Determining
Needs and Setting Priorities for Systems Change
Tool:
Best Practice Model
The
Indian Health Service (IHS)
Integrated
Best Practice Model. Basic Diabetes Care and Education: A Systems
Approach
Why
is this Important?
This
self-assessment tool defines the important components of a diabetes
care system somewhat differently, but is an example of a three stage
multicomponent approach towards change.
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The
Indian Health Service diabetes programs have developed a Provider
Recognition program for IHS facilities in American Indian/Alaska
Native communities. Activities are described for three levels, with
each level building on the earlier one. Nine elements are identified
that contribute to quality diabetes care and education, based on
recognized standards of care. Programs perform self-assessment to
determine their level within an element, implement changes as needed,
and have a qualitative means to follow progress towards improvement.
What
are the three levels?
Level
1 - Developmental: Completion of all elements at this level
indicates that health services are starting work to develop a
quality diabetes program.
Level 2 - Educational: Completion of all elements at this
level indicates that the local health care system provides quality
diabetes education services.
Level 3 - Integrated Diabetes Program: Completion of all
elements at this level indicates that the health care system provides
quality diabetes education, clinical and public health services
including community-wide prevention programs.
What
measures are used?
In
order to evaluate your own practice as described in the three levels,
a method of assessing outcomes is necessary. Here is an example.
What
are the nine elements of quality diabetes care and education?
1. Case Management
Case
Management has been shown to improve adherence to standards of
care and patient outcomes. Two examples might include an RN who
coordinates the care of people with
diabetes who are seen by contract providers or an RN/CDE who is
actively involved in the care and follow-up of a set group of
people with diabetes.
- Level
I: 1 RN coordinates the care and education of the diabetic population.
- Level
II: RN Case Manager tracks follow-up, appointments not kept, and
people with diabetes lost to follow-up. Also coordinates the annual
diabetes audit.
- Level
III: RN Case Manager is an active participant in the care of a
set group of people with diabetes. This could include phone or
in-office follow-up for blood sugars and blood pressure, facilitating
medication refills, and so on.
2.
Information Management
Whether
a program is starting with a hand-kept patient list or uses a
computerized medical record, managing information on both individuals
and communities helps improve care and monitors whether systems
changes result in process and outcome measures improvement.
- Level
I: Diabetes Registry and Flow sheet (manual or automated) established.
- Level
II: Automated diabetes management program, including computer-generated
health summaries; conducting at least part of the diabetes audit
electronically.
- Level
III: Fully utilize computerized information systems monitoring
data for individual and population-based care, including tracking
patients with complications, giving providers' feedback on their
adherence to standards of care, and generating data on process
and outcome measures.
3.
Diabetes Team
To
meet IHS and ADA guidelines, every diabetes program should have
a clearly identified Diabetes Team with the responsibility of
ensuring the quality of all diabetes care offered at a site.
- Level
I: Diabetes Team consists of at least an RN and an RD
- Level
II: Diabetes Team is multidisciplinary both in composition and
in delivering services to people with diabetes. Team must include
a physician.
- Level
III: At least one team member should be a Certified Diabetes Educator
(CDE) and the program should have achieved both Education Program
and Provider Recognition by the ADA (or, if an IHS program, the
IHS Provider Recognition status).
4.
Systems of Care
(Some
features described here may be more pertinent to IHS but the concepts
are adaptable to other clinical situations)
There
are many ways to deliver quality care and education. Disparities
in the quality of care delivered may result in sites that deliver
care to some patients in the general walk-in clinic and to others
in a specific diabetes clinic when a clearly defined system of
approaching diabetes care has not been established. Provision
of all care on a walk-in basis is discouraged. Some IHS sites
are minimally staffed and must contract out many health services.
Other sites use the Primary Care Model, which focuses on continuity
of care with one provider. Some newer care models, such as Group
Medical Visits, can be incorporated into either the "Diabetes
Clinic"; or "Primary Care" models.
- Level
I: Medical care is contracted out, but the non- medical components
are provided by the program (e.g. Foot Checks, Education, Nutrition
Counseling, etc)
- Level
II: Complete primary care of diabetes is provided by the program,
either in the "Diabetes Clinic" or "Primary Care" model (or a
combination).
- Level
III: Newer models of care are incorporated, such as Group Medical
Visits or a Primary care/case manager caring for a defined panel
of people with diabetes.
5.
Patient Education/Self-management Support
All
quality diabetes programs have a strong education and self-management
support component to help people actively direct their care and
manage their diabetes every day.
- Level
I: A basic body of diabetes knowledge is taught to each patient.
- Level
II: Organized Education Plan with a defined curriculum and lesson
plans.
- Level
III: Inclusion of empowerment strategies, including support groups,
training in coping skills, and problem-solving/behavior-change
interventions as part of self-management support.
6.
Training Providers and Educators
Optimally
all providers, not just those directly involved with the Diabetes
team, need training in diabetes care appropriate to the providers'
profession
- Level
I: Each member of the Diabetes Team receives basic diabetes training
periodically.
- Level
II: Each member of the Diabetes Team receives a minimum of 12
hours of
diabetes-specific training every 2 years.
- Level
III: Ongoing, coordinated education on-site for all providers,
to include training
in site-specific information management and documentation issues.
7.
Protocol-based Practice
Diabetes
standards of care should be used to create protocols appropriate
to local formularies and staffing
- Level
I: Promotion of diabetes standards of care knowledge and adherence
among providers and people with diabetes.
- Level
II: Protocol-based medical care (both diabetes team and non-team
providers)
- Level
III: Protocol-based medication adjustments by other members of
diabetes team (e.g. RN/CDE, pharmacists).
8.
Specialty Exams and Services
Diabetes
care often requires the services of specialists, both for screening
and treatment of complications (e.g. eye, foot. kidney). Whether
a site contracts outside for the exams or provides them on-site,
ensuring access to specialty care is an essential part of a diabetes
system
- Level
I: Most/all screening exams and specialty services are provided
by contract providers.
- Level
II: Screening exams and basic services are available on-site.
- Level
III: Subspecialty services are available on-site.
9.
Staging of Population
The
care needs of people with diabetes change as their disease progresses.
Following a patient at high risk for diabetes requires a different
set of skills than does management of one experiencing end-stage
complications. For example, a program may choose to assign the
follow- up of people at high risk for diabetes to an RN and/or
an RD, the care of recently diagnosed diabetics to mid-level practitioners,
and the care of patients with complications to physicians. This
fully utilizes the skills of available staff in a cost-effective
manner and matches people with diabetes' needs with the most appropriate
providers.
- Level
I: Optimal use of existing diabetes team specialties.
- Level
II: Provide prevention/early detection services to people at high
risk for diabetes.
- Level
III: Resources are specifically directed toward the care of people
with advanced diabetes complications.
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