Written by: Center for Care Innovations

In our Preventing Heart Attacks and Strokes Everyday (PHASE) program — which brings a Kaiser Permanente population health management system to reduce the risk of heart attack and stroke to more than 200,000 patients in 18 clinics, public hospitals, and consortia — we offer responsive assistance to grantees. Beyond trainings (such as motivational interviewing) and conferences, responsive assistance is also valuable when an organization is seeking an outside perspective to solve a thorny problem.

Which is exactly what happened for Chapa-De Indian Health. They had a QI director and a QI department, but still faced a challenge — better integrating the diabetes department with their care teams and serving more patients — that they couldn’t solve on their own.

So Brandon Bettencourt, Chapa-De’s QI director and very involved PHASE grantee, called us and asked for CCI’s help. The outcome of that assistance was so successful that we asked Brandon to share Chapa-De’s journey at the November 2018 PHASE convening.

The audience for Brandon’s “15 Minutes of PHASE Fame” was so riveted, and Chapa-De’s story so applicable to the Quality Improvement challenges many organizations face, that we wanted to share it with you too.

Brandon Bettencourt
Director of Quality Improvement

Chapa-De Indian Health

At Chapa-De Indian Health, we had a somewhat unique problem in the not-for-profit health care world. An FQHC-look-alike clinic with two sites in Auburn and Grass Valley serving about 11,000 medical patients a year, we had a relatively large diabetes department with plenty of staff to care for our patients with diabetes. Yet, the care teams still didn’t feel like the diabetes staff was there to help them get through their day.

Additionally, though our care teams knew that some of their patients were seeing the diabetes team nutritionist, or RN case manager, or registered dietician, or personal trainer (I told you we had plenty of staff), the care teams still saw the diabetes department as impacting only a small number of Chapa-De patients.  Clearly our diabetes care playbook was not working.

So, we decided to ask for help, in the form of PHASE responsive assistance from CCI. We told CCI about our diabetes challenge, they offered us support, and we got started.

You may be thinking, “Doesn’t Chapa-De have a Quality Improvement department? Shouldn’t they be able to handle something like this themselves?” Believe me, I asked myself the same question — and worried about other people asking it too. But we had a lot to learn about QI, and still do, so we saw CCI’s offer as an opportunity.

This concept of care team support — that the diabetes department shouldn’t be just a co-located program, but rather an integrated part of the primary care team — was something we at the leadership level had wanted for a long time. Our participation in PHASE had us taking a closer look at all of our departments, trying to find ways for them to be more supportive of our primary care teams.

Our diabetes program manager, Deb DeCarlo, is a nurse with 20 years of experience. Though she was new to diabetes and new to QI, we had no doubt that she could successfully transform her department and make this integration happen — with a little extra help. Which is where CCI came in.

They matched us with a coach, Wendy Jameson, who encouraged us to do two things right away: go slow, and take our project to the front lines. Both sound simple and are things we talk about a lot, but in fact are very hard to do.

One of the first things Deb and her team did was to run a series of meetings with frontline staff. They stifled the urge to wrap up discussion and start fixing things and instead listened. It really paid off.

A problem identified in the meetings was that the registered dietician and lifestyle coach were using 60-minute appointments for one-on-one education — and consequently were booked out for months. We quickly agreed that this content could instead be covered in a class setting. This wasn’t a major revelation; Deb had discussed this before. But there was power in letting the folks doing the work identify both the problem and the solution themselves.

Within a couple weeks we had a weight loss fundamentals class — and the TNAA for our dietician and our lifestyle coach dropped from a couple months to a couple weeks, which also freed up time for new group visits, too. (Something we are working on with CCI through the Population Health Learning Network.)

A second big issue we found was no consistent, agreed-upon way for primary care teams to connect with the diabetes team about patients being seen that day. So we ran a PDSA (another thing that’s really hard to do correctly) on building predictable, same-day brief intervention spots into diabetes case managers’ schedules.

Our first PDSA cycle totally flopped. We built new schedules with plenty of 15-minute spots for the care teams. The diabetes case managers waited eagerly in their offices for the calls to roll in. Crickets. Deb went hoarse telling folks about these spots, but no one used them.

So Deb brought her team back together and asked what they wanted to try next. They suggested a more proactive approach and requested a report identifying patients for the next day with gaps in care or A1cs > 9. Now the diabetes case managers started using those open spots to go out into the pods and connect with patients proactively. Success!

A third thing that helped this process was Skype. Skype was already being used at Chapa-De. In fact, I had been asking the diabetes team to use it for months. They always smiled and nodded, and went back to the phone. What enabled Skype to finally take off was the team deciding themselves to use it, and their connecting using Skype, and the related workflow changes, with something they really cared about: getting to see patients.

Looking back on the process overall, I feel like everyone involved was at some point frustrated with the slow pace of change. But running multiple PDSAs, involving frontline staff from the very beginning, and not jumping to solutions too quickly really paid off.

The solutions that we developed —including group visits and classes to free up schedules, proactive in-reach by the diabetes team, and using Skype — not only work better but are also being followed more consistently than other changes that used a different process. It’s better for staff, and better for our patients.

This project produced some real wins for us. We have fewer patients with A1cs over 9 and are doing more diabetic eye exams. But what I’m most proud of is the influence this process is having on future projects. We are going slow, involving the frontlines, and being careful not to jump to solutions too quickly. It’s hard, and we still have to suppress the urge to fix things right away, but now that we’ve seen how well this QI approach works, thanks to CCI, we at Chapa-De are sticking with it.

As part of this project, diabetes program protocols and RN Case Manager workflows were created.

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