Patient Self-Management: in Primary Care Team SPANK: St Peter Aims for New Knowledge

1. Patient Self-Management:in Primary CareTeam SPANK: St Peter Aims for New Knowledge March 9, 2004 Devin Sawyer, MD Joseph Wall, MHA Shari Gioimo, MA Janet Wolfram, CDE

2. We are… • A Residency Program- Full Scope FM • 37,000 patient visits a year • Residents & UW med students- 6 per year • Aprox. 300 diabetics • Participated in WSDC II and RWJ grant • Getting better at a TEAM APPROACH to chronic care and patient Self-Management

3. What we have done lately… • WA Diabetes Collaborative, 2000-2001 • Focused on Patient Self-Management • The role of each player: providers, medical assistants, administrative support, patients, and mentors • RWJ funding for Advancing Diabetes Self-Management ($300,000)

4. What is Self-Management?… • Checking blood sugars • Taking meds (pills and shots) • Eating right (CDE, doctor, other diabetics) • Exercising (30 mins/day, 150 mins/week) • Checking feet • Making appointments (PCP, eye doc, CDE) What is missing?

5. 24/7/365 • “The patients right and responsibility to make decisions that make sense within the contextof their lives” • “Education and support refocused on helping patients make & achieve goals and outcomes that they themselves have selected” • “Must acknowledge and support the patients role as the key decision maker in self-management” • Patient role? Provider role? Staff role? Others?

6. The NPR news report on ‘effective diabetes care’ in 2003N Engl J Med, 2003; 348,5:383-459 (Steno-2 study in Copenhagen) • An Experienced TEAM • Motivated • Enthusiastic • With a Gung Ho attitude

7. Our program… • MA Planned Visits with goal setting • Provider Visits with emphasis on patient goal setting • Medical Group Visits • Registry to support patient care (CDEMS) • Exercise opportunities • Patient Mentoring (buddy system) • Newsletter

8. CDEMS: Our Run Charts

9. CDEMS: Our Run Charts

10. What it has taken to get us here… • MA training (Boldt Center) • Provider training (faculty development, and resident workshops and precepting - BBSWAR) • Patient education • Practical description of self-management: an SMG cycles (new way of thinking for our clinic)

12. How do we teach this to the MA’s? • A new curriculum for the MA’s (A new service for diabetes educators?) • Skills in-service; foot checks, CDEMS, planned visits, phone skills, group visits (Camp SPANK) • Shadowing • On the job training

13. MA planned visits:(see standing orders) • They follow the standing orders • Introduce SMG • Occur 1 week before provider visit • 90% of our MA’s perform planned visits • This frees up some of the provider time

14. How do we do and teach this to the providers? Big Bad Sugar WAR

15. The 15 minute encounter: A toolBig Bad Sugar W.A.R. • Background • Barriers • Successes • Willingness to change • Action plan • Reinforcement

16. An Action Plan: • Something the patient comes up with and WANTS to do • Should be REASONABLE • Behavior specific • Should answer the questions: • What? • How much? • When? • How often? • Confidence level (likelihood-of-success) 1-10

17. Patient Goal Quality • Evaluate, record, and track patient SMG quality • 1 point for activity (what- i.e.: briskly walk, or stop skipping breakfast) • 1 point for location (where- i.e: around Capital Lake, or at home and at the office) • 1 point for frequency (how often- i.e: M,W,F, or 5 days a week) • 1 point for time/duration (how long- i.e.: for 45 minutes at 7:00 am, or 8 am before I leave for work) • 1 point for LOS score (from 1 to 10)

19. SMG quality over time:

20. The Group Visit

21. The Group Visit • Developing patient oriented self-management curriculum • More providers (faculty), more staff being trained • More patients coming • Now an educational expectation for residents • High patient satisfaction • Outcomes in 2001: • HbA1C of our practice: 7.7 • HbA1C of those who come to DGV: 6.3

22. Patient Data Registry(CDEMS) • Free from the DOH, developed locally • MA’s do data entry and us for patient outreach • PCP’s use patient report with the patient visit • PCP/MA team can query their data to target care (outliers), for patient recall, and for patient goal reinforcement

23. Exercise Opportunities • Walking Club • Pedometer Program • “SPFP Moves With You” Video

24. Walking Club

25. Pedometer Program

26. “SPFP Moves With You”… The Video

27. Patient Mentoring (buddy system) • Patients are supporting Patients • One patient calls another about 2 months after the provider visit to “check-in” with their SMG • Sent a card with a patient’s information • Provides additional support and accountability • Bridges the gap between the planned/provider visit and the beginning of the next cycle

28. What is next? Spread… • Graduate trained providers • More grant money- Phase II • In-service local providers- Elma • Provide training to local MA’s • A role in the STEPS grant

29. Contact Info… • Devin Sawyer, MD- devin.sawyer@providence.org • Joseph Wall, MHA- (360)493-4001 joseph.wall@providence.org • Shari Gioimo, Medical Assistant- shari.gioimo@providence.org • Janet Wolfram, Diabetes Educator janet.wolfram@providence.org