AUGUST 28, 2014

RHP – 15 Diabetes Learning

CollaborativeMeeting

What is a Collaborative

To work with another or others on a joint project. (World English Dictionary)

What is a Learning Collaborative

An educational approach that involves groups of learners working together to solve a problem, complete a task, or create a product. (Curtin University)

GOALS• A1C – every 3 months• Blood Pressure – every 3

months• Weight (BMI) every 3 months• Physician / Clinic visit – every 3

months• Foot exam – annually• Eye exam – annually

• A1C – every 3 months• Blood Pressure – every 3

months• Weight (BMI) every 3 months• Physician / Clinic visit – every 3

months• Foot exam – annually• Eye exam – annually

STANDARDS ESTABLISHED

Standards Established:A1C – less or equal to 7.0Blood pressure – 130/80 (normal range)BMI – 24.90 - Below 18.5 – Underweight - 18.5 – 24.90 = Normal - 25.0 – 29.9 – Overweight - 30.0 – above - Obese

Texas Tech

Texas Tech – August Data

Intial DateLast Seen

(Days) (<365)

HBA1c

( <9)Weight

BMI (<30)

Blood Pressur

eSystolic (<140)

Blood Pressur

eDiastolic (<80)

Eye Exam within year Yes/No (Date)

Days Since Last Eye Exam

(<365)

Foot Exam within year

Yes/No (Date)

Days Since Last Foot

Exam (<365)

Recent Diabetes or DKA Related Hospitalization?

AgeGende

r

10/8/2013 317 6.6 161.00 33.77 134.00 68.00 02-May-13 473 05-Mar-13 530   73 M

3/10/2014 165 9.4 149.00 22.74 110.00 66.00     15-May-13 460   57 F

2/13/2014 192 7.4 190.00 36.63 125.00 64.00     27-Aug-13 358   70 F

2/19/2013 546 7.1 151.80 24.40 115.00 72.00           73 M

4/14/2014 131 6.6 211.00 35.24 129.00 75.00     14-Jan-14 221   58 M

3/27/2013 508 8.5 212.00 35.41 117.00 60.00         27-Mar-12 66 M

2/13/2013 552 12.9 233.00 38.91 145.00 96.00           48 M

5/30/2014 85 8.2 156.00 26.87 117.00 67.00           60 M

3/14/2014 161 6.4 216.00 39.02 204.00 93.00     14-Mar-14 161   68 F

9/20/2013 335   183.00 38.39 127.00 62.00         28-Oct-12 70 F

4/2/2013 503   163.25 29.97 128.00 72.00           55 F

6/23/2014 62 9.8 191.00 29.15 128.00 71.00         03-Jun-14 60 M

12/11/2013 254 11.6 228.00 35.84 121.00 69.00     16-May-14 99   24 M

5/16/2014 99 9.0 177.00 29.56 129.00 78.00     16-May-14 99 09-Oct-12 55 F

2/12/2014 193 7.0 208.00 37.57 128.00 74.00     20-Dec-12 605   57 F

5/28/2014 87 6.1 211.80 36.49 113.00 65.00     28-May-14 87   51 F

2/25/2014 180 6.4 206.00 34.14 119.00 60.00 31-Jul-14 25 23-Jul-14 32   67 F

3/10/2014 165 9.4 260.00 43.42 185.00 94.00     19-Feb-14 186   53 M

10/2/2012 683 6.9 325.00 45.49 121.00 64.00           65 M

6/23/2014 62 9.5 177.00 34.98 116.00 51.00 11-Mar-14 164       59 F

3/25/2014 150 8.4 213.00 36.69 187.00 96.00     20-Sep-13 335   60 F

7/15/2013 400 8.2 249.00 40.95 121.00 66.00     30-Jul-14 25   75 M

4/30/2014 115 6.5 154.40 28.34 126.00 66.00     18-Jul-14 37   72 F

4/21/2014 124 13.8 160.00 28.90 116.00 71.00     21-Apr-14 124   58 M

1/10/2014 225   133.20 27.94 125.00 86.00 02-Sep-13 353 22-Aug-14 3   30 F

7.8 196.8 34.0 131.4 72.2 253.8 210.1 59.4

IN-COMPLIANCE 64% 36% 84% 8% 52% 96% 48%

Texas Tech – Patient Profile

25 Random Patients diagnosed with Diabetes

2 or more visits to our clinic within the past 24 months

48% Male52% Female4% (1/25) had a recent

hospitalization due to DiabetesMany blanks (unreported fields)

Texas Tech – ProgressComparison Graph

Improvement Methodology

This learning collaborative will utilize the PDSA method for process improvement. Each participating clinical team had agreed to openly share patient data for sample of patients being seen at their practice. Each team will conduct chart audits.

PlanDoStudyAct

PDSA

Pal Home

Retinol Eye Exam

Texas Tech

University Medical Center Neighborhood Clinic Ysleta

Primary Care Medical Home

Project Option 2.1.1

Reorganize into Teams to provide care

NHC will obtain Medical Home Certification

Improve quality care for Fabens, Ysleta, East & West

First visit achieved in less than 60 days

Y

Patient Tracking Number

Inti

Data 1 - A1C

Data 2 - Weight

Data 3 - BMI

Data 4 - Blood

Pressure

Eye Exam within year

Yes/No (Date)

Foot Exam within year

Yes/No (Date)

Any Recent Diabetes or DKA Related Hospitalization?

A01 6.8 192 29.19 125/73 Y Y N

A02 8.6 229 36.96 129/72 Y N N

A03 6.9 176 28.41 106/61 Y Y N

A04 10.7 189 34.56 118/62 Y Y N

A05 6.5 220 36.61 128/62 Y Y N

A06 7.5 150 24.21 133/71 Y Y N

A07 7.3 188 40.68 175/71 Y Y N

A08 5.7 181 31.05 148/82 Y Y N

A09 6.9 152 28.33 127/56 Y N N

A10 8.2 200 38.73 135/86 Y Y N

A11 6.9 175 29.25 138/61 Y Y N

A12 10 106 20.7 115/71 N y N

A13 13.4 364 57.47 144/78 N N N

A14 7.7 216 38.26 120/81 Y Y N

A15 8.4 171 33.39 128/72 Y Y N

A16 7 201 32.44 133/72 N Y N

A17 7 202 32.44 133/72 Y N N

A18 5.5 130 19.2 130/74 Y Y N

A19 9.4 231 35.12 125/62 N N N

A20 6.5 166 26.79 169/86 Y Y N

A21 6.2 213 44.52 191/97 Y N N

A22 6.3 154 30.86 141/74 N N N

A23 7.8 128 20.05 111/71 Y Y N

A24 6.5 162 31.64 135/61 N N N

A25 10.9 183 33.47 121/81 Y Y N

7.78 187 33 12% 24% 32% 0%

UMC Ysleta – ProgressComparison Graph

University Medical Center Neighborhood Healthcare Centers Diabetes Collaborative

                       lan

vent Readmissions Complications of Diabetes A1C in target for Type II DM Heart Attacks by 16% Eye Problems      by 21% Kidney Problems     by 34% 

Establishment of DM and Chronic Plan

Do

Study

Act PDSA

4. Act 4 providers  I2i System  Standardized and 

Monitor  Plan for future growth  Target pediatrics  Partnership with 

specialist 

2. Do Medical Director 

leadership and guidance EMR Standards PCMH

 

3. Study Analyze data  Patient goals  Satisfaction surveys 

1. Plan Prevent Readmissions  Prevent complications   A1C in target for Type II 

DM 

Heart Attacks   by 16% 

Eye Problems   by 21% 

Kidney Problems   by 34%  Establishment of DM and 

Chronic Care Clinics  

THANK YOU!!

RHP – 15 Diabetes Learning

Collaborative