ࡱ> $& !"#q` 0objbjqPqP ::{zN+, 4$ h< ɥ8  .   86nd4$hir& 68&^^  P ;F###`^  ###F@f h    @^fPT, Hɥ@۪B$۪۪ H#&&f#ɥ   {0z  0  $ <P^^^^ IPIP Change Package (Version 1.6.1) Table of Contents Key Components of IPIP Change Package High Leverage Changes Overview 1 IPIP System Diagram 2 High-leverage Changes Details 3 Registry. .. 4 Template for Planned Care 7 Protocols 8 Self-Management Support 10 IPIP Measures Measurement Approach.. 13 Measures Chart for Diabetes 13 Measures Chart for Asthma 14 IPIP Rating Scales Team Assessment Scale 15 Progress on Changes Scales 16 Other Rating Scales 17 Appendix A. List of Tools on IPIP Extranet 18 B. Chronic Care Model 20 IPIP CHANGE PACKAGE KEY COMPONENTS High Leverage Changes Overview Step 1: Implementing a Registry Select and install a registry tool Determine staff workflow to support registry use Populate registry with patient data Routinely maintain registry data Use registry to manage patient care and support population management Step 2: Use Planned Care Template Select template tool from registry or create a flow sheet Determine staff workflow to support use of template Use template with all patients Ensure registry updated each time template used Monitor use of template Step 3: Use Protocols Select and customize evidence-based protocols to office Determine staff workflow to support protocols, including standing orders Use protocols with all patients Monitor use of protocols ASTHMA-SPECIFIC PROTOCOL Assess and document asthma severity and control Prescribe appropriate asthma medications & monitor overuse of beta agonists Use asthma management plans Establish visit frequency protocol Assess and treat co-morbidities Assess, counsel, and prevent exposure to environmental triggers DIABETES-SPECIFIC PROTOCOL Check and treat BP <130/80 Check and treat cholesterol Check A1C and treat hyperglycemia Assess aspirin and prescribe if not using Assess need for eye exam and make referral if needed Assess nephropathy risk Perform foot exam Provide appropriate vaccines Counseled to stop tobacco use Step 4: Self-Management Support Obtain patient education materials (e.g., asthma action plans) Determine staff workflow to support SMS Provide training to staff in SMS techniques Set patient goals collaboratively Document & monitor patient progress toward goals Link with community resources (schools, service organizations) IPIP System Diagram Outcomes Key Drivers Intervention/Change Concepts   PART II: HIGH LEVERAGE CHANGES DETAILS High Leverage Changes The approach outlined here is a way to focus efforts on high leverage changes within a practice to ensure that the planned process of care gets done with every patient every time. Rationale: IPIPs key emphasis is on re-design of the care delivery in practices. Clinical experience and research evidence demonstrate that such re-design is more effective for care delivery, easier for the physicians and staff, takes less time, and is more satisfying for patients. We want to bring greater focus on specific elements of care delivery and get to implementation of these changes as quickly as possible. IPIP high leverage changes fall into 4 steps: Use registry to identify asthmatics/diabetics prior to visit (this requires the work of implementing a registry or fixing the EHR) Use a template for planned care (e.g., visit planner) Use protocols to standardize the care process Standard Protocols Nursing Standing Orders to increase reliable execution Defined Care team roles: who does what in the protocol Use of self-management support strategies with patients Implementing these changes only works if they are implemented reliably so that they are used for every patient every time. As such, we emphasize the importance of sustainable, executable plans that are monitored to ensure tools and processes are used consistently. STEP 1 Registry (Using diabetes as a model) Select a registry A system that records relevant patient care information for a specific subpopulation is called a "registry." The care team can use the registry to record critical elements of the care plan, produce care summaries at the time of a visit, and enter data to alter the care plan as needed. A registry is essential to assessing both how care is delivered and how well care is delivered. Identifying the population of patients with asthma or diabetes and understanding their needs for care are at the core of a population-based care delivery system. Choose a registry application that allows for flexible data handling and reporting. Electronic registries such as DocSite, RMD or CDEMS are configured to support IPIP data. Make sure that the application makes it easy to get patient information into and out of the system. Ideally it should also be easy to transfer information to and from other systems (e.g., billing, lab, appointments), or even have a direct interface with these systems. If your practice has an Electronic Health Record (EHR) it is possible that this application can serve the functions of a registry, with appropriate programming. Some EHRs have registry functions built into the system. Setting up the programming for an EHR to support IPIP improvement functions can be time-consuming and may require the input of clinicians, IT staff and the EHR vendor. Using the EHR to perform registry functions can minimize data entry and serve to centralize patient information; however, it may take months before registry functions are in place. In the interim it is essential to collect and report data. Practices can also accomplish the registry function using a paper-based approach. A paper-based approach is not likely to be a viable long-term tool, but can get a practice started in understanding how to integrate a registry into their daily process. Populate the registry Once a registry has been identified and installed in a practice, the next step is to populate the registry with patient data. Some practices with an EHR can electronically transfer data from the EHR into the registry; however, this may require some additional support from IT. Alternatively, some practices can use their billing system to generate a list of patients with a given condition to populate the registry. When an electronic transfer is not possible, data must be entered manually. Many practices will enter data in batches, starting with demographic information (name, age, date of birth) so that when patients come in for a visit, their clinical data can be entered. Other practices may find it easiest to systematically enter demographic and clinical data in batches. The goal is to have all patients with the condition of interest entered into the registry, enabling the practice to move to a planned care approach by using pertinent data to plan patient care. Set a deadline for completion of this task. Much of the practice redesign depends on it. Give your practice 1 month to accomplish this task. Using the registry to support patient visits This is the first step in using health information technology to assist in improving quality. In order to ensure that all key processes are carried out efficiently, the patient must be identified at the time of entry into the clinic, preferably at the front desk, but no later than while rooming the patient. If no IT solution is available to identify the patient with diabetes (or other target condition), consider the following: Sticker (or other indicator) on the chart Provider identifies all diabetics at pre-clinic huddle Paper-based solutions are limited because they are not easily adapted to include multiple chronic illness programs and protocols Using IT, use one or more of the following: Names on schedule entered into registry to identify if diabetic Front desk queries registry to identify if patient has diabetes EHR has diabetes in problem list that is reviewed by rooming person Scheduling program sends names to registry and those with diabetes identified automatically EHR/Registry puts out list of all medical problems on entry to clinic Successful implementation of registry All patients with condition are entered into registry and registry is used to manage the entire population with condition. Common challenges to implementation 1. Entire population is not in the registry Use a billing system or some method of identifying all patients with condition. Then make sure these patients get entered into the system. Dont worry about perfection. A registry is a living system; maintenance of population is part of population management. 2. Ongoing data entry is not reliable Revisit roles and responsibilities Create clear protocol Identify barriers in the system that are preventing 90% completion Relevant Registry Tools The IPIP Extranet has tools related to registries in the Registry folder Three registries have been configured to support IPIP measures. The table below compares some of the features offered by each registry. More information and instructions are available through your QIC. Sample IPIP Registries FeatureCDEMSDocSiteRMDDiabetes & asthma management ( ( (Other chronic conditions(Preventive Services(IPIP Measure Support(((Approximate cost to physiciansMinimal$600/year/MD 1-2 MDs: $300/yr 3-5 MDs: $900/yr >5 MDs: $150/MD/yr Graphs of lab values(((Encounter Forms(((Patient Education Materials(((Web-based application((Multi-user((Need to install software on PC or server(Data exports to EMRs(((Automatic import of lab results for all patients with Quest & Lab Corps((Ad Hoc reporting easily customizable reports(((E-Prescribing (addl fee)(Medication tracking by medication name or class without e-prescribing(Secure HIPPA compliant e-mail to patients & other providers(Recall reminders to patients & providers when care is due( STEP 2- Template for Planned Care Identify a template Often called decision support, a template can mean a lot of things. In this context, the idea for this level of decision support is to identify all needed services that have not been completed and make a recommendation to the clinic staff. Many registries, including those used in IPIP (CDEMS, DocSite, and RMD), have visit planners built into the system. Such visit planners are decision support tools or templates for care. Implementing a template A visit planner or template is a paper or electronic interface used by the staff and clinician to evaluate needed services and to document the completed services for each patient. This is analogous to the flow sheet that many practices use in a paper chart. Most registry-based templates integrate treatment algorithms and self-management support through prompts. Practices need to choose a system that will work for them. Most practices choose to print out a paper visit planner that serves as a reminder for all members of the care team what needs to get done. The visit planner should be organized by who needs to complete the task so that all staff is involved in using the visit planner (front desk, nurse, physician, etc). Monitor use of the template Ensure that the template is used for every patient and at every opportunity for care. A series of implementation PDSAs can get a practice to 100% reliable use of the template within a couple of weeks. At end of the day, review all diabetes charts to measure: How many patients had a visit planner used? How many of the nurse opportunities were available and how many completed? How many of the physician opportunities were available and how many completed? Was all data entered into the registry within the protocol planned time for the clinic? Post results at the end of each day until all aspects of process are >90%. When processes are at 90%, weekly summaries can be used. Successful implementation of template All processes are occurring >90% of the time. Common challenges to implementing template 1. Cannot get nurses/doctors/others to complete all tasks on their part of visit planner Ensure that all know their roles/responsibilities Identify barriers to completion (this requires discussion and often reassessing how the process flows) Repeat Relevant tools for templates The IPIP Extranet has sample templates and other relevant tools located in the Templates folder STEP 3 Protocols (Using diabetes as a model) Standardize the system of care The use of protocols and standing orders, coupled with clear care team roles is the critical step for seeing results. To accomplish standardization of care, the practice needs to understand the flow of the patient through the clinic and the key contacts during the visit. This step is intimately tied to step 2: Using a planned care template. Delegate care team roles Protocols require that responsibilities be delegated across the staff. Each staff makes a contribution to the care of the patient with chronic illness. In fact, non-physician staff can effectively perform many steps in high quality chronic illness care. For example, referrals for eye exams, foot exams, orders for required blood tests, and immunizations are steps appropriate for non-physician staff. The clinic needs to agree upon nursing standing orders, a standard protocol for what needs to happen for the patient, and specific care team roles in carrying out the protocol. Often times the standing orders can be the same as a protocol. Combine the information in the flow diagram and the protocol to decide who will do what. Build redundancy into the process. For example, the front desk identifies diabetics and places decision support tool in an easy to use location. LPN (or rooming staff) will begin to implement those aspects of diabetes care that are part of their protocol. Once they have completed their role, patient sees the physician. Physician sees all that the nurse performed and ensures completion of his own responsibilities. Patient carries visit planner back to check out where the clerk reviews to make sure all steps are taken care of and reinforces any key issues for the patient to follow up on. The clerk or another designated staff enters any remaining data into registry or EHR. (One way to monitor this process is to collect paper visit planners for analysis at the end of the day). Monitor processes Implementing such care processes is not automatic. The entire staff needs to accept this process and understand their roles and responsibilities for patients with diabetes. Just creating the protocols will not be enough. The front desk, the rooming staff, the nurses, and the physicians all need to participate and brainstorm the barriers to completing this every time the patient come in. All need to accept that this is part of the job, not optional, and that a good system will get this done every time. Consider the process of recording blood pressure. In most practices, blood pressure recording is close to 100%. We should expect the same for all other processes. Successful implementation of protocols Protocols are followed 90% of the time with patients with condition Common challenges to implementing protocols 1. Difference of opinion among clinical staff about which protocol to use Conduct PDSA cycles on several protocols to determine which version best matches the process in the office 2. Lack of agreement that a protocol is needed Use guidelines as basis for discussion and share data that demonstrates the gap in care as compared to IPIP goals Resources for diabetes protocols The IPIP Extranet has sample protocols and other relevant tools in the Protocols-Diabetes folder Example protocol/standing orders from ACP Diabetes Guide. Practices can build their own customized standing orders and protocols on this website for free  HYPERLINK "http://www.diabetes.acponline.org" www.diabetes.acponline.org Several active protocols are posted on the University of North Carolina General Medicine website  HYPERLINK "http://www.med.unc.edu/wrkunits/2depts/medicine/generalm/resourcepages.html#diabetes" www.med.unc.edu/wrkunits/2depts/medicine/generalm/resourcepages.html#diabetes Resources for asthma protocols The IPIP Extranet has sample protocols and other relevant tools in the Protocols-Asthma folder The American Academy of Allergy, Asthma and Immunology has numerous resources on its website:  HYPERLINK "http://www.aaaai.org/professionals.stm/" http://www.aaaai.org/professionals.stm/ Maine Healths website has numerous resources on asthma protocols available on their website:  HYPERLINK "http://www.mainehealth.org/mh_body.cfm?id=363" http://www.mainehealth.org/mh_body.cfm?id=363 Step 4: Self-Management Support (Using diabetes as a model) Educating patients in self-management is necessary to improve patient outcomes when treating chronic illnesses such as diabetes. Successful self-management education relies on educational tools that are evidence-based, incorporating demographic and cultural variables, and emphasizing patient collaboration and empowerment. All members of the practice team can help patients set goals for self-management. These goals must be clearly documented and reviewed with patients frequently. Success relies on active collaboration of the health care team and patients to improve outcomes. Obtaining tools for self-management education Diabetes self-management tools are available in print, video, and computer based formats. Most practices use some sort of printed materials, as they are usually less expensive and easier to obtain. Materials should be patient oriented and include information on what the patient NEEDS TO KNOW AND NEEDS TO DO. Materials should foster conversation and plans for action. Implementing self-management support Self-management support starts with the following key steps: Assessing the patients skill and understanding Setting up plans and goals with patients Following up with patients to determine if goals are achieved Problem solving when the patient has been unable to meet goals and revising goals when necessary Documenting the goals and plans as well as the results As this process of health education is new to the physician and/or nursing staff, some element of staff training is needed to have successful implementation. All staff that will help with this process should be part of a training session. The doctor does not need to do all of this. Many successful self-management support programs rely upon nursing staff, medical assistants or others to help patients learn to set goals and provide systematic follow-up. A specific member of the health care team needs to be designated to encourage patients to set goals. After goals are set a follow-up system must be in place. One option would be to assign a staff member to call patients at a designated follow-up interval (for example one week after the goals are set). Alternatively if telephone follow-up is not feasible, staff can review goals with patients at each and every appointment. Once a support system is created, it is important to set clear expectations of the staff for implementation like any process improvement. While testing the implementation, monitor whether the medical staff are documenting goal setting and follow-up with patients. Document and follow-up self-management support Documentation is an essential component of self-management. It is necessary to document the initial goals of the patient. A copy of these goals should be placed in the chart and given to the patient. During follow up it is necessary to document 1) progress toward achieving goals, 2) barriers to reaching goals, and 3) modification of existing goals or a new set of goals. Having all of this information in the chart will allow multiple members of the clinical staff to participate in supporting self-management of an individual patient. It is also important to measure whether or not self-management support is occurring. Examples of measures are: Percent of patients with diabetes who have a documented set of goals in chart/registry Percent of patients who receive follow up after goal set Standardized documentation using the registry and/or electronic medical record could be used. In an electronic medical record a field documenting goals reviewed at each visit could be added. In practices that regularly perform goal setting with their patients, the patients learn to expect it and the process becomes a natural part of care. Successful implementation of self-management support All patients have self-management goals. A reliable method of follow-up is in place and carried out regularly. Common challenges to implementation of self-management support 1. Dont know what to teach the patient Review ACP Foundation Diabetes Guide. Most of what patients need to know and need to do does not require intimate knowledge of diabetes or physiology. Helping to activate patients is the key issue here. Establish ties with community based diabetes educators for more detailed teaching. Focus primary care efforts on behavioral modification. 2. Dont have time Time is always a problem. Patients can be overwhelmed by too much information at one visit. Keep goal setting brief. Delegate responsibilities throughout the office and share responsibilities for roles among multiple staff when possible. 3. Dont have resources for follow-up Develop protocols that can keep this brief. Consider developing peer support groups that can do this for each other Resources for Self-Management The IPIP Extranet has Self-management tools and other relevant materials in the Self-Management Support folder Self-Management Support Resources for Diabetes: The most basic form to start with is the Setting your Self-Management Goals worksheet. A copy of this form is available online at:  HYPERLINK "http://diabetes.acponline.org/clinician/CL-PI-ET.html" http://diabetes.acponline.org/clinician/CL-PI-ET.html Select the link Setting your self management goal A more detailed set of materials is the Living with Diabetes Guide by the American College of Physicians Foundation (available at diabetes.acponline.org). This guide contains helpful information on diet, exercise, monitoring, medications, and taking insulin. It is accompanied by brief instructions for doctors and other medical staff. Basic goals worksheet can be found online at:  HYPERLINK "http://diabetes.acponline.org/clinician/CL-PI-ET.html" http://diabetes.acponline.org/clinician/CL-PI-ET.html Select the link For better health- your self-management workbook Diabetes Educators: Certified diabetes educators are specially trained members of the health care team who work with patients to promote healthier living through self-management of diabetes. Insurance will often pay for a visit to a diabetes educator. Such a visit may help to augment the work of the primary care practice. Most patients do not sustain a long-term relationship with a diabetes educator, so the role of the primary practice is still critical. To find a diabetes educator in your area, go to the following link:  HYPERLINK "http://www.diabeteseducator.org/DiabetesEducation/Find.html" http://www.diabeteseducator.org/DiabetesEducation/Find.html Self-Management Support Resources for Asthma: The American Academy of Family Physicians has a wide range of tools to support self-management support strategies for patients with asthma on its website:  HYPERLINK "http://familydoctor.org/online/famdocen/home/common/asthma.html/" http://familydoctor.org/online/famdocen/home/common/asthma.html/ Improving Chronic Illness Care has several links and information on implementing self-management support strategies on its website:  HYPERLINK "http://improvingchroniccare.org/index.php?p=Self-Management_Support&s=39/" http://improvingchroniccare.org/index.php?p=Self-Management_Support&s=39/ The King County Department of Public Health has a variety of resources for both clinicians and patients available on its website:  HYPERLINK "http://www.metrokc.gov/health/asthma/" http://www.metrokc.gov/health/asthma/ III. IPIP MEASURES Measurement Approach Current measures and goals for IPIP are listed below. Goals are set at very good care and based on national standards when indicated. All measures are % of patients with a given disease who have had the process or outcome designated within the measurement year. In year 1, practices should close the gap between their baseline performance and the goal by 30%. (For example, if the goal is 90% and baseline performance is 40%, the gap is 50%. 30% of the gap is 15%. A practice should strive to reach 55% by the end of year 1). Diabetes GoalRequired MeasuresBlood Pressure BP documented in the last year <130/80>70%CholesterolLDL Control <100 mg/dl>70%A1CMost recent A1C level greater than 9.0%< 5%Eye ExamReceived a dilated eye exam>80%NephropathyTested for nephropathy or already under treatment>90%Smoking StatusCounseled to stop tobacco use>90%Optional Diabetes Measures Patients over age 40 on an aspirin>85%BP documented in the last year <140/90>90%Most recent A1C level less than 7.0%>75%At least one LDL>90%LDL Control <130 mg/dl>90%Foot exam>90%Influenza vaccination>75%Documented diabetes SMS goals>90% Asthma GoalRequired MeasuresAssessment of ControlControl assessed>90%Anti-inflammatoryPersistent asthma (or equivalent level of control) on anti-inflammatory medication>90%PreventionInfluenza vaccination>90%Composite MeasureReceive 3 key strategies for asthma care (assessment of control, anti-inflammatory, influenza vaccination)>75%Optional Asthma MeasuresSmoking StatusCounseled to stop tobacco use>90%ED visit<0.3%Hospitalization<0.1%Action plan or self-management plan>90% PART IV: RATING SCALES Team Assessment Scale RatingDefinition0.5Practice has completed application and participated in informational call but the practice aim has not been customized nor has the QI team been formed1.0An aim statement has been completed and reviewed. Individuals have been assigned to QI Team, but no work has been accomplished yet.1.5Team is engaged in planning improvement activities but no testing has begun.2.0Initial testing cycles for team learning and planning have begun. For example, testing has started on measurement, data collection, study of processes, surveys, etc.2.5Initial cycles for testing changes have begun and some PDSA results have been studied. 3.0Successful tests of changes have been completed for up to 2 high-leverage changes. Some improvements have been noted in run charts, monthly data, and monitoring data in at least 2 change areas.3.5Improvement toward project goals is demonstrated in at least 3 change areas.4.0Practice-wide implementation has begun for all components of the change package. Testing and implementation is occurring in all 4 high-leverage change areas. Progress in monthly measures of at least 50% can be seen in monthly reports.4.5Data on IPIP measures begins to indicate sustainability of changes and improvements across the practice.5.0Implementation cycles have been completed and all project goals and expected results have been accomplished. Organizational changes have occurred to support permanent improvements. Progress on Changes Scales Registry 1.0Practice has chosen a registry, but not yet begun using it.2.0Practice has registry installed on a computer, set up a template, entered demographic data on patients of interest (e.g., diabetes) or has a process outlined to systematically enter the data.3.0Practice is testing process for entering clinical data into registry; not yet using the registry to help with daily care of patients.4.0All clinical data is entered into the registry and practice is using the registry daily to plan care for patients and is able to produce consistent reports on population performance.5.0Registry is kept up to date with consistent, reliable processes. Practice has checks and monitors registry processes. Practice uses registry to manage entire patient panel (population). Template for Planned Care 1.0Practice has a template for planned care but has not yet begun using the template.2.0Clear delineation of staff roles and process flow to support use of template has occurred. Team is starting to test using the template.3.0Team is testing template and ensuring that the process flow is working. May only be occurring in a part of the practice, though could be done across the clinic.4.0Process is implemented across the entire clinic, but practice is still working on consistency throughout clinic. To get a 4, the practice should have a consistent process that works at least in part of the clinic.5.0Template is used with every patient with target condition, consistently completed, and entered into the registry. Ongoing monitoring of system to ensure the template is used consistently is occurring. Protocols 1.0Practice has identified protocols as examples and begun the process of customizing the protocols for their own practice.2.0Practice has version of template and planning tests of implementation. Often in only one part of the practice, but could be across the entire clinic.3.0Successful testing of the process for using the protocol is occurring. Ongoing implementation and optimization of the process is underway.4.0Spread of the process across the entire practice is occurring. The reliability of using the protocol is above 70%.5.0Reliability of protocol use is over 90% throughout the entire practice. Ongoing monitoring of the system to ensure that protocols are used consistently is also occurring. Self-Management Support 1.0Practice has obtained patient education materials and handouts to support self-management.2.0Practice has completed a plan for providing self-management support that includes all of the elements indicated in the change package. Staff roles and responsibilities are clearly delineated.3.0Practice actively testing their process for self-management support. All staff involved in self-management support has undergone appropriate training. Patient goal setting and systematic follow-up are being implemented at least in part of the practice.4.0Self-management support is consistently offered. Practice documents self-management goals for patient in the chart or registry, getting performed across the entire practice. Monitoring reliability is occurring.5.0Patients consistently have self-management goals documented, follow-up system is reliable, staff are comfortable providing self-management support. Ongoing monitoring ensures the process is carried out consistently for all patients. Other Rating Scales Leadership 0No management or leadership support for improvement work exists.1A manager or physician champion is involved but no organized improvement structure exists. Try & see approach is the norm for improvement activities.2A leader who supports improvement activities is identified, temporary tasks and roles to support improvement are assigned to staff, and some coordination of aim among projects exists (when multiple projects).3QI work is integrated into daily routines, roles to support improvement are assigned, and performance evaluations are tied to improvement activities. Leadership for improvement exists to select and launch new improvement efforts (e.g., identifying aim, assigning team). Engagement 0No improvement activity exists.1Occasional meetings or discussion regarding improvement but no organization-wide understanding of improvement work or aim exists.2Improvement team communicates regularly (through meetings, huddles, email, memos, etc) to plan tests & discuss results. Improvement team can describe project aim and measures.3Improvement team is planning and discussing multiple tests simultaneously and communicates findings to each other. Improvement progress is communicated to entire office staff. Most staff can describe improvement aim and measures. Improvement team participates in collaborative activities such as conference calls and listserv.  APPENDIX A The following tools are located on the IPIP Extranet: IPIP Tools ASTHMA Registry Tools - Asthma Identification of Asthma Patients.pdf Constructing an Asthma Registry.doc Step by Step Planning Guide EHR.doc Step by Step Planning Guide paper based.doc Templates - Asthma Asthma Visit Planner.doc Asthma Encounter Form.pdf CCHMC Asthma Flow Sheet.pdf Protocols Asthma Asthma Severity & Controller Meds.pdf Asthma Severity Assessment Qs.doc Living with Asthma Imbedded.doc Monitor Beta-agonist Use.pdf Prescribe Meds According to Severity.pdf Quick Peak Flow Card.pdf Quick Spacer Card.pdf Schedule of Routine Follow-up for Asthma.pdf Treatment and Prevention of Co-morbid conditions.pdf Team roles.doc Specialist Fax back form.doc Self-Management Support Asthma Three-part Action Plan.pdf Self-management Goals for Children.pdf How to Control Things That Make Your Asthma Worse.doc CEASE Annual Smoke Review.pdf Asthma Stoplight Tool.doc Decisional balance worksheet.ppt Asthma Management Plan SPANISH.doc SMS goals worksheet.doc Living with Asthma Questionnaire and Goals2.doc General Improvement Tools Monitoring Worksheet.xls Monitoring Example.xls Roles & Responsibilities worksheet.pdf Example Roles & Responsibilities.doc DIABETES Registry Tools - Diabetes Constructing a Diabetes Registry.doc Step by Step Planning Guide EHR.doc Step by Step Planning Guide paper based.doc Template Diabetes Diabetes Care Flow Sheet.pdf Diabetes Flow Sheet for paper chart.pdf Sample Visit Planner from DocSite.pdf Protocols - Diabetes A1C, Blood Pressure and LDL Chol Plan.pdf ABCS Chart sticker.pdf ASA-ACEI-Statin Checklist.pdf Diabetes Patient Questionnaire Grace Hill.doc Diabetes Foot Example Chart Stickers.pdf Eye Exam Report.pdf RXPedometer.pdf Standing orders protocol diabetes.pdf Smoking Cessation Pocket Card.pdf Group Visits Progress Note.doc Specialist Fax-Back form2.doc Self-Management Support - Diabetes Smoking Status questionnaire.pdf Diabetes Questionnaire.pdf My Diabetes Self-Mgmt Goal Sheet.pdf Diabetes Checkbook.pdf Diabetes SMS goal setting.pdf General Improvement Tools Monitoring Worksheet.xls Monitoring Example.xls Roles & Responsibilities worksheet.pdf Example Roles & Responsibilities.doc Appendix B Chronic Care Model/IPIP High Leverage Change Crosswalk RegistryTemplateProtocolsSelf Management SupportHealth SystemAddressed by each state in IPIPDelivery System DesignDetermine staff workflow to support registry use Determine staff workflow to support use of template Monitor use of template Determine staff workflow to support protocols, including standing orders Monitor use of protocolsDetermine staff workflow to support SMS Provide training to staff in SMS techniques Document & monitor patient progress toward goalsDecision SupportUse registry to manage patient care and support population management Select template tool from registry or create a flow sheet Use template with all patients Select and customize evidence-based protocols to office Use protocols with all patients Assess and document asthma severity and control Establish visit frequency protocol Clinical Information SystemsSelect and install a registry tool Populate registry with patient data Routinely maintain registry data Ensure registry updated each time template used  Self Management SupportObtain patient education materials (e.g., asthma action plans) Set patient goals collaboratively Use Asthma Management plansCommunity  Link with community resources (schools, service organizations)  The IPIP high leverage changes were adapted from the Chronic Care Model and placed in a simple sequence for rapid implementation. See the Chronic Care Model/High Leverage Change Grid in Appendix B for a crosswalk. (The Improving Chronic Illness Careprogram is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health's MacColl Institute for Healthcare Innovation)  The Improving Chronic Illness Careprogram is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health's MacColl Institute for Healthcare Innovation.     PAGE  PAGE 17 4/15/08 PAGE  19 18 20 Standardized Care Processes Practice-wide guidelines implemented per condition (asthma, diabetes) Provide Self-Management Support Obtain patient education materials Determine staff workflow to support SMS Provide training to staff in SMS Set patient goals collaboratively Document & monitor patient progress toward goals Link with community resources Employ Protocols Select & customize evidence-based protocols for asthma and diabetes Determine staff workflow to support protocol, including standing orders Use protocols with all patients Monitor use of protocols Self Management Support Realized patient and care team partnership Use Templates for Planned Care Select template tool from registry or create a flow sheet Determine staff workflow to support template Use template with all patients Ensure registry updated each time template used Monitor use of template Implement Registry Determine staff workflow to support registry Populate registry with patient data Routinely maintain registry data Use registry to manage patient care & support population management Planned Care Care Team is aware of patient needs and work together to ensure all needed services are completed Use Registry to Manage Population Identify each affected patient at every visit Identify needed services for each patient Recall patients for follow-up Improved clinical outcomes for patients with diabetes and asthma Measures of success: Diabetes: >70% BP < 130/80 >70% LDL < 100 mg/dl <5% A1c greater than 9.0% >80% received dilated eye exam >90% tested (or treated) for nephropathy >90% counseled to stop tobacco use Asthma: >90% control assessed >90% with persistent asthma on anti-inflammatory medication >90% with influenza vaccination >75% with: assessment of control + anti-inflammatory + influenza vaccination !#&89}~  ; M k r  ' / 0 2 6 H I K N X Y ߶ h%nCJhoh%nCJaJh)9h%nCJh9h%nCJaJh)9h%n5CJhh$+Vh#h%nhohz hNEh%nh)9h%n5 h)9h%nh{hQjh)9h%n5;6%&89_  ' $ ! 8^8a$gdz  ! ^gdo ! 8^8gdz ! ^gdz & F ! gdz ! gdz$a$gd%n$-DM a$gd%n{Cn' P u    3 L N v \ ! 8^8gdc6 ! 8^8gdz ! h^hgdz ! gdz ! ^gdz & F ! gdz$ ! ^a$gdz 3! ^gd# ! ^gd# Y! ^gd# N q  ( I ? o   & F 8^gd%n & F 8^gd%n & F 8^gd%ngd%n $hx^ha$gd%n & F-DM gd%n ? 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" # $ % & Oh+'00( $0 P \ h tIPIP Change PackageJayne Stuart Normal.dotuser2Microsoft Office Word@@yJ@?^@?^wG&VT$m,  3C  ."System~(9)4 -@"Tahoma- ___ 2  @ '@"Tahoma-2 64/15/08t7&77&67 2  6'@"Tahoma- - @ !yTXL- )2 IPIP CHANGE PACKAGE 0B0BCLDMK>BDCFDK> 2 d  @- - '-2 4 (Version 1.6&<5$-68772 4 .17 2 4 )& 2 4?  6 2   7-%2 %XTable of Contents =<?;>&C>@*;@*3 2 % A'- 2 X 7'@"Arial-- 2 I% 2 .- 2 2 -C2 %Key Components of IPIP Change Package;52<6T76858!-6 %7&7<8487574.3475 2 D  8'82 High Leverage Changes OverviewD782525$475<84874-G25$25J;2  ................................#2 L................ 2 117 2 h 7'(2 IPIP System Diagram%7%782-!5TD47%4U;2 p ................................;2 0 ................................2 .. 2 127 2 h 7' 2  7'-2 II%% 2 8.- 2 W -2 HighD78 2 -$/2 leverage Changes Details525$475<84875,D5!4-;2 ` ................................22  .......................... 2 137 2 h 7'2 rRegistry>57-!$2#2 r.RRRQRRRQRRRRQRR 2 r  2 r ..;2 r@ ................................2 r .......... 2 r147 2 rh 7'12 Template for Planned Care.:5T74!5 6$ 748857 <4$5;2 ` ................................22  .......................... 2 177 2 h 7'2 c Protocols7$6!6/6-;2 cT ................................;2 c ................................)2 c .................... 2 c187 2 ch 7'2 Sel85 2 4f 2 T-$&2 xManagement SupportM48475T58!88776$";2 B ................................12  ..........................2 1077 2 h 6' 2 U  7'-2 III%%% 2 ].- 2 | -2  IPIP Measures %7%7M54-8$5- 2  7')2 F Measurement ApproachM54-8$5T58!<77$64/8%2 F ..aRRRQRRRQRRQRRRR&2 F ..................2 F 1377 2 F h 6'42 Measures Chart for DiabetesM54-8$5-<84$! 6$D575!5-2 RRRQRQ;2 ................................2 Z.....2 1377 2 h 6'12 8 Measures Chart for Asthma.M54-8$5-<84$! 6$<-"8T4"2 8 ` RRRRRQRRRQRRRRQ"2 8 ................2 8 1477 2 8 h 6' 2  7'-2 ) IV%< 2 ) O.- 2 ) m -&2 ) IPIP Rating Scales%7%7?4!878/45- 2 ) > 7'+2 Team Assessment Scale :54T<--5--T48!8.45;2  ................................52 ............................2 1577 2 h 6'12  Progress on Changes Scale.7$67$5--68<84875-8.45 2  U s-;2  ................................,2  \ ......................2  1677 2  h 6')2 Other Rating Scales G!85$>4!878.45- ;2 4 ................................;2 ................................2 ..2 1777 2 h 6' 2 X 7'2 Appendix<775872 2  7'12 A. List of Tools on IPIP .<2-!6 ;66-68%8%82 .Extranet82!$485";2  ................................+2 z ..................... 2 1877 2 h 6'2 vB. ;&2 vChronic Care Model<8$68.<4$5N675;2 v ................................;2 v ................................2 vx....2 v2077 2 vh 6'@"Tahoma-'-                    ՜.+,D՜.+,x  ABMSG4 IPIP Change Package4Select the link Setting your self management goalQA more detailed set of materials is the Living with Diabetes Guide by the Amer Title Headings(V^j_PID_LINKBASE _PID_HLINKSAA\<[&http://www.metrokc.gov/health/asthma/1~Jhttp://improvingchroniccare.org/index.php?p=Self-Management_Support&s=39/1[Ahttp://familydoctor.org/online/famdocen/home/common/asthma.html/1tt<http://www.diabeteseducator.org/DiabetesEducation/Find.html16http://diabetes.acponline.org/clinician/CL-PI-ET.html1 6http://diabetes.acponline.org/clinician/CL-PI-ET.html1k .http://www.mainehealth.org/mh_body.cfm?id=3631u (http://www.aaaai.org/professionals.stm/17Lhttp://www.med.unc.edu/wrkunits/2depts/medicine/generalm/resourcepages.html diabetes'}#http://www.diabetes.acponline.org/1  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~     %Root Entry F|@^'Data F1Table,WordDocumentSummaryInformation(`(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q