Better Diabetes Management for Special Populations

2019 Policy & Issues Forum

Thursday, March 28, 2019

This educational session was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,375,000 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov

Jillian Bird, MSN, RN

RN Training Manager

National Nurse-Led Care Consortium

jbird@nncc.us

Jillian Hopewell, MPA, MA

Director of Education and Professional Development

Migrant Clinicians Network

jhopewell@migrantclinician.org

Luke Ertle, MPH

Program Manager, Quality Center

National Association of Community Health Centers

lertle@nachc.org

2017-2020 HRSA Focus on Diabetes

HRSA Funded Diabetes Activities

Whyis HRSA so focused

on Diabetes?

Diabetes by the Numbers (2017 National Health Center Data)

2.44M Health center patients have been diagnosed with type 1 or type 2 diabetes (total patients served: 27.1M)

14.98% Of adult health center patients (~2.26 million) have diabetes, compared to the national prevalence of 9.4% of adults with diabetes

32.95% Of patients with diabetes in health centers have poor control (HbA1c levels greater than 9%) of their diabetes (vs. ~41% of national diabetes patients)

% of HRSA Health Centers that Met the HP 2020 Goal (<16.2%) for Uncontrolled Diabetes

0%

5%

10%

2013 2014 2015 2016

Source: Uniform Data System, 2013 - 2016.9

Diabetes Complications• Ambulatory expenditures are $1,656

less in health centers versus private care settings for patients with diabetes.2

• Almost 280,000, or 12.2%, of health center patients with diabetes either went to the emergency room or were hospitalized because of their diabetes.1

• If health center patients with uncontrolled diabetes reduced their HbA1c by 1.25%, there is a potential to save more than $3 billion over three years.3

Heart Attack

Lower Leg Amputation

Nerve Damage

Blindness

Kidney Disease

Stroke

1.2014 Health Center Patient Survey 2.Richard, P. P Shin, T Beeson, et al. 2015 “Quality and Cost of Diabetes Mellitus Care in Community Health Centers in the United States.” PLoS ONE 10(12)3.Fitch, K. B Pyenson, K Iwasaki. 2013 “Medical Claim Cost Impact of Improved Diabetes Control for Medicare and Commercially Insured Patients with Type 2 Diabetes.” J Manag Care Pharm. 19(8) 10

National Diabetes Quality Improvement Goals

Goal 1: Increase Diabetes Prevention Efforts➢Increase percentage of adult who receive weight

screenings & counseling➢Increase percentage of children who receive weight

screenings & counseling

Goal 2: Improve Diabetes Treatment and Management➢Reduce the proportion of persons with diabetes with an

A1c value greater than 9 percent11

HRSA Approach to Diabetes

Systems Approach

Value Transformation Framework

Packaging and implementing evidence-based transformational strategies for safety-net providers

Bringing science, knowledge, and innovation to practice

Quality Center

Diabetes Change Package

Improving Health Systems

& Infrastructure

Clinical Policy

Standing Orders

EHR: Structured Data

Leadership

Clinical Champion

Optimizing Provider &

Multidisciplinary Teams

Care Team Training

Motivational Interviewing

Pre-Visit Planning

Group Visits

Expand Job Roles

Facilitating Behavior

Change in Patients

Patient Self-Management

Patient Education

Obesity Screening

Obesity Reduction

Depression Screening

Diabetes Change Package

Learning Collaboratives

“Practical solutions at the intersection of vulnerability, mobility, and health”

Training & Technical

Assistance Services

Continuity of Care

Violence Prevention

Environmental and Occupational

Health

Clinical Expertise

The mission of NCHPH is to strengthen the capacity of federally-funded Public Housing Primary Care (PHPC)Health Centers and other Health Center grantees located in or immediately accessible to public housing byperforming research, building partnerships and providing training and a range of technical assistance with theultimate goal of improving the health status of residents in public and assisted housing.

NCHPH Services:

➢ Research

➢ Webinars

➢ Monographs & Toolkits

➢ Provider and Resident-Centered Factsheets

➢ Training Manuals

➢ Newsletters

➢ Mapping

➢ Learning collaboratives and

➢ One-on-One Training

Q u a l i t y | A c c e s s | J u s t i c e | C o m m u n i t y | n h c h c . o r g

The National Health Care for the Homeless Council

• Since 1986, The National Health Care for the Homeless Council, a national non-profit membership organization, has provided training and technical assistance to health care organizations serving homeless populations.

• Based on the principles that homelessness is unacceptable and every person has the right to adequate food, housing, clothing, and health care; the Council’s work is guided and informed by networks and committees consisting of administrators, clinicians, consumers, respite care providers, researchers, academicians, and policy makers.

• This community works together to ensure our educational opportunities and publications focus on tangible ways to improve the health status of people experiencing homelessness, and increase their engagement in health care services.

Diabetes and Hypertension ECHO for CHWS

1st

Quartile

2nd

Quartile

3rd

Quartile

4th

Quartile

UDS Data: % of patients with H1C > 9

Results

40%42%

58% 16%

42% 43% 40%

55%

53%25%

54%38%

32%

67%

72% 62% 23% 31%

0

10

20

30

40

50

60

70

80

90

100

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18

% Change

Pre

%

Knowledge gained by participants to each ability from the self-efficacy questionnaire. The % knowledge gained is not indicative of the knowledge points gained, but rather the knowledge points as a percentage.

Change in Knowledge

Average % change in knowledge

43.3%

Barriers

Integrated Clinical Team

Clinician

Nursing

Pharmacy

Community Health WorkerMental Health

Nutritionist

Team-Based Diabetes Care for Federally Funded Health Centers with a focus on integration of CHWs

Building an Effective Collaborative Care Team to Address Diabetes in Special and Vulnerable Populations

Developing the Role of Community Health Workers and other Support Staff in Diabetes Prevention, Treatment, and Follow-Up

Patient Engagement Strategies for the Collaborative Care Team: Motivational Interviewing I

Patient Engagement Strategies and Goal Setting for the Collaborative Care Team: MI 2 and Goal Setting

Patient Engagement Strategies for the Collaborative Care Team: Pre-Visit Planning

Patient Intervention Strategies for the Collaborative Care Team: Group Visits

National Nurse-Led Care Consortium

Jillian Bird, MSN, RN | 2019 Policy & Issues Forum

nurseledcare.org | @NurseLedCare

Nurse-led care exists at the intersection of multidisciplinary healthcare, where nurses have a transformative role as holistic

caregivers, advocates, and leaders. Nurses have unique skills and insight to treat the whole person, serving as a critical connection

between compassionate and evidence-based healthcare.

National Nurse-Led Care Consortium

The National Nurse-Led Care Consortium (NNCC) is a membership organization that supports nurse-led care and nurses at the front lines of care.

NNCC provides expertise to support comprehensive, community-based primary care.

– Policy research and advocacy

– Technical assistance and support

– Direct, nurse-led healthcare services

NNCC Collaboratives as Vehicles for Transformation

Training on principles of nurse-led care

Practice transformation steps

Impact on Aims

Enhanced Communication

Use of care team huddles and nurse-led teams

Interdisciplinary care teams

Role clarity and optimization for nursing and other staff

Collaborations across medical neighborhood

Identify community partners; share care plans across care continuum;

RN care managers

Reducing duplicative tests and procedures due to improved

communication

Improve efficiency of care and productivity through use of non-

provider care team members

Reduce unnecessary hospitalizations and improve care for chronic

disease patients

Collaborative workshops tie nurse-led care to health center aims

Patient-centered care coordination

Risk screening/stratification; shared care planning; and patient

education from RNs/LPNs

Reduce unnecessary hospitalizations and improve care for chronic

disease patients

Road to Collaborative Practice Transformation

1

Customize trainings to best meet unique practice needs

Draft MOA to outline expectations and deliverables

Identify data metrics to monitor and track

Collect baseline data

Identify ideal audience/learners

Track progressPractice

collaboration and customization

Delivery of critical training elements

Learner-facilitated change

Follow-up technical assistance

5

CQMs: diabetes, HTN, asthma

Unnecessary utilization: ED visits, hospital admissions

Associated cost savings from: ED visits, hospital admissions avoided

2

Training delivery: Didactic and inter-active content; focus on skills development; shared resources; train the trainer format

Audience: Quality improvement coaches and project champions at the clinical staff level

3

Implementation:Learners initiate practice transformation with support from NNCC staff and local quality coaches and project leads

4

NNCC Technical Assistance: 45 Day Check-ins; refresher course, booster session

Training booster sessions: Ongoing QI coaching and resources provided by NNCC via local coaches and project champions

National Training Partnerships:

1267clinical + QIA staff trained

348organizations

NNCC delivers in-person workshops to PCAs and other programpartners around nurse-led principles of care, includinginterdisciplinary care team optimization and patient-centered carecoordination.

NNCC has delivered 16 workshops in 11 states to over 1,200learners. Workshops have been delivered to clinical staff,practice coaches, and more.

In-Person Workshop Activities by State

NNCC is scheduled to deliver 1 workshop in 1 state toroughly 60 learners.

PCAs and NNCC Member Organizations

NNCC Success Story: Care Team Optimization

Track progressDelivery of critical training elements

Learner-facilitated change

Follow-up technical assistance

19.90% 19.55%

22.88%24.26%

29.77%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Baseline 1(collected 6 mo. pre-

workshop)

Baseline 2 (%)(collected at workshop

delivery)

6 Month Follow-Up (%)(collected ~6 mo. post-

workshop)

12 Month Follow-Up(%)

18 Month Follow-Up(%)P

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Diabetes: Optimal Diabetes Composite Score

Activities1. improving health systems and infrastructure2. optimizing provider and multidisciplinary teams 3. and facilitating behavior change in patients

Clarifying and Optimizing Team Roles

• All roles are understood and respected

• Scope and responsibilities of each role are explicit

• Each team member understands how his/her role fits in the work of the team

• Create minimal competencies for all on diabetes care team

– a basis for education, training, development, and performance appraisal

Roles and Responsibilities for Effective Teamwork

Patient

Provide information about own health

and experience

Describe and report changes in health

status

Share response to self-care and treatments

Identify factors that help and hinder engagement and achieving health

goals

THE PATIENT’S ROLE ON PATIENT-CENTERED PRIMARY CARE TEAMS

• Competencies

• Scope of practice

• Licensure

• Values and ethics

• Education / accreditation standards

Care Team Roles Driven By…

Optimizing Team Roles

Who do we have on staff,

who can we afford, who is

available to hire, etc.

Team Composition

Physical space of the clinic,

room types, equipment, etc.

Practice Workflow

What are our visit types, what

are their lengths, flexibility in

scheduling, etc.

Visit Scheduling

What are team members legally

allowed to do, approved scope,

training, etc.

Staff Licensure/Expertise

1. Identify current staffing, functions and responsibilities.

2. Identify the role of patients and families on the care team.

3. Use care mapping tools to assist in assessing and improving role clarity and efficiency.

4. Assess current team role functions and opportunity for role redesign and optimization.

5. Select measures to evaluate role clarity and optimization in your setting.

Steps to Care Team Optimization and Redesign

Primary care team members Redesign examples

Registered nurse

• Expanded role as diabetic care coordinator• Health promotion, chronic illness management for diabetic

patients• Identify priority patient populations (lost to care, high risk,

comorbidities, etc.)

Medical assistant

• Expanded responsibility for tracking and updating diabetic metrics

• EHR superuser and governance of data• Provide patients basic overview of expectations for DM self-

care

Certified Diabetic Educator• Focus on most difficult cases• Train MAs/RNs in diabetic patient self-management

Team Redesign for Enhanced Diabetic Care

Practice Outcomes How to Measure

• Realistic expectations of team

members

• Efficient workflow

• Improved decision-making

• Team member satisfaction, perception

of being valued

• Less conflict

• Enhanced job description with defined roles.

• Wait times, time spent rooming, etc.

• Use of standing orders

• Satisfaction surveys, assessment

Outcomes of Role Clarity and Optimization

An important rule of thumb when mapping a process is “the person who controls the process controls the pen.” This means the person who actually carries out a particular process is the one who maps that step of the process.

Tips on Care Mapping

• Be sure to map current process

• Get key players involved and their input

• Recognize that any care team mapping will take multiple revisions before the final

• Leverage existing experts and experiences

• Remember this is about distribution of duties to be more efficient and remove bottle-necking, ineffective processes

Tips on Care Mapping

Step 0: Assemble your team!

Step 1: Select a process to map out

Step 2: Determine the beginning and ending points

Step 3: Identify each step in the process

Step 4: Put the steps in order, identify who is doing what

Step 5: Review and edit the first draft

Step 6: After a day or two review the diagram with the team for input, missing steps, staff to be consulted

Simple steps on Care Mapping

Look at the workflow and examine it

beginning and ending points

assess wait points

assess decision points

hand-offs

Ask questions about the workflow

does that step need to be there? omit, move, modify

Map out improved workflow map

Now what to do with your completed care map?

• Answering phones• Making appointments• Scheduling procedures• Making referrals• Providing health advice by

phone or e-mail• Assigning patients to panels• Completing new patient

workups• Educating patients and family• Managing patient panels• Planning patient visits

• Coordinating referrals• Conducting patient outreach• Checking formularies• Entering lab results into the

information systems• Making referrals for specialty

care and community services• Consulting with specialists

Processes to be Included in your Care Team Workflow Map Generally

Processes to be Included in your Diabetic Care Team Workflow Map - Nursing

• Assess feet for temperature, pulses, color, and sensation

• Assess the patient’s skin integrity• Consult with the dietitian to educate

the patient on diet regime for diabetics

• Assess the patient’s current knowledge and understanding about the prescribed diet

• Assess the pattern of physical activity• Teach patient how to perform home

glucose monitoring• Instruct patient to take oral

hypoglycemic medications as directed

• Instruct the patient on the proper preparation and administration of insulin

• Teach patient that anxiety, tremors, and slurred speech are signs of hypoglycemia

• Evaluate the patient’s self-management skills, including the ability to perform procedures for blood glucose monitoring

• Supply the patient with a free 30 day supply of testing strips, lancets, one free glucometer, and insulin syringes

Swim Lane Diagramming

A swim lane diagram assists with role clarification and efficiency.

Example: Swim Lane Diagram for a Physician Assistant Office Visit

Adapted from “Physician Assistant (PA) Office Visit” available at: http://www.hrsa.gov/publichealth/business/healthit/toolbox/HealthITAdoptiontoolbox/index.html

Swim Lane Diagramming

1. Read provided case study.

2. Review roles and decide how to optimize for best use of staff skills and licensure.

3. Place roles in swim lane diagram and map out a first visit for patient incase study.

4. Adjust as needed for lag time or inefficiencies.

• Responsible, Accountable, Consulted, Informed

• Defining these roles for a task improves clarity, ownership and communication

• Identify functional roles (e.g., front desk, RN, etc.)

• Identify activities or decisions

• Good for QI projects or introducing new EBIs

RACI Matrix

RACI Matrix

R Who Is Responsible? The person who is assigned to do the work

A Who Is Accountable? The person who makes the final decision and has ultimate ownership

C Who Is Consulted? The person who must be consulted before a decision or action is taken

I Who Is Informed? The person who must be informed that a decision or action has taken place

Patient

Registrar

Nurse

PractitionerRN MA

Clinic Manager

Review charts and scrub prior to visit, for F/U I I C,A R

Approve standing orders to be executed C, A R I

Collect sample for processing C I R

Review lab results A,C R I I

Review plan of care, goals and write updates A C R

Examine extremities A C,I R

Schedule follow up visit R C I A

RACI Matrix Example

R = Responsible: completes task A = Accountable: buck stops here, only ONE C = Consulted: prior to final decision I = Informed: after decision, kept in the picture

• Evaluate

• Schedule

• Write

• Record

• Determine

• Operate

• Monitor

• Prepare

• Update

• Collect

• Approve

• Conduct

• Develop

• Inspect Train

• Publish

• Report

• Review

• Authorize

• Decide

RACI Matrix Tasks should start with good action words:

Do a vertical analysis: too many R’s?, Too many A’s?

Do a horizontal analysis: lots of C’s. No R’s. Too Many I’s?

Analyze: can you place Accountability (A) and Responsibility (R) at the lowest feasible level?

Minimize the number of Consults (C) and Informs (I)

All roles and responsibilities must be documented and communicated

Now what to do with your completed RACI Matrix?

What is the Be Prepared to Be Engaged Strategy?

• Encourages patient & family engagement in three ways:

• Be ready.

• Speak-up and ask questions.

• Take Notes.

• Clinicians and staff support and reinforce use of the tools to support engagement.

• Orient the patient to the Be Prepared Strategy − Patient Fact Sheet

• Discuss expectations for use

• Reinforce behaviors at every level of the encounter

Orient Patients to Be Prepared to be Engaged

How can I get Started?

• Identify a champion leader

• Develop a process for engaging patients and families using the intervention

• Engage entire practice team

• Inform patients & families

• Evaluate & refine process

Free resources on AHRQ website: http://bit.ly/2km87G1

RACI Role Optimization Activity

1. Identify tasks for introducing patients to the Be Prepared to Be Engaged tool (“Task” column)

2. Review roles and identify Accountable and Responsible actors for each task.

3. Review roles and identify Consulted and Informed actors for each task, as necessary.

4. Analyze vertically and horizontally for undue burden or inefficiencies.

Questions?

This educational session was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,375,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

FOR MORE INFORMATION CONTACT:

Luke ErtleProgram Manager, Quality CenterNational Association of Community Health Centerslertle@nachc.orgqualitycenter@nachc.org