As one of the triple aims of healthcare reform, improving population health is critical for hospitals and health systems. One of the major focuses of population health efforts is chronic disease management, as chronic diseases affect a large portion of the population, and self-management can prevent other medical complications. For example, diabetes increases the risk of heart disease and stroke, among other issues. Maintaining blood sugar and blood pressure control, however, can help to mitigate these risks. With 8.3 percent of the U.S. population living with diabetes, we as healthcare providers have the opportunity to improve the lives of millions of people by helping patients manage their condition.
At Catholic Health Partners, the parent organization of Mercy, we have a system-wide focus on the D5 composite measure for diabetes, which we're driving mainly through our patient-centered medical home practices. The D5 measure has five standards:
1. Blood pressure less than 140/90 mmHG
2. LDL cholesterol less than 100 mg/dl
3. Hemoglobin A1c less than 8 percent
4. Tobacco-free
5. Taking aspirin as appropriate in patients at high risk for cardiovascular disease
Measuring and reporting on D5
We are using a number of different mechanisms to increase patients' adherence to the D5 measure. The first step is reporting. Our electronic health record and a linked quality metrics reporting tool can generate reports as a scorecard with an intuitive, visual presentation of D5 compliance data. These scorecards can be generated at the individual physician level, the practice level and for the whole medical group, allowing physicians to compare their performance individually and as a practice. This format has created friendly competition among clinicians within an office and among offices.
Each practice has a practice operations council, composed of the physicians and other key practice leaders, that meets at least monthly. The D5 goal and other quality and process improvement initiatives are standing agenda items. The data is reported up to regional managers, who work with several practices. They give feedback on how practices are doing individually and compared with others in the medical group. The entire medical group has a physician-led governance council focused on these goals as well.
Creating action plans
With one click in the scorecard, physicians and their clinical staff can drill down and see a list of their diabetic patients who are not adherent to the D5 composite measure, and what components they're missing. Physicians and staff then create action plans to improve patients' compliance. These plans include phone calls and patient portal communications that don't rely on a patient coming in to the office. The D5 initiative is about improving chronic disease management across our practice population, and that includes engaging patients who aren't coming in for appointments.
For example, a common action plan for patients whose hemoglobin A1c numbers are not controlled is to promote self-monitoring of blood sugar levels. First we make sure patients have a home glucose meter and supplies, and then we ask them to report these levels. We encourage patients to use MyChart, our patient portal, to report their blood sugar levels, which automatically get sent to the ordering physician at specified intervals determined by the patient and physician. MyChart can also send physicians immediate alerts if the blood sugar level is above or below physician-determined critical levels. Physicians can send messages to patients through the portal to change their medication or behavior as needed.
Developing patient-specific goals
In addition to the action plans, we use "planned visits" in our patient-centered medical homes, which use a template for a comprehensive diabetes visit to make sure we're touching on all the goals we're working on, including the D5. As part of the planned visit, we set patient-specific, realistic goals that acknowledge patient-specific barriers to success. For example, we want the A1c level to be less than 7 percent. But what does that number mean for most patients other than being an arbitrary number? We develop patient-level specific goals that are understandable, meaningful and measurable as intermediate steps to achieving the A1c measurement goal. It might be to start monitoring blood sugar levels twice a day, or if they drink a lot of soda, to reduce the amount of soda they drink by a specified amount or switch to diet soda.
We make the goals very specific and unique to the patient, which hopefully make them more achievable. We also ask patients to identify barriers. In the soda example, a barrier might be that the patient doesn't do the grocery shopping. We then develop solutions to overcome these barriers, and the patient rates how likely the solutions will succeed.
To make the goals concrete and real, we put them in writing in the visit summary given to the patient and in the EHR so when we follow up with patients, we can ask about progress on their goals. Patients come to realize that we will ask how they are doing in meeting their specific goals. This attention increases self-management efforts.
Steady improvement
The individual measures within the D5 composite measure don't improve rapidly even with good patient engagement. The LDL cholesterol, A1c and smoking measures seem to be the most difficult to move positively.
We are now eight months into the D5 initiative, and our practice group in northwest Ohio has gone from a 15.9 percent D5 composite measure adherence rate to 20.5 percent. Our goal is to reach 21 percent this year and top quartile over three years. We're very confident we will reach our goal and hopefully exceed it by the end of the year. We're seeing similar improvement in patient-centered medical home practices across Catholic Health Partners.
Ken Bertka, MD, is a family physician and Chief Medical Officer of Mercy Medical Partners and Mercy Clinically Integrated Network at Toledo, Ohio-based Mercy, part of Catholic Health Partners.
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