In response to the Montefiore Quality Council, this information is provided u nder Section 2805-m of the New York Public Health Law. Making the Montefiore Medical Making the Montefiore Medical Group Group Health Disparities Health Disparities Collaborative Work Collaborative Work at Montefiore Medical Center at Montefiore Medical Center The MMG HDC Team The MMG HDC Team Bronx CREED Bronx CREED September 30, 2005 September 30, 2005
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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
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
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““We don’t just talk about reducing health We don’t just talk about reducing health disparities . . disparities . .
we reduce ‘em!”we reduce ‘em!”
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So . . . So . . . how do we reduce health disparities?how do we reduce health disparities?
‘THE COLLABORATIVE MODEL”
What’s so great about that model?
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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.
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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.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
THE “SOLUTION” TO THESE COMPLEX AND MULTIDIMENSIONAL, REAL
PROBLEMS:
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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
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Chronic Care ModelChronic Care Model
Can be applied to all chronic conditions:• Asthma• Depression• Hypertension• Coronary Artery Disease• HIV• Diabetes• Domestic Violence• Emergency Preparedness
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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)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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.
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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)
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
What is the NationalWhat is the National Diabetes CollaborativeDiabetes Collaborative??
Made up of hundreds of health
centers from all over the country
Northeast Cluster
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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!)
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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.
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Goal #1Goal #1Spread to CHCC, CFCC and WB in DiabetesSpread to CHCC, CFCC and WB in Diabetes
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Montefiore Medical Group Health Disparities Collaborative
FHC(DM)
CHCC(DM)
CFCC(DM)
Montefiore Medical Group Health Disparities Collaborative
WB(non 330)
DM
Bronx Community Health Network Sites
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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.
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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
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Note: Data from FHC and WB are for patients with Pneumococcal Vaccine in the past 10 years
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
Removed patients with no visit in one year
Latest Data as of September 1, 2005
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Clinical Information SystemsClinical Information Systems
DM Collaborative Core Team:
Dr. Jon Swartz, Dr. Zach Rosen, Arthur Blank, Jennifer Klein and Nandini Deb
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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
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Montefiore Medical Group Health Disparities Collaborative
FHC CHCC CFCC WB
CVDEMSPECS
PECSCVDEMS
Montefiore Medical Group Health Disparities Collaborative
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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
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CVDEMS FormCVDEMS Form
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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
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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
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Monthly ReportsMonthly Reports
Monthly report generation:
- Registry Summary Report
- Provider Report
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Registry Summary ReportRegistry Summary Report
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Provider ReportProvider Report
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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
• Use of Motivational Interviewing techniques to elicit Self- Management Goals
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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
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
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
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Montefiore Medical Group Montefiore Medical Group Comprehensive Family Care CenterComprehensive Family Care Center
About Us 75,000 visits / year Internal Medicine, Pediatrics, &
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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
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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
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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.
In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the New York Public Health Law.
Montefiore Family Health CenterMontefiore Family Health Center
360 East 193rd Street
Bronx, New York 10458
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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
Languages English 56.70% Spanish 36.20% Cambodian 5.30% Vietnamese 1.30% Other 0.40%
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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.
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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
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NutritionNutrition
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Ways I Work With PatientsWays I Work With Patients
One to One sessions Group sessions Setting self-management goals Community Outreach
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Teaching MethodsTeaching Methods
Food models Visuals Power points Food demonstrations
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ChallengesChallenges
Scheduling follow-ups Show up rates Reminder calls Follow up on self-management goals
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SuccessesSuccesses
Cooking classes Changes on patients HgA1C Outreach lectures