UNIVERSITY OF MISSOURI

Family & Community Medicine

Improving Perfect Diabetes Care

Performance Improvement Leadership Develop Program

February 19, 2010

UNIVERSITY OF MISSOURIFamily & Community Medicine

Members of the Team and our Advisors

• Karl Kochendorfer, MD (Dir. of Clin. Inform.)• Phil Vinyard, MHA, MBA (Clinic Manager)• Donna Neal, RN (Nurse Manager)• Rhonda Polly, APRN (Chronic Care Nurse)• Jan Gace, LPN (Phone + Floor Nurse)

Advisors:• Carl Hooker, MHA (Finance)• Tim Hogan, PhD (Dept. QI Officer)

UNIVERSITY OF MISSOURIFamily & Community Medicine

Family Medicine

• 8 Clinics in Columbia + Mid-Missouri• ~100,000 ambulatory clinic visits/year• Pilot with Green Meadows Green Team

450 patients with diabetes 7 Faculty members 1 Fellow 9 Residents 1 Chronic Care Nurse 9-11 Nurses 7 Clerical

UNIVERSITY OF MISSOURIFamily & Community Medicine

Chronic Disease and Diabetes Burden

• Half of all Americans have at least one 1

• 70% of all deaths 2

• > 75% of health expenditures 1,3

• 1/5 of health dollars are spent on pts with diabetes 4

• Only 50% of recommended care is delivered 5

1) Wu. Projection of chronic illness prevalence and cost inflation. RAND Health; 2000. 2) Kung. Deaths: final data for 2005. National Vital Statistics Reports 2008.3) Hoffman, C. Persons With Chronic Conditions - Their Prevalence and Costs. JAMA. 1996.4) ADA. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care. March, 2008.5) McGlynn. Quality of Health Care Delivered to Adults in the US. NEJM. 2003.

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Broken healthcare system

“Good Luck with the American Health-Care System” cards

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Diabetes Summary

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DM Quality Measures

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Concept of Perfect Care

Healthcare IT News. 9/2008

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Min. improvement after 1 yr

Clinics w/ Care Coordinators:• 2 FM Clinics b/w 10-15%• 2 FM Clinics b/w 5-10%

Clinics w/o Care Coordinators:• 4 FM Clinics close to 0%• 2 IM Clinics close to 0%

UNIVERSITY OF MISSOURIFamily & Community Medicine

Aim Statement

The Family Medicine Green Team will increase the percentage of our diabetic patients with perfect care from 10% to no less than 50% by June 30, 2010.  This will be accomplished by using a multidisciplinary approach, process change, education and utilization of eight quality measures.

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UMHC & FCM Mission & Focus

• UMHC Mission: advance the health of all people, especially Missourians

• UMHC Focus: Six Columns of Excellence   Quality People Service Growth Community Finance

• FCM Mission: enhance health and primary care for our communities

• FCM Research Focus: preventing and caring for patients with chronic disease

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Fishbone Diagram

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Driver Diagram

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Interventions Considered

• Opportunistic Approach: Every time a patient with diabetes comes

for a clinic visit, review their quality measures and take action

• Proactive Approach: “Run the list” of diabetic patients and pro-

actively contact them about missing items• Patient Engagement Approach:

Educate the patients about the types of services they should be receiving

Process Flow Chart

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Outcomes to DateGreen Team Diabetes Perfect Care* as of 01/14/2010

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

03/12/2

009

03/26/2

009

04/09/2

009

04/23/2

009

05/07/2

009

05/21/2

009

06/04/2

009

06/18/2

009

07/02/2

009

07/16/2

009

07/30/2

009

08/13/2

009

08/27/2

009

09/10/2

009

09/24/2

009

10/08/2

009

10/22/2

009

11/05/2

009

11/19/2

009

12/03/2

009

12/17/2

009

12/31/2

009

01/14/2

010

*Perfect care indicates performance of all 8 DM indicators

Perc

ent p

erfo

rman

ce

Decided to focus on diabetes quality indicators as a practice improvement project

Completed workflow process and began piloting and training for our intervention

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System-wide ROI

• Eye exams (Mason): $25,000/yr from GM Green Team patients When all clinics get to 80% referral rate $225,000/yr in new and return visits $75,000/yr in facility fees

• GM Quality of Care: priceless From < 10% to 20% in a few months Target 50% by June 30th, 2010

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Lessons Learned

• Having data doesn’t mean improvement• Integrate the data into your workflow• Training needs

Learning how to use the reporting tools Documentation, e.g. eye and foot exams

• Team effort (e.g. buy-in, resources, meetings)

• Physician led team• Automate, Automate, Automate

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Future Steps

• Present to FCM Faculty on March 24th

• Celebrate target achievement on 7/1/10• Publish an article in a national journal• Present at Practice Improvement conf.• Integrate PDSA

Continue Meeting (1x/mo) Work on “Proactive” approach Work on “Patient Engagement” approach Expand to other FM + IM Clinics Assist our docs with their Board cert.

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Questions?