September 2012 Webinar• Overcoming Clinical Inertia with

Stepped Care• Self-Management Support:

Kathleen Drozdiak: Clymer Family Medicine, Indiana, PA

Overcoming Clinical Inertia with Stepped CareUncovering the Root of the Problem and Then Addressing It

Clinical Inertia in Diabetes Care“Clinical inertia encompasses both failure to initiate therapy when indicated, and failure to titrate therapy until evidence-based clinical goals are achieved.

Over 80% of diabetes patients are on pharmacotherapy for glucose control, and in many settings, over 70% of heart disease patients are on statins for LDL control.

Yet, many patients on treatment are not at their evidence-based goals. This suggests that failure to uptitrate therapy may be the lion's share of clinical inertia in chronic disease care.”

Improving Diabetes Care by Combating Clinical Inertia. Commentary by Patrick J. O’Conner, assistant medical director and senior clinical research investigator, HealthPartners Research Foundation. Health Serv Res. 2005 December; 40(6 Pt 1): 1854–1861. www.ncbi.nlm.nih.gov/pmc/articles/PMC1361230/

Let’s Look at LDL<100

Failure to Initiate or Failure to Titrate?

Baseline June 2012 July 2012 August 20120%

10%

20%

30%

40%

50%

60%

70%

% DM Patients with LDL <100NorthWest

Baseline June 2012 July 2012 August 20120%

10%

20%

30%

40%

50%

60%

70%

% DM Patients with LDL <100SouthCentral

Addressing Clinical Inertia Through Stepped Care• Often begins with lifestyle change or adaptation

(eliminate triggers, lose weight, exercise more)• First choice medication• Either increase dose or add second medication,

and so on• Includes referral guideline

Self-mgmt support for lifestyle change

Add medication

Intensify medication

Specialty referral?

Standing Orders to Reduce Clinical Inertia• Evidence based guidelines built into care• Allows someone other than the provider to help• Could be as simple as: if BP high on lisinopril 5mg,

increase to 10mg• Could be: LDL high, increase statin• Could be: advancing medications for glucose

control• Develop consensus in practice around evidence-

based guidelines

Antihyperglycemic Therapy in Type 2 Diabetes:General Recommendations

Inzucchi S E et al. Dia Care 2012;35:1364-1379Copyright © 2011 American Diabetes Association, Inc.

Have Any Questions?• South Central – Sharon Adams

814-344-2222, sadams@scpa-ahec.org• North West – Patty Stubber

814-217-6029, pstubber@nwpaahec.org

Self-Management Support: Advice from PA CCI PracticeKathleen Drozdiak: Clymer Family Medicine, Indiana, PA

CLYMER FAMILY MEDICINE

2009 - 2012

I think I can, I think I can, I think I can

“For the things we have to learn before we can do them, we learn by doing them.”

Aristotle

CHANGES THAT HAVE IMPROVED CARE

• Regular follow-up visits scheduled based on severity of disease

• Pre-visit work• Planned care at every visit• Physician & Practice “report cards”• “Close the Gap” reports and F/U letters to pts.• Education Center classes and support group• Clinics for retinal exams, flu shots• Earlier referrals to specialists• Use of standing orders

HbA1c < 7 Trending 2009 – 2012

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HbA1c Interventions

• Close Tracking of A1c’s independent of physician orders

• Lab requests sent to patients• Classes at Health Education Center• One-on-one nurse visits with Care Manager• Physician Care – more aggressive with meds• Reinforcement and rewards for patients with

improved outcomes

Cholesterol Trending 2009- 2012(LDL < 100)

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Cholesterol Population Management

• Patient Visits are scheduled by disease severity• Pre-visit work requesting labs when necessary• Semi-annual reports to round up patients who have

not had annual lipid profiles • Reports of statin use are given to docs, hard sell to

the patients. Keep trying.• Queried entire practice, over 4,000 patients.

Identified 44 patients with CAD not on statins.

Blood Pressure Trending 2009-2012BP < 130/80

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Blood Pressure TrendingBP < 140/90

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Blood Pressure Population Management

• Free and frequent BP rechecks• Offer walking program• Docs prescribe medicine• One doc uses red reminder cards on charge

slips.• Nurses check for medication compliance and

timing• Nurses encourage low salt diet, decrease in

caffeine intake

Walk with Clymer Family Medicine!

56 Patients’ Outcome Measures2009 - 2011

• Pre and Post Intervention Data:– HbA1c’s– BPs– Cholesterol

Healthy Life Styles Class Participants

Patient Care• Pre-visit work completed, using standing orders• Planned care at every visit• Self management stressed, help patient understand they can control their

disease not the other way around• Self management goals are reviewed, renewed and recorded in pt. record at

every visit• Patient visits and lab frequency is determined by risk assessment• “Process Measure Round Ups” e.g. pneumonia vaccine, aspirin, GFR

assessments, etc.• Clinical outcomes are tracked and information given to patient and to

physicians• Patient attended classes at learning center• THE ABOVE INTERVENTIONS in addition to the clinical decision making of a

caring, involved physician

Interpretation

• A paired-samples t-test was conducted to evaluate the impact of the interventions on A1c, Systolic BP, Diastolic BP, and Weight.

• There was no statistically significant difference found in Systolic BP and Weight.

• There was a statistically significant decrease in A1c from 2009 (M = 7.43, SD = 1.78) to 2011 (M = 6.69, SD = 1.11), t(51) = 3.118, p = .003 (two-tailed).

Interpretation

• The mean decrease in HgA1c was 0.73 with a 95% confidence interval ranging from 0.26 to 1.20.

• The eta squared statistic (0.16) indicates a large effect size. This means there was a large effect, with substantial difference in the A1c scores obtained before and after intervention.

Interpretation

• There was a statistically significant decrease in Diastolic BP from 2009 (M = 79.13, SD = 12.22) to 2011 (M = 75.04, SD = 9.60), t(55) = 2.39, and p = 0.020 (two-tailed).

• The mean decrease in Diastolic BP was 4.09 with a 95% confidence interval ranging from 0.66 to 7.51.

• The eta squared statistic (0.09) indicated a moderate effect size. This means there was a moderate effect, with some substantial differences in the Diastolic BP obtained before and after intervention.

Self Management

• Emphasize the patient’s central role in managing his illness

• Assess patient self-management knowledge, behaviors, confidence, and barriers

• Provide effective behavior change interventions and ongoing support with peers or professionals

• Assure collaborative care-planning and problem-solving by the team

• Provide self-management support at all visits

Where is CFM in Self Management?

• Opened Clymer Family Medicine Health Education Center

• Classes and educational resources available for patients

• Walking program available for patients • Assessment of self management knowledge,

behaviors, confidence and barriers is done in the classes and in one on one sessions with care manager

• Self management goals are discussed and recorded at each “planned care” visit

Clymer Family Medicine Health Education Center

Clymer Family Medicine Health Education Center

Clymer Family Medicine Health Education Center

Clymer Family Medicine Health Education Center

Where is CFM in Self Management?continued

• Patients receive disease education information with mailed reminders from their physician to “close the gap” in their care

• Shift in use of our language to the patient, it is more patient centered, i.e. team up to help you, working together

Process Measures Success

• Driven by team leader and done by staff members

• Training for “planned care” visit• These measures tend to stay on track if

patient comes for visit• Use of queries to inform physicians. For

example who is NOT on aspirin, who needs a flu immunization, etc.

Specialty Care Trending 2009-2012Aspirin

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Specialty Care Trending 2009-2012Flu Vaccine

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Specialty Care Trending 2009-2012Foot Assessment

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Specialty Care Trending 2009-2012Kidney Assessment

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Specialty Care Trending 2009-2012Self Management

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Retinal Screening Trending 2009-2012

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Eye Exam Interventions

• Quarterly retinal exams on site. • Queries done quarterly• Patient Education Letter sent with Highmark

card

Retinal Screening Letter

Retinal Screening

Tobacco Use Population Management

• Every patient asked if they smoke• Every smoker receives motivational interviewing and

a packet of materials to take home• Semiannual smoking cessation classes held at Clymer

Family Medicine Health Education Center. Taught by local drug and alcohol center.

• Patients are identified through queries, letters sent to them informing them of classes. We follow up with phone calls.

Smoking Status Assessed

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Other Projects using Population Management Interventions

• Colorectal Cancer Screening Project• Mammogram Screening Project• PAP Screening• CAD Query• Pneumonia Vaccine • Aspirin Query

Where do we go from here?

• Population Management Project for Each Month of the Year

• Continue learning the query systems of Allscripts• Get Patient Portal in place• Continue developing our CM program• Continue work on Physician Buy-In and continued

staff training• Finish interface from our office to the local hospital

Far and away the best prize that life has to offer is the chance to work hard at work worth doing.

- Theodore Roosevelt