Chronic Disease ManagementQuality Improvement ProjectMackenzie Family Health Clinic
Aim: To further improve the care of patientswith chronic diseases,90% of patients with one or more chronic diseases will h...
Scope and BoundariesPatients over 18 in Mackenzie who attend the clinic and have one ormore chronic diseases.The qualifyin...
A Sense of Urgency!                 Are we                prepared?                            Primary Health Care Charter...
Primary care physicians in a 15 min visit can no longer meet what patients need               or deserve.             42% ...
Evidence shows anincrease in patients with multiple agendas and a  decrease in time and  availability with the        phys...
50% of patients  leave the visit     withoutunderstanding what   advice their  physician gave                 Bodenheimer,...
wonder manypreventative servicesgo undone and manypatients with chronic disease are poorly     controlled.          Bodenh...
WHAT CAN BE DONE?   • The creation of high-     functioning primary care teams   • Systematic, planned care for     people...
Chronic Disease RegistryManagement Process Map
Systematic, planned care for    people with chronic conditions   Helps care providers target care to meet patient    need...
Tasks that are now performed by            non-physician team membersPrimary    Obtaining point of care measurements     ...
Tasks that will be performed byPrimary     non-physician team members           Develop Educational Materials Care      ...
Total Number of Patients in the EMR 4784                    Total Number of Patients Identified with Complex or Chronic   ...
On December 31, 2011, 58% of patientsidentified with chronic diseases had attended theclinic for a planned chronic disease...
As of December 30, 2011, 77% of the patients with  chronic diseases were on a recall list for their               annual p...
% of Diabetic Patients with an Annual Foot Exam                       As of December90%80%                                ...
As of December 31, 62.5% of the patients with       COPD had an exacerbation plan.
14%                                                                                  % of Diabetic and COPD Patient Visits...
Are appointments available to meet the          demand for care?
Office efficiency has been demonstrated to              build capacity in primary care offices and            improve the ...
Does displaying data on the walls for thecare providers to see make a difference?
FeedbackInterview with Dr. David Abbott: “The reports on the wall are inspirational. It made a   difference to my work. I ...
Displaying data on the wall for the patients to      beinformed, ac tivated andempowered.
FeedbackPatient Surveys: • Most people felt their experience at the   clinic was excellent or good. • Some patients do not...
FeedbackMOA Surveys:• MOAs feel confident in their jobs and their  workload.• They feel part of a team working for the  go...
Indications That Improvements Made In This Clinic Will Continue• This community is focusing on improving the  integration ...
Indications That Improvements Made In This Clinic Will Continue• The clinic staff are keen to take more  training, includi...
G2 Rapid Fire:  Building on Care in the Community - C. Wenninger
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G2 Rapid Fire: Building on Care in the Community - C. Wenninger

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  • Acceptable, appropriateness, Accessible, Safety, Effectivenress
  • QI = any systematic data guided activities designed to bring about immediate improvement in a health care settingSocial or scientific valueGains justify risk (can include any extra visits, paper work, surveys)Gains justify expenseScientific validity Is it properly structured to achieve its goal?Consider context and how to make something happen in local contextFair subject selectionConsider other QI programs going on in your organizationConsider vulnerable populations Favorable risk-benefit ratioFocus particularly on individualRespect for potential and enrolled participants:Includes respect for privacy and confidentialityOnly that health information that is necessary for the QI activitySame confidentiality obligations as for health care providers6. Informed ConsentNot required unless poses more than minimum risk7. Independent Review- If conditions exist that justify a need for a review – should be an external review body – but not a REBShould be internal to the organizationIn general, ongoing monitoring of ethical principles in QI activities should become part of the clinical care or management structureQI is considered an essential part of normal health care, therefore, consent for QI is assumed in consent to receive health care (within reasonable limits and no more than minimal additional risk)QI staff/teams can use health information in the same way staff use it to provide care
  • Over 3100 in 1996 to 4600 in 2006By 2031, it is estimated the country will have 14,000 people centenarians 13% stats can will be in BC 1800address the significant challenges of aging populations, the growing burden of chronic disease and the need to strengthen primary health care. approximately one in three British Columbians now has at least one confirmed chronic condition (Figure 1). For example, in 2005/06 there were over 26,000 new cases of diabetes diagnosed in B.C. over the next 25 years, and during this period, the seniors population is projected to grow over 100 per cent (Figure 4). Managing chronic disease is, therefore, a significant issue that affects British Columbians’ quality of life
  • For example, in 2005/06, 44 percent of people with diabetes received the recommendedcare according to B.C.’s guideline for diabetes.9
  • For example, in 2005/06, 44 percent of people with diabetes received the recommendedcare according to B.C.’s guideline for diabetes.9
  • For example, in 2005/06, 44 percent of people with diabetes received the recommendedcare according to B.C.’s guideline for diabetes.9
  • For example, in 2005/06, 44 percent of people with diabetes received the recommendedcare according to B.C.’s guideline for diabetes.9
  • This model guides the improvement process by addressing the basic elements for improving care in health systems at the community, organization, practice and patient levels. The elements are interrelated recognizing that to promote high quality health care a systems approach is required – highlighting that the various service providers do not function in a vacuum but need to consider how actions in one area affect those in other areas.
  • A Patient Journey Map was organized (a patient was invited) as part of the planning for incorporating annual chronic disease visits into the clinic. The group articulated and reflected on the current state of chronic disease care with the goal to consider improvements, and gaps in care.
  • Total Number of Patients in the Clinic 5173 512 ppl had Chronic diseaseTotal Number of Patients Identified with Complex or Chronic Disease (9.9%) from the EMR For example, in 2005/06, 44 percent of people with diabetes received the recommendedcare according to B.C.’s guideline for diabetes.9
  • Patient registries provide feedback on patient outcomes and help care providers improve clinical outcomes and care processes for all conditions
  • Benefits of a Patient registry is that it improves health and lifestyle and allows patients to manage their care and be part of the care team. Patients meeting clinical guidelines for COPD care? As the project continued more patients were identified as having COPD (36 in April compared to 60 in September).
  • Patient registries facilitate managing patients with chronic disease in a more proactive way, leading to fewer patients visiting for acute or crisis conditions.
  • The third next available appointment was tracked to determine appointments available to meet the demand for care. Access was taken into account when changes to the clinic appointments were considered. Office efficiency has been demonstrated to: Build capacity in primary care offices Improve the quality of life for practitionersImprove patient outcomes.GPSC, PSP Advanced Access and Office Efficiency, 2010Patients should see their own care provider on the day they call for any problem, whether urgent, routine or preventive. Space should be available each day to meet the demand for care.
  • This will assist with building a culture of continuous quality improvement and will integrate the patients as partners in their care.
  • G2 Rapid Fire: Building on Care in the Community - C. Wenninger

    1. 1. Chronic Disease ManagementQuality Improvement ProjectMackenzie Family Health Clinic
    2. 2. Aim: To further improve the care of patientswith chronic diseases,90% of patients with one or more chronic diseases will have an annual,planned appointment and will be provided with a care plan and/or discussion of self management goals.
    3. 3. Scope and BoundariesPatients over 18 in Mackenzie who attend the clinic and have one ormore chronic diseases.The qualifying chronic conditions are based on the GPSC guidelines forcomplex and chronic disease care. Diabetes Congestive heart failure COPD Hypertension Co-morbidity - patients with two of more chronic diseases  Chronic renal failure with eGFR values consistently less than 60  Chronic respiratory condition  Cerebrovascular disease  Ischemic heart disease, excluding the acute phase of myocardial infarct  Chronic neurodegenerative diseases  Chronic liver disease with evidence of hepatic dysfunction
    4. 4. A Sense of Urgency! Are we prepared? Primary Health Care Charter : a collaborative approach
    5. 5. Primary care physicians in a 15 min visit can no longer meet what patients need or deserve. 42% of primary care physicians report not having adequate time to spend with their patients Bodenheimer, Building Teams in Primary Care: Lessons Learned, chcf.org, 2007
    6. 6. Evidence shows anincrease in patients with multiple agendas and a decrease in time and availability with the physician Bodenheimer, Building Teams in Primary Care: Lessons Learned, chcf.org, 2007
    7. 7. 50% of patients leave the visit withoutunderstanding what advice their physician gave Bodenheimer, Building Teams in Primary Care: Lessons Learned, chcf.org, 2007
    8. 8. wonder manypreventative servicesgo undone and manypatients with chronic disease are poorly controlled. Bodenheimer, Building Teams in Primary Care: Lessons Learned, chcf.org, 2007
    9. 9. WHAT CAN BE DONE? • The creation of high- functioning primary care teams • Systematic, planned care for people with chronic conditions • Improve Access • Group Medical Appointments
    10. 10. Chronic Disease RegistryManagement Process Map
    11. 11. Systematic, planned care for people with chronic conditions Helps care providers target care to meet patient needs Facilitates other practice improvements, such as group visits and patient self-management Improves professional satisfaction Increases likelihood of follow-up for patients who need it. Targets hard-to-reach patients. Prevents complications through proactive treatment Increases patient satisfaction
    12. 12. Tasks that are now performed by non-physician team membersPrimary  Obtaining point of care measurements  Updating the Electronic Medical Record Care  Advising patients to go to the lab prior to their appointmentTeams  Advising patients to bring their medications for reconciliation  Monitoring and updating patient registries  Organizing Group Medical Appointments  Managing quality improvement initiatives in the office  Managing and encouraging patients to book annual appointments
    13. 13. Tasks that will be performed byPrimary non-physician team members  Develop Educational Materials Care  Notify and review lab results with the patient under care provider’s direction.Teams  Assist with the development of Self Management Skills  Implement smoking cessation intervention  Manage standing orders and complete standing Lab requisitions
    14. 14. Total Number of Patients in the EMR 4784 Total Number of Patients Identified with Complex or Chronic Diseases 552 (11.5%) No. of Patents Identified with Complex or Chronic Diseases in the MacKenzie Health Centre 500 450 400 350 300# of Patients 250 200 150 100 50 0 79.7% 33.9% 10.9% 10.7% 9.2% 4.2% 3.1% 3.3% 2.5% 0.7% HTN DM COPD CKD ISCH CBVD CHF RESP NEURO LIVER 552 patients 440 187 60 59 51 23 17 18 14 4 47% of these patients have more than one chronic disease
    15. 15. On December 31, 2011, 58% of patientsidentified with chronic diseases had attended theclinic for a planned chronic disease appointment.70% % of Planned Visits for Patients with Chronic Diseases60%50% UCL 0.43740% CL 0.37430%20%10%0% 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec Januarly to December 2011
    16. 16. As of December 30, 2011, 77% of the patients with chronic diseases were on a recall list for their annual planed care. Number of Patients with Chronic Diseases on the Recall List100% 90% 80% 70% 60% UCL 0.601 CL 0.536 50% 40% 30% 20% 10% 0% 26-Apr 6-May 24-May 31-May 20-Jun 8-Jul 11-Aug 8-Sep 27-Sep 31-Oct 30-Nov 31-Dec April 2011 to December 2011
    17. 17. % of Diabetic Patients with an Annual Foot Exam As of December90%80% 31, 2011, 73.5%70%60% UCL 0.648 of patients with50% CL 0.537 diabetes had a foot exam40%30%20% documented in10%0% the EMR. 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec January to December 2011 As of December 85% % of Diabetic Patients with HGBA1c in past 6 mos31, 2011, 71.9% 80% UCL 0.813had their HgbA1c 75% checked in the CL 0.712 70%past six months. 65% 60% 55% 50% 30-Jan Feb-29 29-Mar 30-Apr 30-May 30-Jun 30-Jul 30-Aug 30-Sep 30-Oct 30-Nov 30-Dec January to December 2011
    18. 18. As of December 31, 62.5% of the patients with COPD had an exacerbation plan.
    19. 19. 14% % of Diabetic and COPD Patient Visits to ER from Will managing 12% April to December 2011patients with chronic 10% disease in a more 8% CL 0.078 proactive way, lead 6% to fewer patients 4% visiting the ER for acute or crisis 2% conditions? 0% 29-Mar 30-Apr 30-May 30-Jun 30-Jul 30-Aug 30-Sep 30-Oct 30-Nov 31-Dec Visits to the ER from March - December 2011 Of 231 patients 47 who had Diabetes and/or COPD, there 19 were 127 visits to the 18 16 14 11 8 6 5 5 4 emergency room 3 3 3 2 1 1 resp injury skin musc GI other syncope blood BP renal urinary cardio cerebr MH Gland post op seizure sugar
    20. 20. Are appointments available to meet the demand for care?
    21. 21. Office efficiency has been demonstrated to build capacity in primary care offices and improve the quality of life for practitioners. Total No Show Appointments 138# of Patients who did not show for their 118 98 appointment 78 58 38 18 31-Jan 28-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 30-Sep 31-Oct 30-Nov 31-Dec No Show 54 52 69 54 75 122 88 121 78 96 130 85
    22. 22. Does displaying data on the walls for thecare providers to see make a difference?
    23. 23. FeedbackInterview with Dr. David Abbott: “The reports on the wall are inspirational. It made a difference to my work. I seem to have an antennae now for when I care for patients. I am looking for gaps in care…” “I became enthusiastic which surprised even me” “There were many little things that were changed that amounted to major changes in how we look after patients”
    24. 24. Displaying data on the wall for the patients to beinformed, ac tivated andempowered.
    25. 25. FeedbackPatient Surveys: • Most people felt their experience at the clinic was excellent or good. • Some patients do not know what the plan is for their care… were not asked about their beliefs or ideas did not know they should be booking a yearly exam.
    26. 26. FeedbackMOA Surveys:• MOAs feel confident in their jobs and their workload.• They feel part of a team working for the good of the patients• They rated patient care very high.
    27. 27. Indications That Improvements Made In This Clinic Will Continue• This community is focusing on improving the integration of health services• The Primary Health Care Developer is working on an improvement charter to improve access• The care providers will be engaged in the Chronic Disease Module and Group Medical Visit Module of the Practice Support Program.• The leadership is continuing to encourage site visits and is supporting the improvement work.
    28. 28. Indications That Improvements Made In This Clinic Will Continue• The clinic staff are keen to take more training, including patient self- management, and the leadership has built time into their day for this training.• A third permanent doctor is expected to arrive which will create stability with patient care.• The clinic staff and physicians are keen to organize a group medical appointment for people with chronic diseases.

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