There are approximately 8,000 patients with diabetes at the Northport (N.Y.) VA Medical Center (VAMC). Diabetes is treated with diet and lifestyle changes such as exercise and weight control. It may also require medications, such as oral medications or insulin. If blood glucose levels are maintained at the recommended range, the risk of many complications from diabetes decreases. Improving diabetes care also results in decreased morbidity and mortality, greater patient satisfaction, and lower healthcare costs.
Learning from the past
Let's travel back in time to 2008, where we'll follow a veteran through a visit to his primary care provider (PCP). He arrived at the scheduled appointment and was greeted by the medical administrative support assistant. He was then seen by a member of the nursing staff. Depending on the time constraints, a discussion of medications and diet occurred, with the goal of providing the veteran with education on all aspects of diabetes care. The veteran was then sent back to the waiting room to wait his turn to be called by the PCP.
When he was finally seen by the PCP, the finger stick reports were reviewed. Diet and medications were discussed. If the veteran required any consults, they were entered electronically at this visit. Consults for a veteran with diabetes may include any of the following: ophthalmology/optometry, podiatry, nutrition, psychology, exercise physiology, endocrinology, and a visit with the certified diabetes nurse educator. The veteran would then need to return to the VA for as many as seven additional consult visits, which required him to make a total of eight trips over a 3-month period, costing him a $50 copay for each of the specialty visits. In addition, if the veteran was employed, he needed to miss 8 days of work, unless they were able to coordinate some of the specialty visits for the same day.
Due to the fact that the veteran had to make so many trips to the VA, he often didn't show up for consult specialty appointments, which are crucial for the comprehensive medical management of diabetes. Another identified barrier was disconnect due to the length of time required to obtain consult appointments.
Formulating a plan
Northport's war on diabetes began with the PCP and performance improvement staff looking for ways to improve diabetes outcomes through education and the coordination of care. After months of meetings that focused on best practices and discussion of literature reviews, a multidisciplinary team was created in February 2009, named the Diabetic Performance Improvement Team (DPIT). The goal of the team was to improve veteran outcomes through education and multidisciplinary management of diabetes.
The DPIT consists of an endocrinologist, PCP, optometrist or ophthalmologist, certified diabetes nurse educator, nurse leader of primary care, veteran health education coordinator, psychologist, registered dietitian, care coordinator (Telehealth), medical librarian, My HealtheVet coordinator, performance improvement specialist, health system specialist, and clinic manager. The integrated team includes all healthcare providers the veteran is required to see.
The team was charged with the task of finding out what makes treating diabetes so difficult at the VA. Problem areas identified were patient-centered regarding obesity, poor diet, lack of exercise, psychological factors, lack of medication compliance, and poor understanding of medication administration times. The team established the Diabetes Wellness Clinic with the goal of providing “one-stop” diabetes care to veterans.
The clinic provides:
* medical review of systems and intervention if necessary by a PCP
* retinal eye exams
* foot exams
* endocrinology consults
* general diabetes and medication education
* pharmacy services
* psychology services
* access to enroll in My HealtheVet, Telehealth, and MOVE (the VA's weight management program for veterans)
* information on how to navigate the Internet to find trusted and credible websites.
Weekly team meetings discussed how the clinic would operate, the types of educational materials to provide, the copay amount, and documentation of the newly established clinic visit. All of the medical centers within the Department of Veterans Affairs have a computerized patient record system (CPRS); therefore, “note titles” were created to direct the readers to the Diabetes Wellness Clinic visit. The management service officer of ambulatory care and the clinical applications coordinator were responsible for creating this new note title in the CPRS.
The PCP was provided with educational sessions held by the endocrinologist and certified diabetes nurse educator. These sessions helped alleviate uncertainties regarding the adjustment of medications and/or starting the veteran on insulin, if needed. A review of the diabetes performance measures was held with providers during staff meetings to foster an awareness of diabetes management between specialty clinic and other support services.
Over 400 letters were sent inviting veterans to attend the first Diabetes Wellness Clinic. The veterans invited to participate were selected based on their poor diabetes control, as evidenced by an HgbA1c greater than 9, or because they required an annual eye exam. The letter instructed the veterans to call for an appointment. One week before the clinic opening, a chart review was performed by the PCPs, NP, and RNs on the team. Charts were reviewed to determine if the veteran needed:
* a dilated retinal eye exam
* medication adjustment
* starting insulin
* a foot exam
* dual care status established
* an HgbA1c level
* a psychology consult.
This allowed the team to be prepared for the veteran, making for an efficient visit. It was decided that all participants would visit a nutritionist, an exercise physiologist, RNs for medication education, other nursing staff for foot exams and retinal dilation, Telehealth, My HealtheVet, and the medical librarian.
Implementing the solution
On April 29, 2009, the first Diabetes Wellness Clinic was held with 27 veterans in attendance. Veterans' appointment lengths were approximately 1.5 hours, and each veteran received a “passport” type document that designated the clinic stops they were required to visit. Upon checking in, the veterans were given a self-assessment tool to determine their diabetes knowledge base, as well as to identify the potential need for health behavior modification.
After completing the tool, each veteran was given a folder that included the date of their last foot exam, eye exam, HgbA1c level, and low-density lipoprotein (LDL) cholesterol level; the dual care policy; and diabetes educational materials, such as the When to Go to the ER booklet; the Warning Signs of a Heart Attack and Stroke booklet; a wallet card to record HgbA1c and LDL levels; and a Diabetes Information Resources booklet. They then proceeded through the different stations and each provider initialed the passport after his or her station was completed.
After the veterans visited all the stations, they were asked to complete a satisfaction survey, which included a comment section. A total of 27 surveys were received and the results showed that 27 patients found the Diabetes Wellness Program Clinic helpful.
The VAMCs use performance measures to improve the quality and annual performance of healthcare for veterans with diabetes. The seven performance measures are LDL measure performed, annual HgbA1c level performed, BP less than 140/90, annual renal testing performed, LDL less than 100, HgbA1c less than 9, and annual retinal eye exam performed (see Performance measures).
To date, there have been 12 Northport Diabetes Wellness Clinics waging the war against diabetes, with a total of 268 veterans attending. These clinic sessions are held quarterly. Below are some lessons learned from the first event:
* Have staff from the DPIT fill out the passport document and a handout of the performance measure results the day before the clinic.
* Appoint a hall monitor to guide the flow of veterans from one station to the next.
* Make sure each veteran stops by the front desk on his or her way out to complete the exit survey and receive any future appointments and/or consults.
* If the veteran was newly started on insulin, make sure he or she received necessary supplies before leaving the VA.
* Schedule veterans to account for no-shows and walk-ins.
We implemented these plans in subsequent clinics and found other areas in which we still needed to make improvements. One challenge was that some DPIT members had down time at the start of the clinic and were rushed at the end. We also changed the nutrition and exercise stations to a group setting instead of a 1:1 approach.
In later clinics, we moved the nutrition station to the first stop for a 20-minute session. Future clinics will have the veteran health education coordinator, care coordinator (Telehealth), medical librarian, and My HealtheVet coordinators see veterans right before the nutrition class.
Although the invitations stated that the veteran had to call to schedule an appointment, walk-ins are accommodated. However, due to time constraints, walk-ins are limited to five per session. If there are more than five walk-ins per session, they're given an appointment for the next clinic session. This also allows us to schedule walk-ins who were unable to attend the clinic being offered on that day.
As the clinic sessions progress, we continue to use a lessons learned approach to enhance the clinic and facilitate care. We also prioritize the lessons learned as we apply them to our long-range goals.
Figure. Performance ...Image Tools
Looking to the future
In the future, Northport VAMC hopes to implement shared medical appointments for veterans with diabetes and facilitate peer support groups. The goal is to increase the frequency of the Diabetes Wellness Clinic to once a month and extend it to the Community-Based Outpatient Clinics.
Through the formation of a Patient Education Resource Center and Healthy Living Centers, our aim is to enhance follow-up with our veterans with diabetes. Each clinic will continue to be discussed by the team and improvements will be implemented in subsequent clinics. We continue to look for ways to streamline the process and increase the number of veterans seen.
Most of the veterans who've attended the clinic have seen a drop in their HgbA1c level. By working together, we can win the war on diabetes!
* My HealtheVet is a web-based application designed specifically for veterans and their families. This site assists the veteran in interacting with his or her healthcare providers through the use of computer-based applications.
* Telehealth, also known as care coordination, is a program developed by the Department of Veteran Affairs that treats veterans at home using telecommunication technologies.
* The MOVE program is a weight management program designed by the National Center for Health Promotion and Disease Prevention to help veterans lose weight, keep it off, and improve their health.
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