This is NOT “Zach’s Diabetes Thing”

In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.

Making the Montefiore Medical GroupMaking the Montefiore Medical GroupHealth Disparities Collaborative WorkHealth Disparities Collaborative Work

at Montefiore Medical Centerat Montefiore Medical Center

The MMG HDC TeamThe MMG HDC Team

Bronx CREEDBronx CREEDSeptember 30, 2005September 30, 2005


This is NOT “Zach’s Diabetes Thing”This is NOT “Zach’s Diabetes Thing”

Coordinated effort on the part of a lot of folks. This afternoon:

• Eleanor Larrier Introduction

• Me Introduction

• Nandini Deb: Clinical Information Systems

• Jennifer Klein: Diabetes Education

• CFCC: Judy Leuchter, Peer Educators

• FHC: April Evangelista, Health Ed PDSA

• WB: Sean Misciagna, M.D., FM Resident

• Nutrition: Helen Persovsky


““We don’t just talk about reducing health We don’t just talk about reducing health disparities . . disparities . .

we reduce ‘em!”we reduce ‘em!”


So . . . So . . . how do we reduce health disparities?how do we reduce health disparities?

‘THE COLLABORATIVE MODEL”

What’s so great about that model?


OLD QI METHODOLOGYOLD QI METHODOLOGY

“Swoop and Poop”

Do everything to everyone all at once. Punish whoever doesn’t have good scores. Create simplistic and token responses to

real problems.


REAL PROBLEMREAL PROBLEM

Health care worker lack of comprehensive understanding of the dimensions of pain, pain control, addiction, emotional response to pain and end of life issues, etc.

Patients feel too much pain in the hospital, report being ignored, addicts turned away from pain treatments, etc.


THE “SOLUTION” TO THESE COMPLEX AND MULTIDIMENSIONAL, REAL

PROBLEMS:


Fix what is wrong, help clean the mess yourself.

Tests of change on small populations, then “SPREAD” to everyone - GRADUALLY

Realize that making mistakes is part of the process. Without mistakes no one learns.

Share senselessly, steal shamelessly

Collaborative Philosophy and Method


Chronic Care ModelChronic Care Model

Can be applied to all chronic conditions:• Asthma• Depression• Hypertension• Coronary Artery Disease• HIV• Diabetes• Domestic Violence• Emergency Preparedness


Six Elements of the Chronic Care ModelSix Elements of the Chronic Care Model

Medical Information Systems • the registry

• populated progress note

Self-Management (e.g., classes, health educators) Community (e.g., salsa classes) Delivery Systems Design (e.g., planned visit) Decision support (listserv guidelines) Organization of Health Care (spread to MMC)


PDSAPDSA

Plan, Do, Study, Act Disciplined, results oriented method of

group discussion. Topic tracking and adherence. Track progress. Learn from failures. Over and over and over and over again.


Collaborative Sponsorships Collaborative Sponsorships of Montefiore Medical Groupof Montefiore Medical Group

• Bureau of Primary Healthcare/National Collaborative

• New York City Department of Health: Spread Collaborative

• Academic Chronic Care Collaborative (ACCC by American Association of Medical Colleges)


What is the NationalWhat is the National Diabetes CollaborativeDiabetes Collaborative??

Made up of hundreds of health

centers from all over the country

Northeast Cluster


That’s all very special, so tell me, how That’s all very special, so tell me, how do you get collaborative stuff going?do you get collaborative stuff going?

Get blessed. • Great leaders, great support, wonderful energy, motivated people.• Where do they come from?• We pick them out.

Do something good with no money. Then write about it and present it to everyone every chance you have.

Get money. “Salvador Dali: With Gold You Get Gold.” Get going. Getting going is easy, thinking about getting

going is hard. Keep going (THE VERY HARDEST PART!)


What were goals in first year What were goals in first year for MMG HDC?for MMG HDC?

1. Identify successes of FHC.2. Spread to CHCC, CFCC and WB in

Diabetes3. Establish working teams.4. Determine key measures for all sites.5. Establish uniform/compatible data

collection system for registry.6. Identify key measures needing

improvement and begin interventions.


Goal #1Goal #1Spread to CHCC, CFCC and WB in DiabetesSpread to CHCC, CFCC and WB in Diabetes


Montefiore Medical Group Health Disparities Collaborative

FHC(DM)

CHCC(DM)

CFCC(DM)


WB(non 330)

DM

Bronx Community Health Network Sites


Goal 2.0Goal 2.0

Create centralized working group/leadership team:• Facilitate, supervise, train, develop the sites.• Coordinate allocation of resources.• Plan for future • Communicate with larger Collaborative

organizations.


Montefiore Medical Group:Montefiore Medical Group:Health Disparities CollaborativeHealth Disparities Collaborative

Senior LeadershipSenior Leadership Jon Swartz, M.D., Senior Leader Arnel Tirado, Senior Leader Victoria Gorski, Senior (Academic Leader) Jennifer Klein, Director, Health Education Nandini Deb, Information Specialist Arthur Blank, PhD Eleanor Larrier and Celia Alfalla, M.D., Bronx

Community Health Network Rita Louard, M.D., Joel Zonszein, M.D., Endocrine Clyde Schecter, M.D., Research Helen Persovsky, Nutritionist Zach Rosen, M.D., Project Director


Bronx Defeat Diabetes ProjectBronx Defeat Diabetes Project(BDDP)(BDDP)

Bronx Community Health Network (Eleanor Larrier and Celia Alfalla)• Obtained $3 M grant/3 years for community

based initiatives – Diabetes Educators, Peer Educators, Diabetes Training, Specialty Care, etc.


Goal #2.1Goal #2.1Establish working teams.Establish working teams.


MMG HDC MMG HDC Multidisciplinary Multidisciplinary

Work TeamsWork Teams

•Administrative Director

•Medical Director

•Physician Champion

•Nurse or Nurse Manager

•Diabetes Educator

•Peer Educator


Montefiore Family Health CenterMontefiore Family Health CenterThe Bronx Diabeaters: The Bronx Diabeaters:

Ibis Castro, Health Educator, MFHC

Jose Delgado, Associate Director, MFHC

Wayne Joseph, MD, Attending, MFHC

Zach Rosen, MD, Medical Director, MFHC

April Evangelista, Diabetes Educator


Williamsbridge Family Health CenterWilliamsbridge Family Health Center“The Sugarbusters”“The Sugarbusters”

• Sandra Barnaby, R.N. Staff Nurse• Noel Brown, M.D. Medical Director• Joanne Dempster, M.D. Team Leader• Blanche Doati Associate Director• Victoria Gorski, M.D. Academic Leader• Danette Ortiz Front desk

supervisor (day-to-day leader)


Medical Director Marta Rico, MD Physician Champion Chris Meserve, MD Team Leader Carol Lau, FNP, Associate Director

Team Members Carmen CintronLopez, Assistant Administrator

Joanna White, Administrative Nurse Manager Judy Leuchter, Health Education Manager

Bobbie Jamison, Health Educator

Jennifer Sanchez, PECS data entry Estelle Vargas, LCSW

Comprehensive Family Care Center Comprehensive Family Care Center (CFCC)(CFCC)


CHCC TeamCHCC Team

Joe Deluca, M.D., Team Leader and Physician Champion

Jennifer Santiago-Rivera Health Educator Donna Wade, Nurse Manager Erwin Duran, Data Entry Carmen Guerra , Nurse


Goal #3: Goal #3: Determine key measures for all sites.Determine key measures for all sites.


Goal Shared Core Measures

<8% Average HgbA1c

70% % of patients with BP< or = 130/80

70% % of patients with an LDL <100

90% % of patients who have had pneumococcal vaccine

90% % of patients with documented LEAP foot exam in the past 12 months

(90% % of patients receiving annual flu shots)

90% % patients on aspirin (or other anti-coagulant)

70% Signed self management contract in chart


Other measuresOther measures

Smoking Passive smoking (asthmatics) Nutrition Exercise . . .


Goal #4Goal #4 Establish uniform/compatible Establish uniform/compatible

data collection system - Registrydata collection system - Registry


Goal #5Goal #5Identify key measures Identify key measures needing improvementneeding improvement

and begin PDSA’s and begin PDSA’s


FHC: Percent of DM Patients with Pneumococcal Vaccine FHC: Percent of DM Patients with Pneumococcal Vaccine (10 years)(10 years)

Percent DM Patient with Pneumococcal Vaccine (10 years)

0%

20%

40%

60%

80%

100%

Perc

ent Removed patients

with no visit in one year

Latest Data as of September 1, 2005

PDSA


FOOT EXAM PDSA (s)FOOT EXAM PDSA (s)

1. From registry get print out of all charts without pneumovax.

2. Pull charts and have provider review (some charts didn’t have it recorded but had pneumovax given).

3. Put yellow stickies in charts without pneumovax.

4. Combine fluvax and pneumovax forms.5. Etc. etc. etc.


So where’s So where’s the data?the data?


DM Collaborative: Key Measures By SiteDM Collaborative: Key Measures By SiteMay 2004 – May 2005May 2004 – May 2005

Clinic

Number of

Patients with 1+ visits

% Patients with HbA1c

< 8.0

Average HbA1c for

DM Patients

% Patients with BP <=

130/80

% Patients with

LDL<100

% Patients on Aspirin

% Patients with LEAP exam (12 months)

% Patients with

Pneumoccocal vaccine

(ever)*

% Patients with Flu

Vaccine (12 months)

% Patients with Retinal Exam (12 months)

% DM Patients with SM Goal (12 months)

ACTIVE PT.

ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.ACTIVE

PT.ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.

FHC 760 60% 7.9 56% 54% 53% 60% 78% 40% 28% 33%CFCC 191 64% 7.8 47% 66% 59% 35% 54% 18% 31% 47%CHCC 273 64% 7.7 65% 57% 59% 38% 54% 35% 22% 15%WB 606 61% 8.0 46% 50% 38% 32% 69% 19% 22% 8%

TOTAL 1830 61% 7.9 53% 54% 50% 45% 69% 30% 25% 23%

70% 6.5 70% 70% 70% 90% 90% 70% 70% 70%Goal

Note: Data from FHC and WB are for patients with Pneumococcal Vaccine in the past 10 years


FHC: Number of Patients in RegistryFHC: Number of Patients in Registry

Number of Patients in Registry

0

200

400

600

800

1000

Perc

ent Removed patients

with no visit in one year



FHC: Average HbA1c for DM PatientsFHC: Average HbA1c for DM Patients

Average HbA1c for DM Patients

6.0

7.0

8.0

9.0

10.0

11.0

12.0

Perc

ent



FHC: Percent of DM Patients with One HbA1c (12 FHC: Percent of DM Patients with One HbA1c (12 months)months)

Percent DM Patients with One HbA1c (12 months)

0%

20%

40%

60%

80%

100%

Perc

ent

Removed patients with no visit in one year



FHC: Percent of DM Patients with Last HbA1c >=9.5FHC: Percent of DM Patients with Last HbA1c >=9.5

Percent DM Patients with Last HbA1c >= 9.5

0%

10%

20%

30%

40%

50%

Perc

ent



FHC: Percent of DM Patients with BP <=130/80FHC: Percent of DM Patients with BP <=130/80

Percent DM Patients with BP <= 130/80

0%

20%

40%

60%

80%

100%

Perc

ent

Data before this point represent % patients with BP < 135/85



FHC: Percent of DM Patients with LDL <100 (of DM FHC: Percent of DM Patients with LDL <100 (of DM patients with Lipid Screen)patients with Lipid Screen)

Percent DM Patients with LDL < 100 (of DM patients with Lipid Screen)

0%

20%

40%

60%

80%

100%

Perc

ent



FHC: Percent of DM patients with SM Goal (12 months)FHC: Percent of DM patients with SM Goal (12 months)

Percent DM Patients with SM Goal (12 months)

0%

20%

40%

60%

80%

100%

Perc

ent




FHC: Percent of DM Patients with Daily Aspirin UseFHC: Percent of DM Patients with Daily Aspirin Use

Percent DM Patients with Daily Aspirin Use

0%

20%

40%

60%

80%

100%

Perc

ent




FHC: Percent of DM Patients with Foot Exam (12 FHC: Percent of DM Patients with Foot Exam (12 months)months)

Percent DM Patients with Foot Exam (12 months)

0%

20%

40%

60%

80%

100%

Perc

ent




FHC: Percent of DM Patients with Retinal Exam (12 FHC: Percent of DM Patients with Retinal Exam (12 months)months)

Percent DM Patient with Retinal Exam (12 months)

0%

20%

40%

60%

80%

100%

Perc

ent




FHC: Percent of DM Patients with Microalbumin Screen FHC: Percent of DM Patients with Microalbumin Screen (12 months)(12 months)

Percent DM Patient with Microalbumin Screen (12 months)

0%

20%

40%

60%

80%

100%

Perc

ent




Moving Forward:Moving Forward:Goals for MMG HDC DiabetesGoals for MMG HDC Diabetes

ABC’s improvement. Selected Targeted Population Parameters for

MMG HDC (e.g. self-management scores) Selected Targeted Population Parameters by site

(e.g. LEAP at FHC) Incorporation of MIS into MMC CISIncorporation of MIS into MMC CIS Monte Home Care Collaboration Build on Peer and Health Educator gains.


Clinical Information SystemsClinical Information Systems

DM Collaborative Core Team:

Dr. Jon Swartz, Dr. Zach Rosen, Arthur Blank, Jennifer Klein and Nandini Deb


CIS currently used:CIS currently used:

CVDEMS

- Cardiovascular and Diabetic Electronic Management System

- Microsoft Access Based Program

PECS

- Patient Electronic Care System

- Microsoft Access Based Program



FHC CHCC CFCC WB

CVDEMSPECS

PECSCVDEMS



CVDEMS Data Capturing CVDEMS Data Capturing Process: FHC AS MODELProcess: FHC AS MODEL

Data Collection: At each visit, Nurses print out CVDEMS form with last

encounter data and demographic information of the patient

Providers update form at current visit—CVDEMS form gets into chart

EHIT generates weekly encounter list at FHC (~100/week)

Charts pulled and data entered from the CVDEMS form to CVDEMS CIS system


CVDEMS FormCVDEMS Form


CVDEMS Data Capturing Contd.CVDEMS Data Capturing Contd.

Data Monitoring Semi-annual generation of list of all patients with no visits

in the last 6 months, given to Health Educators for outreach

Annual pruning of patients with no visits in the past year (after outreach attempted)

Bi-yearly reassignment of Providers/matching Providers with patients

Data quality checks—random sample of 5% charts reviewed to assess validity, reliability and completeness of data


CVDEMS Data Capturing Contd.CVDEMS Data Capturing Contd.Bi-weekly automatic lab data transfer to CVDEMS and PECS for FHC, WB, CFCC and CHCC:

Tuesday: Program identifies all patients who had labs done in the last two weeks

Wednesday: Program dumps all labs for the identified patients

Wednesday: Lab results are sent back to the sites


Monthly ReportsMonthly Reports

Monthly report generation:

- Registry Summary Report

- Provider Report


Registry Summary ReportRegistry Summary Report


Provider ReportProvider Report


Key Measures by SiteKey Measures by Site

Clinic

Number of

Patients with 1+ visits

% Patients with HbA1c

< 8.0

Average HbA1c for

DM Patients

% Patients with BP <=

130/80

% Patients with

LDL<100

% Patients on Aspirin

% Patients with LEAP exam (12 months)

% Patients with

Pneumoccocal vaccine

(ever)*

% Patients with Flu

Vaccine (12 months)

% Patients with Retinal Exam (12 months)

% DM Patients with SM Goal (12 months)

ACTIVE PT.

ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.ACTIVE

PT.ACTIVE PT. ACTIVE PT. ACTIVE PT. ACTIVE PT.

FHC 760 60% 7.9 56% 54% 53% 60% 78% 40% 28% 33%CFCC 191 64% 7.8 47% 66% 59% 35% 54% 18% 31% 47%CHCC 273 64% 7.7 65% 57% 59% 38% 54% 35% 22% 15%WB 606 61% 8.0 46% 50% 38% 32% 69% 19% 22% 8%

TOTAL 1830 61% 7.9 53% 54% 50% 45% 69% 30% 25% 23%

70% 6.5 70% 70% 70% 90% 90% 70% 70% 70%Goal

Reporting Period: May 2004-May 2005


Our Persistent ChallengesOur Persistent Challenges CVDEMS and PECS rigidities

CVDEMS forms not completely filled out

Problems due to manual data entry

Resource constraints at the sites

System crashes—very painful!


Our SuccessesOur Successes

Structured monitoring of data

Automatic lab data transfer for all the sites

Monthly Reports for FHC, WB, CFCC and CHCC


Our Plans for the FutureOur Plans for the Future

Montefiore CIS system with Provider entry of data

Chronic Disease Management Screen—with capabilities to present the entire history of the patient.

How to use this data repository to ask research questions?


AcknowledgementsAcknowledgements

Each and everybody who has worked and currently working with the DM Collaborative

Special thanks to Jasmine Smith, Erwin Duran and Jennifer Sanchez — our data support personnel

Nadav Tanners (Having fun at Yale!)

Yan Chai — DFSM Data Manager


SELF-MANAGEMENTSELF-MANAGEMENT


Patient Self-ManagementPatient Self-Management

Patients already self manage • All patients make decisions and engage in

behaviors that affect their health.• They are in control. • They decide on what health behaviors they will

or will not engage in.


Traditional vs Collaborative CareTraditional vs Collaborative Care

Provider as expert Provider is principle

caregiver and problem solver Provider gives instructions to

be complied with Behavior is externally

motivated Provider identifies

problem Provider solves

problems

Shared expertise Shared responsibility

Patient sets goals Internal Motivation

Patient identifies the problem

Patient is taught problem solving skills


Self-Management EducationSelf-Management Education

Based on Self Efficacy Theory (Self Confidence)

Emphasizes• Problem Solving• Decision making• Confidence building

Goal Setting


What would What would youyou like to do to improve like to do to improve your health? your health?

You choos

e

Monitoring Physical Activity

MedicationsCoping Unhealthy Behaviors


Self-Management Goal SettingSelf-Management Goal Setting

My Action Plan • What• Where• When • How often

Barriers Problem Solving to overcome barriers Support needed to reach goal Confidence level


Self-Management Goals Self-Management Goals

Teaching Techniques Facilitative Participatory Collaborative

• Use of Motivational Interviewing techniques to elicit Self- Management Goals


Self-Management Support at MMGSelf-Management Support at MMG

Educational Classes Group Medical visits Support groups Walking club Individual Sessions Cooking Classes

Waiting Room Talks Phone Contacts Salsa Classes Peers Support Community

involvement


Montefiore Comprehensive Family Care Montefiore Comprehensive Family Care Center – Bronx Community Health Network Center – Bronx Community Health Network

(MMG-CFCC/ BCHN)(MMG-CFCC/ BCHN)

1621 Eastchester Road

Bronx, New York 10461


Montefiore Medical Group Montefiore Medical Group Comprehensive Family Care CenterComprehensive Family Care Center

About Us 75,000 visits / year Internal Medicine, Pediatrics, &

ObGyn Residency Programs 60 atttending MDs 102 (48 IM, 31 Peds, 28

ObG)Residents Nurse practitioners, midwives Numerous other providers Total users 2004 – 18,682 Of those 1042 (5.6%) are patients

w/Diabetes mellitus

Demographics Black/African-American 30% Hispanic/Latino 46% White (not H/L) 12% Unknown/unreported 11% Asian/Pacific Islander 1% Native Am/Alaskan Native .02%

Languages English Spanish


AIMAIM

AIM: Montefiore Medical Group – CFCC will redesign our care delivery system to maximize the health and quality of life for our patients with Diabetes mellitus, by assuring that they receive effective, evidence-based services, using a coordinated care plan.

We will achieve this by implementing a comprehensive approach, using the components of the Chronic Care Model


Self Management, Self Management, highlightshighlights

GROUP LEARNING Group Educational Series: English and Spanish Team presentation of learning sessions (Health Educator, Residents,

Physician, Social worker and Nutritionist). Collaborative, interactive format Alumni lunches held once a month to re-visit self-management , education

and problem solving issues

GROUP ACTIVITES Walking club twice a week, open to all CFCC patients Birthday Lunch Breakfast Club: pilot


Self Management, cont.Self Management, cont.

INDIVIDUALIZED GOALS Individualized sessions at the end group to define self-management goals. Individual mini-sessions prior to provider visits consisting of diabetes education,

nutritional counseling, and self-management goal setting. Individualized sessions with nutritionist.

PEER SUPPORT CFCC patients with diabetes trained as Peer Educators for Bronx Defeat Diabetes

Project. We have 4 peer educators. Participation in all group activities. Waiting room contacts with ADA risk assessments completed. Development of peer patient panels to encourage compliance and supply support.

Ongoing training in 1-1 diabetes management education. Outreach activities within the health center and into the community.


Montefiore Family Health CenterMontefiore Family Health Center

360 East 193rd Street

Bronx, New York 10458


Montefiore Medical Group Family Montefiore Medical Group Family Health CenterHealth Center

About Us 45,000 visits / year Family Medicine Residency Program 18 Providers 16 Residents # Diabetic patients: 755

Primary Insurance Medicaid 39% Self Pay 29% Medicare BC/BS Empire 13% Bronx Health Plan GHI

Demographics Black/African-American 30% Hispanic/Latino 41% White (not H/L) 13% Unknown/unreported 8% Asian/Pacific Islander 7% Native Am/Alaskan Native .02%

Languages English 56.70% Spanish 36.20% Cambodian 5.30% Vietnamese 1.30% Other 0.40%


Self Management HighlightSelf Management HighlightDiabetic referrals via Walkie TalkieDiabetic referrals via Walkie Talkie

GOAL: Coordinate efforts with 2nd and 3rd floor PCTs, Health Educators and Nutritionist to increase percentage of self-management goals set at FHC.

ACTION: Individual health educator or nutritionist counseling sessions with diabetic patients pre/post provider visit.

PROCEDURE: Use walkie-talkie between central locations: PCTs call health educator or nutritionist through walkie talkie once a diabetic is prepped. While waiting for the provider patient is then seen by the health educator or nutritionist in the exam room.

RESULT: SUCCESS 8% increase in the percentage of self-management goals set from July until August at FHC.


Resident Collaborative InvolvementResident Collaborative Involvement

Thinking outside the box to improve community oriented primary care of chronic disease

Identifying community resources• Care doesn’t just happen inside the clinic• Better understanding of pt’s social context• Contributing to the community and the bouquet

of services that already exist Looking to the future


NutritionNutrition


Ways I Work With PatientsWays I Work With Patients

One to One sessions Group sessions Setting self-management goals Community Outreach


Teaching MethodsTeaching Methods

Food models Visuals Power points Food demonstrations


ChallengesChallenges

Scheduling follow-ups Show up rates Reminder calls Follow up on self-management goals


SuccessesSuccesses

Cooking classes Changes on patients HgA1C Outreach lectures

This is NOT “Zach’s Diabetes Thing”

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