AMGA and Pfizer Inc. present the Models of Excellence Collaborative on Patient Adherence and Health Literacy

Olmsted Medical Center, Rochester, MN
Diabetes - Chronic Care Model

EXECUTIVE SUMMARY: Diabetes is a common disease that requires significant collaborative management and self care. Adherence to physician designed programs is usually moderate to poor and many patients have limited understanding of the potential for preventing diabetes related complications. Selection of goals aligned with patient preferences based on increased patient literacy about prevention of diabetes complications could improve patient and physician satisfaction with diabetes collaborative care.

Shared decision making and the mutual selection of care goals has been shown to improve management of other chronic diseases such as asthma, hypertension and coronary artery disease. Mutually understood and agreed upon goals assure that patients and families collaborate in the care processes and understand the potential impact of achieving the selected goals. However, developing mutual goals is not a skill taught to or understood by many health professionals or patients. This program is designed to address improved health literacy and adherence by teaching patients and physicians how to determine the course and desired outcomes of therapy.

This organization is well suited to this type of work. In addition to a previously developed diabetes registry, commitment to a large scale QI system-wide effort and collaboration on a past AMGA diabetes management project, we have used this application as an opportunity to develop a team of clinical champions, QI experts, and evaluation experts with the desire to use new methods to address barriers to better diabetes management.

Community, patient, and clinician focus groups will be used to explore barriers to diabetes management in our practice. Using this information and information from other shared decision making, motivational interviewing and mutual goal setting programs, we will develop a curriculum for our staff as well as one for community members and patients with diabetes. The curriculum will focus on the first steps needed to engage clinicians and patients in a discussion of the goals of care and the ability to choose a specific goal in one area (i.e. diet, exercise, eye exams).. In addition, the community and patient curriculum will present basic information related to prevention of diabetes complications.

Following the educational sessions, health care professionals will be expected to use the acquired skills in care of patients with diabetes. The progress of incorporating theskills into practice will be monitored by patient and health care professional surveys and follow-up with patients who say they have set goals to assess their success and desire to develop future goals.

PROJECT PLAN: The project will be accomplished using a series of steps that are presented in diagram form in the Appendix. The first step has already occurred during the grant development, design and writing process, that is, development of a core senior leadership team. During the preliminary work the team has established mutually agreed upon aims, general methods and anticipated outcomes. This process has facilitated development of a long term chronic care QI strategy.

Next, it will be necessary to secure the cooperation of the health care professionals who deal with the care of diabetic patients on a daily basis. This step will begin by using a series of focus groups designed to elicit perceived barriers and frustrations related to diabetes management and patient outcomes. Focus groups will be organized primarily by department and will include receptionists, nursing personnel and physicians. Diabetic educators, laboratory personnel and IT staff will be included in meetings of other departments since diabetes care is a multidisciplinary process. An experienced qualitative researcher with significant work in diabetes care will lead the discussion groups. From previous similar focus group discussions related to chronic care, it is anticipated that issues surrounding adherence and limited patient health literacy will arise quickly. The group leader will direct the discussion to expand upon these issues.

Similar patient and community focus groups will be held to develop the same type of information from the patient, family and community perspectives. The community participants will be identified through the organization’s patient diabetes registry, specific invitations to community leaders and media announcements. At least 4 community focus groups will be planned.

Using the information from the focus groups, the leadership team will spend 3 days working with an outside consultant with expertise in mutual goal setting and motivational interviewing. The chair of the organization’s department of psychiatry (also an organization broad member), one of the organization’s certified diabetic educators with experience in motivational interviewing, a nursing service supervisor and the director of the organization’s foundation will also participate in these sessions. The purpose of the 3-day consultation is to develop an educational curriculum outline for patients and for the organization’s staff. The mutual goal setting curriculum will be based on a program designed for asthma management and will use other information from the medical literature related to motivational interviewing. Case scenarios will be designed that address concerns raised in the focus groups. The scenarios will be used to stimulate discussion and as the basis for a video that models mutual goal setting negotiation in a situation requiring reevaluation by both the patient and the clinician.

Following development of the curriculum the two senior clinical leaders will facilitate the presentation of the educational program in their clinical departments. It is anticipated that the sessions will require two 1-hour lunch meetings and include a video, discussion, didactic material and role-playing scenarios.

Parallel to the educational session for the organization’s staff, community education programs will be offered. The programs will be announced to all persons on the organization’s diabetes registry and through local media. The presentations will address the curriculum developed and will include an overview of diabetes and opportunities to prevent adverse outcomes from diabetes. The second portion of the meeting will discuss goal setting and allow attendees to begin the process of developing their personal goals. Role playing with spouses or family members and health care clinicians will be used to model the processes. At the close of the meeting, all attendees will be encouraged to share their thoughts and initial goals with their doctors, nurses or diabetes educators at a visit in the next month. The organization’s advanced access system should assure the availability of timely appointments for attendees.

Surveys and medical record reviews will be used to assess the impact of the process on patient and clinician satisfaction including short term outcomes such as setting a goal and monitoring progress on at least one goal. The evaluation plan is discussed in more detail in section 5E.

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