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.

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.

• The Indian Health Diabetes Care and Outcomes Audit is similar to DQIP measures. It can be found at www.ihs.gov/MedicalPrograms/Diabetes/Audit/audit_index.asp

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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