Keys to Achieving High Screening Rates for Patients with Diabetes- A Large Clinic Perspective

August 5, 2015   |  Tags: Blog   |  Tags: Team Based Care , Chronic Disease Management , Patient Engagement , Portland , Patient Portal
The Portland Clinic

When it comes to caring for people with diabetes, The Portland Clinic is lucky to have many physician champions that advocate for proper self-management. Some of our physicians had mentors before them that encouraged proactive follow-up for patients with diabetes. This sort of focus is important and because of their focus and efforts, The Portland Clinic continues to strive for great outcomes for patients with diabetes. We have dedicated nurse practitioners and a registered nurse who focus specifically on patients with diabetes. We also provide two different informational classes as well as education options, such as insulin pump training.

When a patient with diabetes is seen at our clinic, the patient's primary care provider will work with them to decide if they need a more specialized approach to manage their care. The educational classes we offer are for patients with pre-diabetes, newly diagnosed with diabetes, or for continued support. If a patient is struggling with managing their diabetes and getting their blood sugar levels to a recommended level, we suggest enrolling the patient in an education class. Sometimes group classes, rather than a follow-up office visit can be more effective for the patient.

Part of our success means continually assessing where we are and adapting and refining our methods. We are currently working on having outside sources come in and do additional training for the primary care providers. This training will focus on helping the providers assess their ability to identify patients who may have additional needs, and their comfort level with addressing needs that arise. In order to make this even more worthwhile for our providers, we plan on offering  CEUs.

We are taking a team approach when it comes to our patient care, which means we involve all clinic staff members. Sometimes patients with diabetes have difficulty accessing care. To make it more feasible for the patient we attempt to meet a variety of needs in just one visit to the clinic. This may mean scheduling their lab work, ophthalmology appointment, foot care, etc. back-to-back so the patient doesn't have to juggle multiple appointment trips. We have encountered some challenges as we work with particularly complex patients, but we have found that everything runs smoother when you get everyone on board to work as a team. It is essential to have the common goal of the best care possible for the patient.

Both HbA1c and kidney disease screenings need to be done on a regular basis, and measuring whether it is done, has helped us refine our process over time. Our clinics decided to eliminate the confusion over when the screening needed to be done by setting health maintenance reminders in our electronic medical record. Now we focus our efforts on getting the screening done versus determining when the screening should be done. When a patient comes in, the system lets the provider know which screenings are due; this helps us streamline our patient care, and it is getting more robust as time goes on and we continue to make improvements.

The last and most important key is our online patient portal. Many electronic medical record systems offer this feature, and it really helps the patient to access their own health information. Patient engagement is a huge part of the health care equation. With education, provider instruction, and access to their own information, our goal is really to get to a point where the patient can practice self-management using all of these tools. There is so much that goes on in our patients’ lives, and our providers only see them for a fraction of their day, week, or month.

Each year the Oregon Health Care Quality Corporation (Q Corp) produces Information for a Healthy Oregon, a statewide report on health care quality and utilization. The report analyzes claims data across populations to identify opportunities for improving the quality, affordability, and patient experience of care. For this year’s report we interviewed top performing practices to learn what they have done to achieve high screening rates. Stay tuned for the release of this year’s report later this summer; it will be available for download on the Q Corp website. Tara Bergeron from The Portland Clinic – Yamhill shared the keys to the clinic’s high performance on quality measures for Diabetes Blood Sugar (HbA1c) and Diabetes Kidney Disease screenings.

The Portland Clinic has been recognized as a Patient Centered Primary Care Home through the Oregon Health Authority's Patient-Centered Primary Care Home Program. The Portland Clinic is also part of the Portland Coordinated Care Association (PCCA), a network of independent medical groups in Portland that pool resources to help lower costs, improve quality outcomes and prefect the patient experience.