NovaHealth Diabetes Task Force
William R. Ervin, MD, Chair, Diabetologist
John Erickson, MD, Chair Member, Quality Improvement Committee
Nate Wilson, MD
Merle Westbrook, NP
Laurie Laliberte, PA
Libby Collet, NovaHealth Executive Director
Heather Cabading, NovaHealth Professional Relations Representative
Vicky Lyons, COO, Participating Provider Group
Erinn Crane, Summer Intern

Pinnacle Development
Pamela Kick – President
Bobbie Manson – Analyst and software engineer
John Ustach – Project Manager
Heather Cabading, NovaHealth Professional Relations Representative

To increase the percentage of patients with diabetes at goal for HbA1c, blood pressure, and LDL by January 2005.

Percent of Patients with Diabetes with:

• HbA1c less than 7
• Blood pressure less than 130/80
• LDL less than 100

• IPA Board (based in part upon recommendation from IOM Quality Chasm Report) adopted diabetes project as a key strategic initiative for the IPA and its participating provider organizations.
• Established Diabetes Task Force (DTF) with physician, mid-level, and practice management participation.  DTF defined goals, reviewed registry options.
• Budgeted financial resources and physician leadership time to support implementing the program and ongoing expansion.
• Established initial goals.
• Piloted CVDEMS in one practice with 400 patients with diabetes.
• Electronically imported patient data (generated from practice system) into registry and reviewed patient lists for accuracy (deleted if not diabetic, transferred or died).
• Selected Pinnacle to develop registry.
• Designed Touch Every Life (“TEL”)  Registry:
  • Developed TEL reporting tools to identify needs of population.
  • Developed TEL reports to provide actionable feedback to care team.
  • Imbedded evidence-based guidelines into TEL Progress Note.   
  • Developed patient trend charts and guideline information for second page.
• Established workflow.
• Implemented electronic importation of lab results from two member labs.
• DTF adopted clinical protocols.
• DTF adopted standing orders.
• Engaged communications consultant to develop visible communication strategy to engage staff and increase energy around the initiative.
• Generated and delivered reports monthly, providing performance measures / feedback on the physician, site, practice level, and IPA level.
• Presented key measurements monthly to IPA, practice and site leadership.
• Adopted self-management tool.
• Developed comprehensive patient education materials (adopted by DTF) after extensive review of resources.
• Invested in high speed color printers for large sites to increase energy around project and to improve office operations in printing TEL flow sheet and patient information sheet with color charts.
• Enhanced TEL (e.g., to track ADEF participation, to facilitate E & M coding documentation, to separate pre-diabetes from reporting, to track use of risk assessment tool, to report by NP/PA, multiple ease of use enhancements).
• Adopted Yale Guidelines among other decision support tools.
• Utilized interactive provider education methods to spread project.
• Integrated with specialists throughout project (cardiology, nephrology, diabetology, and dietician).
• Established strong community linkage with local ADEF program and increased visibility of resources available through meetings and trainings and involvement in project.
• Developed, implemented, and measured spread of team care concept.
• Integrated TEL flow sheet, data update, and reporting into daily workflow.
• Established role definition and accountability within practice sites.
• Trained mid-level providers in diabetes care, Chronic Care Model, and self-management support.
• Conducted physician education program with emphasis on aspects of the Chronic Care Model, including the importance of self-management goals and our team care approach to diabetes.  Also provided clinical update of diabetes care presented by specialists noted above.
• Continually involved staff in outlining systems of improving use of TEL and workflow.
• Developed scorecard to report results and generate constructive competition among physicians relative to process and outcome measures.

The Touch Every Life (TEL) Registry and implementation of the diabetes team care concept has resulted in statistically significant improvement in the percent of the population achieving evidence-based blood pressure and LDL targets.  The data show no significant change in the HbA1c levels yet.  All three process measures have improved, but further progress is needed to meet all outcome goals by January 2005.

• Integrate use of a registry into your workflow.  TEL is the backbone to and starting point for population improvement, proactive care, and actionable feedback.
• Choose talented technical advisors.  Pinnacle’s understanding of the project and ability to listen to our needs was hugely important to the implementation of a user friendly system to improve care and continued enhancements.
• Pilot with well-respected, representative physicians.  Two physicians piloted the approach and were able to provide crucial physician leadership needed to facilitate implementation with all PCPs across the IPA.  One was computer literate; the other was not and was not quick to grasp the value of improvement or change.  The slower to change physician is the greatest and most effective advocate of the project today.
• Educate, educate, educate.  The Chronic Care Model needs to be explained and illustrated repeatedly to be fully understood by practitioners trained prior to 2000. 
• Create energy.  We involved communications experts to develop internal “Touch Every Life” and external “It’s My Life” themes for involving all staff in efforts to partner with patients to improve diabetes care.
• Involve staff in the design of the registry and systems.  Involvement of the front line and representation from all areas involved is crucial to successful implementation.
• Give it time.  Everything takes longer to implement than you anticipate, but eventually you get there and even move on.