Monthly Diabetes Team Meetings

Toolkit for Implementing the Chronic Care Model in an Academic Environment

This presentation provides an overview of the diabetes team meeting that the family practice residency program at Summa Health holds every month. The team meeting is part of the strategy that the program has developed as part of the Academic Chronic Care Collaborative (ACCC).

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Slide 1

Monthly Diabetes Team Meeting

First Things First

Slide 2

Purpose

  • Achieve DM quality goals using the Chronic Care Model:
    • FMC, team, individual physician.
  • Demonstrate Residents' Practice Based Learning & Improvement:
    • Demonstrate leadership in care team.
    • Use database to assess practice quality.
    • Propose & complete PDSA cycle.
    • Teach evidence based practice.

Slide 3

Initial DM Quality Goals

  • >70% have Self management Goals.
  • >60% HgbA1c <7%.
  • >40% BP <130/70.
  • >70% LDL <100.
  • Eye exam, monofilament, microalbumin Q yr.
  • Depression screen each visit.
  • <12% current smoking.
  • ACE/ARB.

Slide 4

The Chronic Care Model

Image of the Care model consisting to one large oval with a smaller oval partially appearing from beneath and behind it.

In the larger oval are the two main aspects of the model: the Community (on the left-hand side) and Health Systems (on the right). There is a smaller oval within this large oval. It is more defined on the right-hand side around "Health Systems" and begins to fade around Community.

Beneath the word Community are the elements this aspect of the model provides patients and health systems: Resources and Policies. Beneath Health Systems are the words "Organization of Health Care."

Beneath these two components within the larger oval are the four major aspects of the model. Beginning on the left near Community is "Self-Management Support." Under Health Systems are "Delivery System Design," "Decision Support," and "Clinical Information Systems."

In the smaller oval in larger type is the word "Services." Above it in smaller type are the following phrases (beginning on the left): "Patient-Centered," "Timely and Efficient," "Evidence-Based and Safe," and "Coordinated."

Beneath the smaller oval is a V-shaped arrow pointing to the phrase "Improved Outcomes." Above this phrase and to the left of the arrow is a small oval with "Informed, Empowered Patient and Family" inside it. To the right of the arrow is another oval with "Prepared, Proactive Practice Team" inside it. Between these oval are the words "Productive Interactions" inside smaller parallel horizontal arrows pointing to both ovals.

Slide 5

Expectations

  • Every month before PGY2/3 core:
    • If unable to schedule before PGY2/3 core, then team decides on alternate.
  • Meeting lasts <30 min.
  • Work will occur outside meeting.
  • All faculty, PGY3, PGY2, RNs.
  • Representatives from ancillary staff.

Slide 6

Agenda

  • Preparation:
    • Review team and personal DM quality.
  • FMC quality data report.
  • Team report on PDSA cycle.
  • Resident presentation related to PDSA.
  • Team meetings to suggest next PDSA.

Slide 7

Chronic Care Portfolio

  • Perform data base query.
  • Propose, complete, report PDSA cycle.
  • Update, present chronic care topic.
  • Case study difficult chronic care patient.
  • Self management goal setting.

Slide 8

Blank Slide

Slide 9

The Chronic Care Model

Image of the Care model consisting to one large oval with a smaller oval partially appearing from beneath and behind it.

In the larger oval are the two main aspects of the model: the Community (on the left-hand side) and Health Systems (on the right). There is a smaller oval within this large oval. It is more defined on the right-hand side around "Health Systems" and begins to fade around Community.

Beneath the word Community are the elements this aspect of the model provides patients and health systems: Resources and Policies. Beneath Health Systems are the words "Organization of Health Care."

Beneath these two components within the larger oval are the four major aspects of the model. Beginning on the left near Community is "Self-Management Support." Under Health Systems are "Delivery System Design," "Decision Support," and "Clinical Information Systems."

In the smaller oval in larger type is the word "Services." Above it in smaller type are the following phrases (beginning on the left): "Patient-Centered," "Timely and Efficient," "Evidence-Based and Safe," and "Coordinated."

Beneath the smaller oval is a V-shaped arrow pointing to the phrase "Improved Outcomes." Above this phrase and to the left of the arrow is a small oval with "Informed, Empowered Patient and Family" inside it. To the right of the arrow is another oval with "Prepared, Proactive Practice Team" inside it. Between these oval are the words "Productive Interactions" inside smaller parallel horizontal arrows pointing to both ovals.

Slide 10

Self-Management

Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.

Slide 11

Delivery System Design

The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient's status; and making follow-up a part of standard procedure.

Slide 12

Decision Support

Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.

Slide 13

Clinical Information System

A registry—an information system that can track individual patients as well as populations of patients—is a necessity when managing chronic illness or preventive care.

Slide 14

Organization of Health Care

Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.

Slide 15

Community

To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.

Slide 16

Blank slide

Slide 17

Predicted Benefits of Control (Archimedes Model)

A box chart showing the predicted benefits of controlling blood sugar rates.

At the top and to the right is "HgbA1c <7"
Beneath it are two columns: Within 6 months (on the left) and Within 24 months (on the right).
On the left side of the box chart is a column with "Proteinuria," "ESRD," "Eye Surgery," and "Blindness."

Across from "Proteinuria" and under the "Within 6 months" column is 52% with an arrow pointing down. Under "Within 24 months" is 15% with an arrow pointing up.

Across from "ESRD" and under "Within 6 months" is 44 % with an arrow pointing down. Beneath "Within 24 Months" is 16 % with an arrow pointing up.

Across from "Eye Surgery" and under "Within 6 months" is 73% with an arrow pointing down. Under "Within 24 Months" is 41% with an arrow pointing up.

Across from "Blindness" and under "Within 6 months" is 73% with an arrow pointing down. Under "Within 24 months" is 47% with an arrow pointing up.

At the bottom of the slide is the citation: Bailey J, Int J Clin Pract 2005; 59:1309-1316.

Slide 18

Joe Average Doc

  • "Not satisified" with HgbA1c >7, but…
    • 68% reinforced diet and exercise.
    • 27% augmented oral agents.
    • 8% increased insulin.

Slide 19

Glargine 2-for-20 Rule

  • Start 10 units Daily (HS or AM).
  • Adjust weekly based on last 2 FPG values.
  • Titration schedule:
    • 2 units for each 20mg above 100mg.
      • FPG 140 → increase 4 units.
      • FPG 200 → Increase 10 units.
  • NO increase in dose if BG <72 or documented severe hypoglycemia.

Slide 20

BP Control Strategies

  • ACE, then diuretic, then ARB.
  • If not a goal confirm:
    • Proper BP measurement.
    • Medication adherence.
    • Low sodium.
    • Avoid EtOH >2 oz/day, NSAID, decongestants, high dose estrogen.

Slide 21

Diabetic Nephropathy
aka microalbuminura

A line graph with "Percentage of kidney function" on the left, "Protein leak, grams/day" on the right, and "Years of diabetes at the bottom."

The "Percentage of kidney function" side ranges from zero at the bottom to 160 at the top, with 20, 40, 60, 80, 100, 120, 140 between. The "Protein leak, grams/day" side begins at zero at the bottom and, in ascending order, has 1, 2, 3, 4, 5, 6.

The "Years of Diabetes" side on the bottom has the following numbers that are have spaces between them: 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 23, 25, 27, 29, 31.

There are two lines within the graph. The first line begins on the left beneath the 20% kidney function on the left, less than 1 protein leak grams per day and reaches horizontally to above 5 years indicated at the bottom. It then begins a steep incline that reaches its apex above 17 years at the bottom, 140% of kidney function on the left, and between 5 and 6 protein leak grams per day on the right. The line then declines across the remainder of the graph and ends at 31 years just below 2 protein leak grams per day and a little over 40% kidney function.

The second line begins at 100% kidney function with about 4 protein leak grams per day. It immediately has a steep increase to over 140% kidney function, with six protein leak grams per day at about 3 years. The line levels off at this point, moving horizontally to after 5 years and then declines sharply above 100% kidney function at about 7 years with 4 protein leak grams per day. The line declines slightly to the right until approximately above the 18 year mark at the bottom and then declines significantly across the rest of the graph until ending at 31 years with less than 1 protein leak gram per day and less than 20 percent kidney function.

Beneath the graph is the URL: www.edren.org

Slide 22

Preserving Renal Function Level 1 recommendations

  • Systolic BP < 120mmHg.
  • Maximum recommended ACE dose.
  • Maximum recommended ARB dose.
  • ACE plus ARB.
  • Avoid dihydropyridine CCBs.
  • Use beta blockers (BB)
    • Preferred over DHCCB.

Slide 23

Preserving Renal Function
Level 2 recommendations

  • Glycemic control (HgbA1c <7).
  • Stop smoking.
  • Statin to achieve LDL <100, or <70.
  • Aspirin.
  • Limit sodium to 2-3 grams/day.
  • Chicken instead of red meat?

Slide 24

OK if creatinine >3 mg/dl

Serum creatinine rises up to 50% OK if no further increase

Herbert LA Kidney Int 2001;59:1211-1226

Slide 25

Safety of ACE + ARB

  • Only decrease BP 4.5/2.5 mmHg.
  • Small increase in K+.
  • Slight decrease in GFR.
  • Proteinuria improves.

Slide 26

Blank slide

Return to Document

Page last reviewed January 2008
Internet Citation: Monthly Diabetes Team Meetings: Toolkit for Implementing the Chronic Care Model in an Academic Environment. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/chronic4d.html