Raising the Bar in Chronic Disease Management

A Diabetes Program in Family Practice

Anne Barber RN(EC) MScN

Michele MacDonald Werstuck, RD MSc CDE

Lisa McCarthy, RPh BScPhm Pharm D

Inge Schabort, MB ChB CCFP

Disclosure

• The presenters perceive no conflict of interest with this presentation.

• Slides will be available at: www.stonechurchclinic.ca

Objectives

• To help you...– Identify your patients with diabetes– Start a diabetes clinic /diabetes day– Build a diabetes team– Experiment with group medical visits – Access resources to get you started

• Provide primary care for nearly 30 000 patients in Hamilton and surrounding area– 2 clinical teaching units affiliated with

McMaster University and Hamilton Health Sciences

Who are we?

Who are we?

Stonechurch MFP

Physicians 16 (12.7 FTE) 13 (7.5 FTE)

Family Medicine Residents

32 (10-12 full-time at any one time)

34 (12-13 at any one time)

RN(EC)s 4 (3.5 FTE ) 4 (4.0 FTE)

Dietitians 2 (1.0 FTE) 1 (0.8 FTE)

Mental Health Therapists 3 (2.6 FTE) 3 (2.4 FTE)

Clinical Pharmacists 2 (0.8 FTE) 2 (0.8 FTE)

Consultants Palliative Care, Psychiatry, Geriatrics, Internal Medicine

Starting a Diabetes Program

• Step 1: Identify your patients with diabetes– Do you currently track your patients with

diabetes (paper, EMR)?– Is your registry accurate?– What criteria did you use to create your

registry?

Step 1: Identifying Patients with Diabetes

• Lessons Learned:– Tidy up data– Team meetings to reinforce consistent data

entry (EMR), documentation– Those with confirmed diabetes enter into your

registry

How do you screen for patients with diabetes?

• Periodic health exam• Patients with other chronic diseases• Maximize screening during opportunistic

encounters• Whatever your strategy, think

sustainability

Step 2: Maximize your Interprofessional Health Team

1. Determine which practitioners are available.

2. Decide essential components for patient care.

3. Discuss your roles.

Bottom Line

“The vast majority of people don’t need glitzy miracles; we need sound, evidence-based, timely, respectful and well communicated

primary health care from a team dedicated to getting it right.”

Steven Lewis, a Saskatoon-based health policy consultant and part-time academic

Interprofessional Diabetes Team

The Need for Teamwork

• Consider:– Number of patients with diabetes– Number of visits per patient per year– Can be overwhelming to manage alone

MYTH:Stress has no effect on diabetes.

FACT:Stress can increase your blood sugar and throw your diabetes out of control. Ask for help with

stress management.

Step 3: A Diabetes Clinic (Day) Should your practice have one?

1. What resources are available to your patients with diabetes right now?

2. What Diabetes Education Clinic (DEC) services exist?

3. Do you have providers with a keen interest in diabetes management?

Diabetes Clinic Cont`d

• Who will you service?– Determined by:

• Patient needs• Skills of your team (e.g., comfort with managing

insulin)• What resources already exist within the community

Preparing for Your Diabetes Clinic

1. Referral system2. Triaging system3. Team meetings

– e.g., case review, team building

4. Debriefing

Time for Team Education

Offering a Diabetes Clinic: Equipment

• Insuiln (consider in-house supply)• Equipment

– Glucometers, one-time use lancets, ketone tests (blood and urine)

• Hypoglycemic Emergency Kit– Glucose tablets, juice boxes, injectable

glucagon, instructions about how to use kit

Offering a Diabetes Clinic: Resources

• If it exists, use it (with permission, of course)!

• Don`t forget team education, training with resources

• HHS patient education library

• www.stonechurchclinic.ca– Goal setting sheet– Diabetes Clinic Follow-Up

Visit (list of expectations, what to bring)

– Starting with Bedtime Insulin

– Diabetes Passport

Step 4: Using a Diabetes Flowsheet

• A management MUST!• Try using different flowsheets to find your

favourite• If using EMR

– Link flowsheet with disease registry and incoming labs

Step 5: Maximize Use of Templates

• For example:– Stamps for documentation (electronic or

paper)– Frequently used patient education materials

• Goal setting, action planning sheets• Hypoglycemia• Starting insulin therapy

Diabetes Group Medical Visits

• Introductory Session – (planned 20 minutes, really 60 min!)– Evolved into discussion with patients

• Patient sharing of experiences– (planned 20-30 minutes, could have been

longer)

What It Looked Like

What It Looked Like Cont’d

• ‘The Circuit’– Planned 30 min, Really 45-60 min– Stations for: vitals, foot exam, doctor check-in– Floating IHPs to do goal setting while awaiting

the circuit

• Group Wrap-Up– Planned 10 minutes, Really cut short!

How We Did It…

1) Find and prepare patients

2) Determine roles, logistics

3) Preparation!!!

4) Deliver

5) Document and Debrief

6) Plan for the next one

Finding Patients

• Identified potential patients through EMR– Assumes disease registry or some other

mechanisms to identify

• Physician vetted list

• RPN reached out to recruit

• Reminder calls day before

Preparing Patients

• Persuasive RPN – Do labs week before, bring all medications,

supplements etc., blood glucose records, 3 day food diary, glucometer, told vitals and feet would be examined, consent and confidentiality required

– Biggest Draw: extended visit with THEIR family doc!

Preparing Ourselves

• Define roles – IMPACT BC Guide

• Logistics– room set up, finding time (evening?), booking

space and equipment

Preparing Ourselves Cont`d

• Planning the Visit (many team meetings)– Presentation

• Intro, what to expect from group visit and for future care, patient sharing of experiences, goal setting

– Detailed chart review, • Prepare labs, flowsheet for physician

– (most time consuming)

What We Learned

• Minimum 15-20 patients registered

• Patient packages helped to speed up process

• Factor in preparation and documentation time

• Patients Loved this Experience!

Group Introductory Visits

• Building on prepared patient concept• Initial session offered to patients referred

to DM clinic– Introductory diabetes education– How to prepare for follow-up visits

• What to expect• What to bring

Resources

• Visit our website– www.stonechurchclinic.

ca

• Canadian Diabetes Association– www.diabetes.ca

• Dietitians of Canada – www.dietitians.ca

• Hamilton Health Sciences Patient Education Library– www.hamiltonhealthsciences

.ca

• The Diabetes Food Guide– www.centretown.chc.org

Thank you!

Slides will be available at: www.stonechurchclinic.ca

Contact Information:ischabo@mcmaster.calmccart@mcmaster.camacdonmic@hhsc.ca