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Back: Diabetes Quality Markers and Office Re-design

Doron Schneider, MD
Medical Director
Center for Patient Safety and Healthcare Quality
Abingdon Hospital
Abingdon, Pennsylvania

So…Where do we go from here?  It seems like every day we have more regulations, more insurance pre-authorizations, less control, more demands, more patients, less reimbursement, less joy.  How do we find what it takes to dig us out of the current morass that is primary care?   How do we revitalize ourselves, meet the challenges for today and build a sustainable future for ourselves and our children?  And what about those pesky diabetes quality markers?  How do we fit them in to the picture?

While this blog is about diabetes and measures of quality, it cannot do so without regard to the context upon which we must deliver optimal diabetes management.  For physicians (and their staff) who are in the primary care environment, the context includes numerous other concurrent chronic conditions coexisting in our patients with diabetes (i.e hypertension, CAD, COPD, hyperlipidemia etc).  It includes patients who are illiterate, enumerate, depressed, underinsured, overwhelmed by the demands of modern life – need I go on?

The answer to the above series of conundrums revolves around redesigning our work.  We can’t solve today’s problems by thinking and acting the same way.  We need new relationships, new standard work for each member of our office staff AND we need to engage our patients in this redesign.  We need to the voice of the customer to be our guide!

So in essence we need a model.  The model for us to understand and begin to deploy is the Chronic Care Model.  This model is at the heart of the Patient Centered Medical Home.  In this blog I focus on defining the Chronic Care Model.  I will provide examples of each section of the model.  The reader is encouraged to consider examples from his or her practice with the intent to begin an idea exchange through reader responses.

What is the Chronic Care Model?

The Chronic Care Model, as defined by Dr. Edward Wagner focuses both on structures and processes that exist inside the physician’s office and to an understanding of the outer community at large.  The intent of the model is to create an engaged and prepared patient and an engaged and prepared practice team.  When this exists and the chaos of primary care recedes, each encounter will more likely produce improved results.  Practices that begin their practice redesign journey often don’t know where to begin and focus.  I would suggest that the PQRI measures are a wonderful place to start.  For diabetes these include: 

  • 1 Diabetes Mellitus: Hemoglobin A1C Poor Control in Diabetes Mellitus
  • 2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus
  • 3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
  • 117 Diabetes Mellitus: Dilated Eye Exam in the Diabetic Patient
  • 119 Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients
  • 163 Diabetes Mellitus: Foot Exam

The model can be used to improve any of the above measured (as well as any associated with chronic illness or prevention services).  It’s further broken down as outlined below.

In the Office

Patient Engagement
– systematically empower patient with the knowledge and skills to perform self management of chronic disease. Diabetes Examples: 

  • Distribute an information sheet to patients that describes what an A1C is and what it should be
  • Show patients in the exam room a video of how to check blood sugars
  • Provide a guide for patients that describes “portion control”
  • Provide a “Goal” sheet for patients to complete during the encounter to declare a self selected attainable lifestyle change in the interval between visits

Practice Redesign – offload the physician from shouldering the entire clinical burden by redesigning the job description of each member of the care team to align with shared practice clinical goals.  The goal of the redesign is to ensure that the patient’s visit is with a prepared practice team. Diabetes Examples: 

  • Ask the office staff who check in patients to provide the sheet on goal setting
  • Have the nurse ask all diabetic patients to take off their shoes and socks during their annual visit
  • Have the nurse help assess adherence of diabetes (and all) medications as part of the intake process
  • Have a 10 minute huddle in the morning to review the schedule and ensure that lab work, referral letters, etc. are present for all patients as well as care supplies
  • Perform diabetes group visits
  • Have the staff member who is calling patients to remind them of their next day appointment, also ask patients to remember to bring in their blood sugar log book and medication bottles

Decision Support – integrate clinical decision support into clinician workflow with the goal of bringing best evidence and clinical guidelines to the exam room. Diabetes Examples:

  • Have standing order sets for lab ordering (to ensure quarterly A1Cs, yearly lipids, etc.)
  • Agree to algorithms for intensification of care with your partner.  Select ones from national guidelines or consensus statements from (ADA/EASD/AACE etc)
  • Ensure that these algorithms are readily available to you in each exam room.  Consider giving these to patients as well
  • Work with your EMR vendor, or select an EMR that will allow you to create embedded clinical decision support for chronic diseases within a workflow that makes it easy to do the right thing
  • Consider adding key elements of guidelines and algorithms directly onto paper flowsheets, thus bringing documentation of progress to date and expected next steps together .

Clinical Information Systems – utilize electronic registries to perform “population management”.  This allows the practice to run query reports for multiple endpoint of interest. Diabetes Examples: 

  • Patients at goal A1C, blood pressure, LDL level
  • Patients who are completely out of control (A1C >9)
  • Patients have not been seen in the practice in the past 6 months
  • Patients who have not been to the ophthalmologist in the past year
In the Community

Physicians need to know what resources are available for patients in their community that will support their health and wellness.  Examples include diabetes education centers, formal exercise programs offered through local YMCAs or employers, pharmacies with low cost diabetes supplies etc.

The above examples are only that – examples.  Some of these examples will be easy to implement and other s will not fit your practice.  I urge you to consider your system of care.  Are you achieving good clinical outcomes?  Are you satisfied with your workday?  It is only through changing the systems that we work in, where we offload the entire burden of success from the back of the busy physician that we will be able to change our current realities.  In order to accomplish that, we have to get good at flying the airplane and redesigning it at the same time!   That is hard work.  It is through understanding how to create small cycles and change that we can do this seemingly impossible task.  Stay tuned to the next blog when I review PDSA cycles and how they can be used to customize the examples above for you and your team.

Join the Dialogue! 

For now - please join the dialogue and submit to us any other examples of practice redesign you would like our community to know about.  It is only through sharing that we can accelerate the pace of change.  Once we have mastered this - the diabetes metrics will fall into place!