From Silos to Success
The effects of collaboration with a focus on diabetes and group visits
North Lambton Community Health Centre
Dr. Sonja Burgel MD CCFP FCFP Leah Willemse M.A.N. RD CDE Janet Wilpstra RN CDE North Lambton CHC
Declaration Slide No conflicts of interest or financial endorsements to disclose.
North Lambton Community Health Centre
North Lambton Community Health Centre
Objectives
By the end of this workshop you should: • Understand what a group visit is • Know what a group visit can accomplish • Have some confidence in the concept • Have all the tools to start doing group visits in your own practices – jump the fish bowl! • Have had some fun watching a real group visit!
North Lambton Community Health Centre
Agenda
Why group visits? Connection to CCM and CDA guidelines How to do a group visit - “Tool Kit” Watch a real group visit and embrace the chaos… (warning – we will be looking for volunteers!) • Review of our results • Questions • • • •
For starters… • Who are we? • Who are you?
Why Group Visits?
Why Group Visits? • QIIP – Quality Improvement and Innovation Partnerships • HCO – Health Quality Ontario • Access issues • Complex patients with multiple needs • Provider and Patient Frustrations • 3 years… North Lambton Community Health Centre
Why Group Visits Evidence Perspective… • Applies principles from the Chronic Care Model (CCM) • Meets CDA recommendations re organization of care
North Lambton Community Health Centre
CDA, 2013
CCM Applied to Group Visits • Decision Support: Diabetes flow sheets • Information Systems: Diabetes registry, follow-up needs tracked using EMR “inbox” • Self-Management Support: Stand up to Diabetes Passports, goal setting and action planning • Delivery System Design: Inter-professional team, including primary provider • Community Resources: Group members linked to additional selfmanagement programs in the community North Lambton Community Health Centre
Organization of Care - CDA Register: Develop diabetes registry Resource: Support self-management through use of inter-professional teams Relay: Facilitate info sharing b/t person with diabetes and care team for timely management changes Recall: Develop system to remind patients and caregivers of timely review/reassessment North Lambton Community Health Centre
Why Group Visits? Provider Perspective… • Improved efficiency • Increase in use of multiple disciplines • Increase in access • Patients are more knowledgeable, take more ownership of their disease, participate in selfmanagement goals • Improvement in targets, overall health • Decrease in visits and phone calls • Improved provider satisfaction North Lambton Community Health Centre
Why group visits? Client Perspective… • Efficient - “one stop shop” • Recommended and supported by their primary provider/MD • Support from peers with similar challenges • Improved knowledge in a comfortable setting • Improved health • Improved client satisfaction North Lambton Community Health Centre
Getting Started‌
North Lambton Community Health Centre
First Steps
• Buy-in – administration, providers, clients • Room – space, EMR access, private area • Review diabetes registry – “hand-pick” initial attendees • Invite letters • Determine facilitator roles, group agenda • Follow-up calls to invitees • Then…
No really…snacks are a must!
North Lambton Community Health Centre
Who?
Good Candidates? • Clients with similar health needs that also require time and education • Clients who require regular follow-up or predictable interventions (e.g. DM, prenatal, well baby) • Frequent visitors • High emotional or support needs
Who? Not so good candidates? • Language barriers • Some mental health diagnoses • Complex medical issues • Memory issues ….but you never know!!! North Lambton Community Health Centre
What? What did we expect? • Clients would find the concept difficult • Only a small number would embrace groups • It would be chaos • No-one would talk in the group • Clients would still book appts with provider North Lambton Community Health Centre
North Lambton Community Health Centre
What?
What did we get? • After some initial reluctance and lots of questions, clients have embraced the idea • Confidentiality agreements every group helps to ease concerns • They don’t STOP talking!!! • Good organization and pre-planning reduces the chaos • The team learns from each other
North Lambton Community Health Centre
What did we get?
• Providers had more difficulty “letting go” of classical visit concept • Need lots of charting time • Results were far better than we expected • Group has become very cohesive, problem solving and helping each other (e.g.. rides, walking programs, information) • Provider satisfaction
Challenges? • • • • • • • •
Buy-in (client, provider) Time Room Organization Meeting needs of everyone Personal issues during group Significant medical issues brought up in group Dominant client or provider North Lambton Community Health Centre
Best Advice • Pick your team wisely… • Make lots of lists… • Dive in!!!
See for Yourself! Sample Group Visit
Results
Retrospective Visit Comparison 50
ACCESS: Average 38% ↓ in visit demand since attending group visits.
45 40 35
# Visits
30 25
2011-12 appts 2012-13 appts
20 15 10 5 0
1
2
3
4
5
6
7
8
9
10 Client #
11
12
13
14
15
16
17
18
19
Group visit vs Traditional Appointment Time ACCESS/EFFICIENCY: Average 45% ↓ in appointment time = average ↑ of 3 appointments / month.
6
Time (hours)
5 4 3 GV Time
2
Traditional Appt Time
1 0 May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
HbA1c Change CLINICAL OUTCOMES: Average HbA1c unchanged. HbA1c ↓ for 55% of group.
12
10
HbA1c (%)
8
6
Initial HbA1c Second HbA1c
4
2
0
1
2
3
4
5
6
7
8
9
10
11
Client #
12
13
14
15
16
17
18
19
20
Questions?