improving diabetes and hypertension november 2014 – june 2015 pilot maine chronic disease...
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IMPROVING DIABETES AND HYPERTENSIONNOVEMBER 2014 – JUNE 2015 PILOT
Maine Chronic Disease Improvement Collaborative (CDIC)
Learning Session #1
House-Keeping
Remote access with Pines, Presque IsleTone for the day: Conversational Needs / Norms / Requests from group?
Agenda
Welcome and Introductions Setting the Stage for team-based improvement
Key Drivers #1 & #2: Standardizing Care throughout your Team Optimizing your Registry
Sticky Issues & Common ChallengesTeam Time & Cross-PollinationNext Steps
Maine Quality Counts Staff : Your Resources
Sue Butts-Dion, Improvement Advisor
Louise Morang Quality Coach
Josh Farr – QI Specialist
Change is Personal AND It Takes a Village!
Holly Richards & Nathan Morse
CDC Statewide Efforts
Rhonda Selvin
Setting the contextTeam-Based
Improvement
Why Us? Why Now?
How will WE know we’ve succeeded?
Michelle Mitchell, Partnerships for HealthContext of the Evaluation workInvitation to participate in initial interviews
Welcome
Our Patients Live with Chronic Disease‘Tis the Season…
Naples Family PracticeYork Family Practice
Midcoast Brunswick Family PracticeCapeheart Community Health Center
(PCHC)Pines Presque Isle
CDIC Participating Teams
What we’ve learned from you (Baseline Assessment) Payment model important to improvement (but not imperative!) Wide variation exists throughout any given practice
Decision Support (protocols, patient education) Pre-Visit Planning Identifying patients most at risk
Standards begin with engaging everyone on improvement
Data helps drive this engagement
Setting the Stage
Setting the Stage
Where you all are so far…
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Environment CDIC Scope
Setting the Stage
Current Strengths
High Performers to learn from
Community Linkages
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Opportunities to learn together
Self Management Support Decision Support0.0
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P.I.
Opportunities to learn together
Self Management Support Decision Support0.0
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Education ToolsBehavior ChangeEngaging all Team Members
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GuidelinesProtocolsOptimizing Team-Roles
Setting the Stage
What you’ve told us (your Top Three Things)
1. If we can engage all members of our staff…2. If we could standardize risk assessment tools…3. If we could better educate our patients…
1. Education Materials 2. Patient Goals & Action Plans3. Shared Care Plans throughout the Team
4. “….WHILE SUPPORTING WORK-LIFE BALANCE!”
A Team
So, Improvement Requires …
So, Improvement Requires …
Data
Rhythm!
So, Improvement Requires…
Aim
Measure
Change Idea
CDIC Aim Structure
Measures Global Aims Specific Aims
Let your Aims Drive your Change Ideas
Let your Aims Drive your Change Ideas
Standard Care Processes
Clinical Guidelines / Protocols
Medical Team composition
Technology Use
Communication (e.g., referral standards)
Community Resources
Optimize Registry
Embedded Guidelines on EMR
Clinical Decision Support Tools (e.g., alerts & reminders) accessible to all team members
Access to Labs/Tests across setting/system
Ability to ID Populations
ID sub-populations
Stratify based on complexity, severity, CM services
Capture/Track outcomes by provider
Access to clinical information by practice-based and community-based members (CCT)
Ability to get data for improvement from registry (e.g., run charts)
What are Your Aims?
On a scale of 1 (clueless) to 10 (ready to roll):What will you work to improve?How will you measure improvement?What small test will you start with?
Optional slides to follow…Use as needed
Guidelines / Protocols
Medical Team Composition
Team-based care, including: Expanded nursing/MA protocols Standing Orders Health Coaches, Care Coordinators, Navigators
Technology Use
Utilize EMR for action plans.Inter-connected EMR systems for coordination
of care (incl. e-consults with specialists).Use biometric devices (digital scale, BP
monitoring, etc.)
Communication
HuddlesTime for Improvement MeetingsStaff training that maximizes scopes of practice
for all practice staffImprove coordination between primary care
provider and hospital
Community Resources
Partnerships with community organizations (e.g., YMCA and pharmacies for lifestyle changes education, counseling and support)
Identify areas resources that support on-gong self-management support. (e.g., Diabetes Self-Management Support (DSMS) planning).