PHA lean tools help a rural, Southern Indiana FQHC surpass CMS Healthy People 2020 goals for diabetes management

Valley Health Clinic, part of the nonprofit community health center Southern Indiana Community Health Care (SICHC), is a “very tiny, rural office with great people but limited resources,” according to Nurse Practitioner Brittany Stout, FNP, who worked with Purdue Healthcare Advisors (PHA) to improve management of its Type 2 diabetes patient population.

Working with Purdue

Although Stout understood the barriers to optimal diabetes care, she wanted direction on how to make changes to workflow to reach the Centers for Medicare and Medicaid Services’ (CMS) Healthy People 2020 goal of an uncontrolled rate of less than 16.2%. As a member of the Great Lakes Practice Transformation Network, SICHC was able to receive no-cost, quality improvement assistance on a project of their choice in 2019 from PHA at Purdue University. The chronic care management of diabetes at the center’s Valley Health office in French Lick, Ind., was chosen as the focus, and Stout began a project to test and implement best practices.

The six-month project, which used PHA’s Lean Daily Improvement (LDI) methodology to make small, daily, coordinated changes to processes without disrupting the work environment, resulted in the reduction of Valley Health’s Diabetes Mellitus Type 2 Poor Control (hemoglobin A1c levels >9%) reporting metrics from 45% to 16%.

“Brittany’s passion for diabetic education combined with her role as a family nurse practitioner and quality lead at SICHC made her the perfect candidate for a lean process improvement project,” said PHA Quality Improvement Advisor Kelley Gillaspy, LPC, CMPE, CHIIS, who worked with Stout to implement workflow changes using LDI. “I could tell she genuinely cared about her patients, the clinic and the overall organization, and felt she would want to make a positive, long-term change for her patients. Once she understood the basics of LDI, Brittany and her team were able to quickly made the necessary changes.”

Brainstorming barriers

At the beginning of the project, Stout and Gillaspy brainstormed to determine which factors were contributing to the center’s higher number of patients with uncontrolled diabetes. Initial discussions revealed that patients weren’t getting the education they needed to make the behavioral changes necessary to avoid diabetes medication. Secondly, many diabetes patients weren’t being seen regularly and others had trouble getting their prescribed medications. Finally, shared decision making on treatment, while being sensitive to the desires of the patient, didn’t always help to normalize their levels.

“This was one of the biggest issues for me personally as a newer prescriber,” said Stout, who previously had trained in motivational interviewing techniques to positively influence behavioral change but said she lacked the assertiveness necessary to always convince patients to make the correct treatment choice for their condition. “When it came down to choosing an option that involved injections or a pill, patients often went for the oral medication when the shot would have made a much bigger difference for them.”

Acting on the plan

Stout said Gillaspy’s lean coaching and encouragement gave her the confidence she needed to work more effectively with patients by weighing their receptivity for change with the latest science and protocols for controlling diabetes. Stout says, “I made sure my patients knew that the treatment doesn’t have to be permanent, and that I love to discontinue medications! This helped them feel like we were working together and that their lifestyle and eating habits really did impact treatment.”

Specific actions by the center to address their diabetes population of about 120 individuals included offering 5-10 minutes of diabetes education from the provider per diabetic patient, and giving patients at greater risk (A1C >9%) an additional 10-15 minutes with the medical assistant after the appointment.

In addition, staff worked to identify and contact patients to schedule future appointments and to remind them to come in. Patients with A1c numbers greater than 9% were called every two weeks for a wellness check.

Valley Health Clinic also placed more importance on the need to get sugars better controlled quickly due to end organ damage that can result from uncontrolled diabetes. They added GLP-1 (a glucagon-like peptide-1 agonist) to their prescribing protocol to increase insulin levels. This medication was added to or followed by other oral options and/or insulin, if needed. If new, branded medications were prescribed and it was unclear whether the patient’s insurance would cover the cost, the staff worked with insurance on prior approvals and called the patient several days later to make sure they had obtained the medication from the pharmacy.

Expanding pilot project

Previously a Federally Qualified Health Center (FQHC)-look-alike, SICHC received its official FQHC designation following the project, and plans ― with the additional federal funding ― to incorporate some of the project recommendations, such as increasing diabetic patient office visits to 30 minutes; allocating education time to allow patients to better understand the disease state, diet and exercise needs; offering more flexibility in follow-up calls (not everybody likes the two-week intervals); and prescribing medication and motivating behavior change more assertively. Dedicating a portion of an assistant’s time to chronic care education will be important for Valley Health and other offices that are located far from diabetes group training programs, Stout said.

Stout said the success of this project has prompted SICHC, which serves patients in a four-county area, to consider changing workflows across all its sites to better manage all its chronically ill patients, not just the ones with Type 2 diabetes. “Even though our rural office is tiny and budget-constrained, Lean Daily Improvement allowed my office manager, medical assistant and I to make the kinds of patient-interaction changes that really make a difference, and we were able to show this statistically to make a broader impact for our organization,” Stout said.

PHOTO CAPTION: Shown left-to-right in back: Debby Heinz, Office Manager; Megan Manship, Medical Assistant; and Carrie Graves, Medical Assistant. Shown left-to-right in front: Britanny Stout, NP; and Jessica Foddrill, Medical Assistant.