American Nurses Association National Database of Nursing Quality Indicators (NDNQI) Conference

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Change in Diabetes Outcomes as a Result of Self-Management Support by Health

Coaches in Mercy Clinics

American Nurses Association National Database of Nursing Quality Indicators (NDNQI)

Conference February 1, 2008, Orlando, FLA

Del Konopka, RN, MS, Clinics’ Education Coordinator

Kelly Taylor, RN, MSN, CCM, Clinics’ Director for Quality Improvement

Sharon Phillips, RN, Chief Operating Officer

www.mercyclinicsdesmoines.org

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Mercy Clinics, Inc. (MCI)

• Des Moines, IA & suburbs• 40 Clinics• 145 Physicians

– 70% Primary Care

• 877,808 Patient visits in FY07• 100% Fee-for-service

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Learning Objectives

• Recognize the Health Coaches’ role in patient self-management support in primary care clinics.

• Identify data capabilities of a disease registry in improving chronic disease management outcomes.

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Purpose• We set out to improve the health status of our

clinic patients with diabetes by providing consistent and proactive treatment using the standards of care recommended by the ADA.

• To do this, we redesigned the clinic system and added a measurement tool.

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How This is Relevant

We are able to show how we: • Quantified nursing care to change chronic

disease outcomes. • Built a business case.• Used data to have a voice within the health care

and insurance community.

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Triggers• The book by the Institute of Medicine Crossing

the Quality Chasm.• Problems to explore:

– How to measure our performance on diabetes care at the clinic level. We knew we gave good care, but measures had not been in place to quantify this.

– How to improve the level of care, based on the data, the following year.

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Health Coaches

• Nursing Staff– Key in making delivery system redesign work

• Decision Support for the Staff– Practice Guidelines for Diabetes– Standing Orders– Disease Registry

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Health Coaches

• Mercy Clinics have 16 full time Health Coaches– Four clinics have 2 Health Coaches

• New clinic staff role– Started as RN, CMA, LPN, receptionist– Were mostly data oriented– Now new Health Coaches must be RNs – Now more clinically oriented

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Health Coaches’ Job Description• Facilitate planned care visits for patients.• Maintain the disease registry.• Conduct pre-visit chart reviews to evaluate

& ensure patients are current within standards of care.

• Work with patients & families on Self-Management Support using a behavioral

change approach.

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Coaches Plan the Visit

• Review the charts of patients before they are seen for– Chronic disease standards of care – Preventive health care – Immunizations

• More effective than doctor reviewing chart

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Process• Labs and referrals are done before the patients

are seen – (based on standing orders)– Frees up doctor’s time

• Health Coaches enter data in the registry to track– Diagnoses– Appointments– Lab Tests– Process and Outcome Goals

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Coaches Oversee the Registry

• Contact patients overdue for visits or not meeting goals (opportunities list)– 90% of patients respond positively

• In the past, only 70% of patients with diabetes came in for a visit within one year, now 95% come in yearly

• Review performance reports

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Self-Management Support

• Health Behavior Change– 5A’s: Assess, Advise, Agree, Assist, Arrange

• Medication Adherence– Only 40% of MCI patients are highly adherent – Major area for health behavior change

• Didactic Patient Education– Provided or arranged by Health Coaches

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Measurement

• Measures chosen to quantify care for 9054 patients with diabetes– Hemoglobin A1c– Blood pressure – Lipids– Urine microalbumin results

• Descriptive statistical analyses were used.

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Process & Outcome Measures 10/05 – 12/07

• Compared to National Quality Forum – National benchmark for performance, created by

leaders in quality. Focus is on outcomes as well as processes: How to get there.

• We passed the 90th percentile benchmarks for diabetes performance.

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National Quality Forum Diabetes Measures: Jan.- Dec. 2007

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

HgA1c in 1year

HgA1c > 9 ornot done (low

is better)

LDL in lastyear

LDL < 130 LDL < 100 Urine ProteinScreen

Eye Exam

MCI 2007 % at Goal NQF 2006 90% n = 1,430 P4P Patients with Diabetes

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Process Performance Report

ALL Diabetes Data: 11/1/06-10/31/07

Provider Brown Goal

Total Patients 154Diabetes Process Goals:

HgAlc last 12 mo. 95% 94%

LDL last 12 mo. 95% 94%

Microalb last 12 mo. 85% 90%

Eye Exam last 12 mo. 44% 70%

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Outcome Goals Attainment Report

Diabetes Outcome Goals: 11/1/06-10/31/07

Brown Goal

% HgAlc < 8.0 85% 75%

% HgAlc < 7.0 67% 50%

% LDL < 130 66% 75%

% BP < 140/80 67% 75%

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Surpassing Goals Since 2003

System Level Diabetes Outcomes% HgAlc < 8.0

50%

60%

70%

80%

90%

100%

All Diabetes Goal

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Whole Clinic Report

Care Measures Performance Reports

South Clinic Oct 2007

WELLMARK HTN Data: 11/1/06-10/31/07

Whole Clinic Goal

Total Patients 956

Outcome goal: % BP < 140/90 76% 75%

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What the Data Showed

• Monthly, transparent reporting of processes & outcomes to physicians & clinics revealed the status of their own diabetic patient population.

• This allowed Mercy Clinics to:– Compare results for the clinics– Identify trends– Identify progress in disease management.

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Implications for Practice

• We were concerned patients might resist more frequent office visits & lab tests, but they appreciated the extra support in meeting their self-identified goals.

• Easy point of contact for patients.• “A gallon of milk in a day” story of a patient

new to diabetes.

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Significance• The system redesign involved coordination of

all the team members to ensure efficient, thorough, patient-centered care.

• When processes were retooled, diabetes outcome measures significantly surpassed the NQF measures for quality of care over one

year.

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Benefits from Having Coaches• Improved quality and patient outcomes• Patient satisfaction• Moved practices from reactive to proactive• Increased ancillary revenue

– DEXA, lipids, Pap tests, mammograms, immunizations– Supported the business case.

• They partner with patients to optimally manage diabetes.

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Revenue Comments

EM visit & lab differential $76,879

Level 1 visits $45,025

Offset Dr. & Nurse work $15,183 probably low estimate

P4P Wellmark - 2006 paid $114,000

CMS PQRI (potential) $14,000

Total Revenue $265,087

Expenses

Coach Salary RN II $36,728 0.7 FTE & benefits

Coach Salary LPN $36,434 0.9 FTE & benefits

Differential Microalbumin cost $9,932

Differential HgA1c cost $4,763

Total Expenses $87,857

Contribution to Overhead $177,230

Business Case: Mercy North Coaches

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Coaches are Change Agents• Trained to use Plan-Do-Study-Act cycles• Time dedicated to proactive QI• Leading their clinics in improvement

collaboratives:– Iowa Academy of Family Practice– Wellmark– American Medical Group Association

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Next Steps

• AEHR – process standardization • Expansion to all chronic diseases &

preventive health care• Mine the registry data on our 20,000 patients• Expanded Self-Management Support• Improvements in patient satisfaction• Never ending improvement processes

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Recognition• Wellmark grant awarded to provide

depression screening in the clinics.• Recognition by NCQA & AMGA• Thanks to our physician champion,

David Swieskowski, MD, MBA, Vice President for Quality.

• Our gratitude to: The Health Coaches for all their great work.

Our patients for the privilege of serving them.