Diabetes Best Practices SymposiumDiabetes Best Practices SymposiumSponsored by AMGA and Merck & Co., Inc.Sponsored by AMGA and Merck & Co., Inc.

October 21-22, 2009October 21-22, 2009Detroit, MIDetroit, MI

Allina Medical Clinic

Improving Diabetes Outcomes

Bruce McCarthy MD, MPH – Chief Medical Officer

Bev Reiman – Director of Quality

Medical Group ProfileMedical Group Profile• The Allina Medical Clinic is a multi-specialty medical group The Allina Medical Clinic is a multi-specialty medical group

serving more than 40 communities in Minnesota at 44 clinic serving more than 40 communities in Minnesota at 44 clinic locations and 14 hospitals.locations and 14 hospitals.

• Part of a not-for-profit health system, The Allina Medical Clinic Part of a not-for-profit health system, The Allina Medical Clinic grew from mergers and acquisitions of independent practices in grew from mergers and acquisitions of independent practices in the 1990s.the 1990s.

• 3,800 clinic employees, including 575 physicians (400 primary 3,800 clinic employees, including 575 physicians (400 primary care physicians and 175 specialists) and 170 advanced practice care physicians and 175 specialists) and 170 advanced practice clinicians (Nurse Practitioners, Physician Assistants, etc.) We clinicians (Nurse Practitioners, Physician Assistants, etc.) We provide over 2.7 million out-patient visits annually.provide over 2.7 million out-patient visits annually.

• From 2004-2008 we implemented an EMR (Epic) to manage care From 2004-2008 we implemented an EMR (Epic) to manage care seamlessly across the continuum by connecting offices, seamlessly across the continuum by connecting offices, emergency departments, and hospitals.emergency departments, and hospitals.

Diabetes Goals & ObjectivesDiabetes Goals & Objectives• Deliver the best care that science has to offer.Deliver the best care that science has to offer.

• Achieve top 10 percentile national performance in control of each Achieve top 10 percentile national performance in control of each diabetes risk factor (HEDIS):diabetes risk factor (HEDIS):– A1c < 8% A1c < 8% – LDL < 100LDL < 100– BP < 130/80BP < 130/80

• Achieve top 10 percentile performance in Minnesota for “Optimal Achieve top 10 percentile performance in Minnesota for “Optimal Diabetes Care”: Diabetes Care”: Percent of patients with all risk factors controlled (i.e. A1c < 8 Percent of patients with all risk factors controlled (i.e. A1c < 8 andand LDL < 100 LDL < 100 andand BP < 130/80 BP < 130/80 andand ASA use ASA use andand tobacco free) tobacco free)

Diabetes Population & RegistryDiabetes Population & Registry• All patients with type 1 or 2 diabetes based on ICD-9 All patients with type 1 or 2 diabetes based on ICD-9

codescodes• Only pts. age 18 – 75 are included in quality measuresOnly pts. age 18 – 75 are included in quality measures• Demographics (population included in quality measure):Demographics (population included in quality measure):

• 21% Medicaid, 30% Medicare, 47% Commercial/FFS, 21% Medicaid, 30% Medicare, 47% Commercial/FFS, 20% Charity Care20% Charity Care

• 25% age 18 – 49 and 75% age 50 –7525% age 18 – 49 and 75% age 50 –75• 16% urban, 55% suburban, 29% rural16% urban, 55% suburban, 29% rural• Significant ethnic groups include Hispanic, Russian, Significant ethnic groups include Hispanic, Russian,

Hmong, Somali, Northern EuropeanHmong, Somali, Northern European

Diabetes Population & RegistryDiabetes Population & Registry

• 2009 registry currently includes 20,200 unique 2009 registry currently includes 20,200 unique patients.patients.

• Captures PCP, clinical, lab, medication and visit data.Captures PCP, clinical, lab, medication and visit data.

• Reports are produced for the group overall as well as Reports are produced for the group overall as well as for district, site and individual physicians.for district, site and individual physicians.

Allina Medical ClinicControl of Individual Diabetes Risk Factors

National Comparison (HEDIS)

30%

40%

50%

60%

70%

80%

90%

100%

A1c<7 LDL<100 BP<130/80

2006

2007

2008

Nat'l 90th percentile

Nat'l Average

Allina Medical Clinic Percentage of Patients with Diabetes in Optimal Control

2007-2009

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Jan

-07

Feb

-07

Mar

-07

Ap

r-07

May

-07

Jun

-07

Jul-

07A

ug

-07

Sep

-07

Oct

-07

No

v-07

Dec

-07

Jan

-08

Feb

-08

Mar

-08

Ap

r-08

May

-08

Jun

-08

Jul-

08A

ug

-08

Sep

-08

Oct

-08

No

v-08

Dec

-08

Jan

-09

Feb

-09

Mar

-09

Ap

r-09

May

-09

Jun

-09

Jul-

09A

ug

-09

Sep

-09

Criteria Change

Criteria Change

Optimal Diabetes Care* Minnesota Community Comparison 2008 DOS

* A1c <7% and LDL <100 and BP <130/80 and ASA use and tobacco free

29% 28%25% 23% 23%

19%17% 15% 13%

0%

5%

10%

15%

20%

25%

30%

35%

AllinaMedical

Clinic

SystemB

SystemC

SystemD

SystemE

SystemF

SystemG

SystemH

SystemI

State Average

Improvement ModelImprovement Model

• Establish the Establish the “why”“why” and create a tangible visionand create a tangible vision• AlignAlign leadership leadership -- set and focus on goals set and focus on goals• Develop and execute a Develop and execute a communicationcommunication planplan• EducateEducate physicians - establish a common physicians - establish a common

knowledge baseknowledge base• Implement Implement processprocess changes changes - be specific about the - be specific about the

“what” and the “who”“what” and the “who”• CheckCheck backback on the implementation (be tenacious) on the implementation (be tenacious) • Provide transparent Provide transparent feedbackfeedback• CoachCoach for improvementfor improvement• Teach leaders to Teach leaders to leadlead

Establish the “Why” & Create a Tangible VisionEstablish the “Why” & Create a Tangible Vision• Present the evidence:Present the evidence:

Controlling glucose aggressively Controlling glucose aggressively early in the courseearly in the course of of diabetes reduces the risk of cardiovascular events by 15 – diabetes reduces the risk of cardiovascular events by 15 – 42% and retinopathy and nephropathy 50%.42% and retinopathy and nephropathy 50%.Follow up on cohorts in the DCCT and UKPDS studiesFollow up on cohorts in the DCCT and UKPDS studies

Lower is betterLower is better. Each 20/10 mmHg decrease in BP is . Each 20/10 mmHg decrease in BP is associated with 50% decrease in risk of vascular disease associated with 50% decrease in risk of vascular disease across the entire BP range from 115/75 to 185/115.across the entire BP range from 115/75 to 185/115.Roccella E, Kaplan N. Hypertension Primer: The Essentials of High Blood Roccella E, Kaplan N. Hypertension Primer: The Essentials of High Blood Pressure: 2003.pp. 126-7Pressure: 2003.pp. 126-7

Multiple risk factor control reduces the risk of MI and death Multiple risk factor control reduces the risk of MI and death by 25 – 50%.by 25 – 50%. STENO-2 NEJM 2007, CARDS Lancet 2004STENO-2 NEJM 2007, CARDS Lancet 2004

• Present the evidence for system redesignPresent the evidence for system redesign

Align LeadershipAlign Leadership

• Engage a “guiding coalition”Engage a “guiding coalition”- Diabetes Clinical Action TeamDiabetes Clinical Action Team- Clinical Practice CouncilClinical Practice Council- Use opinion leadersUse opinion leaders

• Set goalsSet goals- Administrative and MD leaders have same clinical and Administrative and MD leaders have same clinical and

operational goalsoperational goals- Threshold goals vs. relative improvementThreshold goals vs. relative improvement

• Focus, focus, focusFocus, focus, focus

Develop and Execute a Communication PlanDevelop and Execute a Communication Plan

• Craft simple, consistent messages that are Craft simple, consistent messages that are meaningful and transmissible.meaningful and transmissible.

- ““Optimal risk factor control reduces risk of MI and death Optimal risk factor control reduces risk of MI and death by 25 – 50%”by 25 – 50%”

• Tailor messages to audience: evidence-based vs. Tailor messages to audience: evidence-based vs. impact on patients.impact on patients.

- 3-5 yr impact of better diabetes control for 17,000 pts.3-5 yr impact of better diabetes control for 17,000 pts. 130 fewer strokes130 fewer strokes 400 fewer heart attacks400 fewer heart attacks 200 fewer deaths200 fewer deaths 300 fewer cases of diabetes eye disease300 fewer cases of diabetes eye disease

Develop and Execute a Communication PlanDevelop and Execute a Communication Plan

• Plan dissemination to all audiences – be specific.Plan dissemination to all audiences – be specific.- NewsletterNewsletter- Quarterly Leadership MeetingQuarterly Leadership Meeting- Local leaders trained to deliver the message at site Local leaders trained to deliver the message at site

meetingsmeetings- Lunch & Learns for staff done by local MD experts Lunch & Learns for staff done by local MD experts

(nephrology, endocrinology)(nephrology, endocrinology)- Repetition: create a “drum beat”Repetition: create a “drum beat”- Leader roundingLeader rounding

• Check that the message got through.Check that the message got through.

““Every physician and staff member should Every physician and staff member should be able to articulate the ‘why’.”be able to articulate the ‘why’.”

Educate Physicians:Educate Physicians:Establish a Common Knowledge BaseEstablish a Common Knowledge Base

(Required CME for all new hire and low performing physicians)(Required CME for all new hire and low performing physicians)

• The evidence for tight risk factor controlThe evidence for tight risk factor control• Algorithm-based approaches to clinical challenges – Algorithm-based approaches to clinical challenges –

e.g., resistant HTNe.g., resistant HTN• Increasing the tempo of treatmentIncreasing the tempo of treatment• How to maximize patient adherenceHow to maximize patient adherence

- E.g., address cost concerns, keep regimen simple, printed E.g., address cost concerns, keep regimen simple, printed instructions, how to ask about adherenceinstructions, how to ask about adherence

- Understand the patient experience (e.g., self injection of saline Understand the patient experience (e.g., self injection of saline using insulin syringe)using insulin syringe)

Educate Physicians:Educate Physicians:Establish a Common Knowledge BaseEstablish a Common Knowledge Base

Practice ManagementPractice Management• How to work as a team with nursing staffHow to work as a team with nursing staff• 1:1 collaboration with RN Certified Diabetes Educator 1:1 collaboration with RN Certified Diabetes Educator

for low performing physiciansfor low performing physicians- Specific advice based on chart reviewsSpecific advice based on chart reviews- Strategies for motivating patientsStrategies for motivating patients

Implement Process ChangesImplement Process ChangesBe Specific About the “What” & the “Who”Be Specific About the “What” & the “Who”

• Rooming standards for clinical assistantsRooming standards for clinical assistants- Chart prep for last A1c, LDLChart prep for last A1c, LDL- Standing orders for pre-visit point-of-care A1c testing, LDL Standing orders for pre-visit point-of-care A1c testing, LDL

testing and DM education testing and DM education

• Give patient “score card” with current lab values and Give patient “score card” with current lab values and goals with follow-up instructionsgoals with follow-up instructions

• Schedule future labs, visits and CDE appts. before the Schedule future labs, visits and CDE appts. before the patient leavespatient leaves

• Rx refill policy: limit refill of diabetes meds to 6 monthsRx refill policy: limit refill of diabetes meds to 6 months

Implement Process ChangesImplement Process ChangesBe Specific About the “What” & the “Who”Be Specific About the “What” & the “Who”

• Quick Start Insulin Program – on-site RN patient Quick Start Insulin Program – on-site RN patient educationeducation

• RN CDE Medication Management (titration) visitsRN CDE Medication Management (titration) visits• MAs “work” the registry reportMAs “work” the registry report

- Update registry (deceased, transferred care)Update registry (deceased, transferred care)- Contact patients who are due for labs and/or a visitContact patients who are due for labs and/or a visit- Schedule BP check nurse visitsSchedule BP check nurse visits

Check BackCheck Back

• Leader roundingLeader rounding• Check in with every care teamCheck in with every care team

““A policy not observed A policy not observed

is worse than no policy at all.”is worse than no policy at all.”

Provide Transparent FeedbackProvide Transparent Feedback

• Share data at team meetings with all physicians and Share data at team meetings with all physicians and staff monthlystaff monthly

• Use un-blinded site and physician-specific dataUse un-blinded site and physician-specific data

Allina Medical Clinic Optimal Diabetes Quality Measure by Site

September 30, 200964

.3%

53.8

%

48.1

%

46.4

%

46.1

%

44.6

%

44.5

%

44.5

%

43.8

%

43.2

%

42.9

%

42.9

%

42.8

%

42.5

%

42.5

%

41.9

%

41.9

%

41.6

%

41.2

%

41.1

%

41.0

%

41.0

%

40.9

%

40.4

%

39.7

%

38.2

%

37.6

%

37.2

%

36.9

%

36.4

%

35.7

%

35.2

%

34.8

%

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10%

20%

30%

40%

50%

60%

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2009 GOAL - 39%

District/Site/Provider

Diabetes Quality Report

Run Date & Time: 9/4/09 & 7:48 am

Click here for report documentation The report is for measurement period 8/1/2009 through 8/31/2009

Component (“optimal” care) measure of the percentage of adult patients whohave type 1 or type 2 diabetes with optimally managed modifiable risk factors. All Crossroad sites are excluded from the District and Total Counts since they have not been up on Excellian for 2 years. 'HbA1c <8' data is used in the optimal control calculation.

Total Registry Population

% BP < 130/80

% LDL < 100

% ASA Ind.

% Tob. N-Usag

% Opt. Control

% A1c <7

% A1c <8

% A1c <9.5

Physician A 99 79.8% 74.7% 69.7% 80.8% 100.0% 42.4% 88.9% 97.0%

Physician B 64 60.9% 78.1% 57.8% 76.6% 100.0% 39.1% 79.7% 95.3%

Physician C 65 69.2% 81.5% 60.0% 90.8% 100.0% 46.2% 84.6% 92.3%

Physician D 22 63.6% 77.3% 45.5% 90.9% 100.0% 45.5% 63.6% 81.8%

Physician E 56 67.9% 75.0% 58.9% 80.4% 100.0% 41.1% 78.6% 91.1%

Clinic 306 70.3% 77.1% 61.4% 82.7% 100.0% 42.5% 82.4% 93.5%

Page 1

. ©2009 Allina Health System

Lower is better. Each increment of 20mmHG in systolic BP or 10mmHG in diastolic BP doubles the risk of vascular disease across the entire BP range from 115/75 to 185/115. Roccella E, Kaplan N. Hypertension Primer: The Essentials of High Blood Pressure. 2003. pp. 126-7

Provide Transparent FeedbackProvide Transparent Feedback

• Comparative data is powerful; however, physicians Comparative data is powerful; however, physicians tend to doubt “the numbers”tend to doubt “the numbers”

• Individual patient data is more powerful; when the Individual patient data is more powerful; when the focus is brought down to the care of individual focus is brought down to the care of individual patients there can be no excuses.patients there can be no excuses.

160

90

Run Date & Time: 8/4/09 & 8:32 am

DIABETES REGISTRY PATIENT LIST

Recent A1c Dt

ASA Indicator

Opt Ctrl (Y/N)

Tobacco Status

Recent Dias. BP Goal <80

Recent Sys. BP

Goal

Recent BP Date

Recent LDL Val.

Goal <100

Recent LDL Date

DOB Recent A1c val Goal <8

Patient Name & MRN ID Med Rev Status

Reg Status

Physician A

Patient One Yes

Active No 05/10/1959 6/11/09 114 72 6/11/09 7.1 Quit 6/11/09 6/11/09 123

Patient Two Yes

Active Yes 08/12/1964 7/9/09 128 5/14/09 6.4 Never 7/9/09 5/19/09 65

Patient Three Yes

Active Yes 11/12/1957 7/9/09 116 70 5/22/09 7.3 Never 7/9/09 5/22/09 78

Patient Four Yes

Active No 12/05/1969 4/17/09 124 78 4/17/09 6.2 Never 4/17/09 4/17/09 184

Patient Five Yes

Active No 07/08/1970 5/21/09 110 74 5/21/09 12.3 Yes 5/21/09 5/21/09 71

Patient Six Yes

Active Yes 01/31/1964 7/6/09 122 76 7/6/09 6.5 Quit 7/6/09 7/6/09 86

Patient Seven Yes

Active No 01/23/1959 7/30/09 70 7/30/09 6.9 Yes 7/30/09 7/16/09 153

Patient Eight Yes

Active No 02/27/1947 7/1/09 118 72 4/3/09 6.5 Quit 7/20/09 7/1/09 104

Coach for ImprovementCoach for Improvement

Focus on individual patients Focus on individual patients

rather than numbersrather than numbers

“ “ At some point all change requires one At some point all change requires one

clinician to talk to another.”clinician to talk to another.”

Teach Leaders to LeadTeach Leaders to Lead

• Communicating the evidence and importanceCommunicating the evidence and importance• Influencing skillsInfluencing skills• Dealing with resistanceDealing with resistance• Checking back and leader rounding on staffChecking back and leader rounding on staff• Coaching skills for 1:1 meetings with physiciansCoaching skills for 1:1 meetings with physicians

Lessons LearnedLessons Learned• Systems can support practice and improve care.Systems can support practice and improve care.

– “ “ Consistency breeds reliability”Consistency breeds reliability”

• The power of nursingThe power of nursing– More than just team work, nursing staff helped drive system More than just team work, nursing staff helped drive system

changes.changes.

• Culture through actionCulture through action– ““Culture is everything you promote and everything you tolerate.”Culture is everything you promote and everything you tolerate.”

• Leadership is everythingLeadership is everything– Financial incentives are not necessary if there are strong moral and Financial incentives are not necessary if there are strong moral and

social incentives.social incentives.