaluation-strategies.aspx2. http://www.qualitymeasures.ahrq.gov/3. http://www.ahrq.gov/4. Institute for Healthcare Improvement; http://www.ihi.org/Pages/default.aspx5. ww.ncqa.org/tabid/139/default.aspx6. http://www.niddk.nih.gov/health-information/health-communication-

programs/ndep/partnership-community-outreach/campaigns/Pages/index.aspx7. http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/improve-

practice-quality/8. http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/patient-

centered-interactions/dimensions-of-patient-care.aspx9. Continuous Quality Improvement (CQI) Strategies to Optimize your Practice: Primer,

provided by The National Learning Consortium, developed by: Health Information Technology Research Center, April 30, 2013

10. Diabetes Education Programs and the CQI Process Recommendations for Joslin Education Programs, 2005

11. 2017 National Standards for Diabetes Self-Management Education and Support, Diabetes Care 2017 Aug; dci170025. https://doi.org/10.2337/dci17-0025

12. Royalty free clipart from https://openclipart.org13. https://www.pdclipart.org/thumbnails.php

Disclaimer of Mary Ann Hodorowicz Consulting, LLC

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This information is intended for educational and reference purposes only. It does not constitute legal, financial, medical or other professional advice. The information does not necessarily reflect opinions, policies and/or official positions of the Center for Medicare and Medicaid Services, private healthcare insurance companies, or other professional associations. Information contained herein is subject to change by these and other organizations at any moment, and is subject to interpretation by its legal representatives, end users and recipients. Readers/users should seek professional counsel for legal, ethical and business concerns. The information is not a replacement for the Academy of Nutrition and Dietetics’ Nutrition Practice Guidelines, the American Diabetes Association’s Standards of Medical Care in Diabetes, guidelines published by the American Association of Diabetes Educators nor any other related guidelines. As always, the reader’s/user’s clinical judgment and expertise must be applied to any and all information in this document.

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Call to Action

• Share a strategy that you learned today that you intend to put into practice. (Chat it in!)

• Identify at least one partner you can ask to join you in your DSMT efforts.

• Complete the post-event assessment: https://www.surveymonkey.com/r/TLMSSYS

139

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CE Credit

• Complete the post-event assessment upon exiting WebEx: https://www.surveymonkey.com/r/TLMSSYS

• It will pop up at the conclusion of the event• There is a separate evaluation required for CE that is

linked within the post-event assessment• Once you submit your CE evaluation, you will be

provided with a certificate to retain for your records• For technical assistance, please email Stacey Davis

(stacey. [email protected])

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This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QINNCC-02443-11/19/18

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