RN Diabetes Group Visit Agenda

Sherrie Elmer kicked off her monthly diabetes group visits last week. I asked her to send me some information about the class so we can help our patients understand the kinds of resources we've got for them.

One of the great things about this class is that Sherrie is such a presence here at Burien. She knows our patients and having the class taught by our own RN helps us with continuity.

Plus, Sherrie is a superstar!

The class is every second Tuesday from 3-4:30pm in the North Annex.

Agenda

1. Warm up (Self Introduction and how long have they had diabetes) and explanation of PAM (Patient Activation Measure). Will need calculators. 10 minutes.

2. PAM 13 Questions and Behavioral Priorities. 25 minutes

BEHAVIORAL PRIORITIES

• STAGE 1: May not yet believe that the patient role is important (having a PAM score of 47.0 or lower, 11.8%)
• STAGE 2: Lacks confidence and knowledge to take action (having a PAM score of 47.1 to 55.1, 29.3%)
• STAGE 3: Beginning to take action (having a PAM score of 55.2 to 67.0, 36.5%)
• STAGE 4: Has difficulty maintaining behaviors over time (having a PAM score of 67.1 or above, 22.3%)

3. Your Diabetes Data and Responsibilities. 30 minutes

Review of patient's own lab results and blood pressure. During this discussion we touch on what diabetes is, why life changes (including diet and exercise) are important and how we can accomplish the changes needed. We also talk about the patient's responsibilities in keeping their disease under control.

4. Action Planning. 20 minutes. I assist them in making one small goal and plan how to accomplish this.

5. Wrap up - Retinal screening/eye exams: phone numbers and maps; AVS to be mailed to patient. (This gives me time to collate the information and get it on his/her chart for their information.)

We also discuss follow up with PCP and Team RN in one month's time, parameters regarding when to call the doctor, what to do if sick and on Metformin, and Sick Day Plan.

I give them resources of who to call and/or web addresses to look for more information.

The patient will get a packet of information at the class, but not too much. Just the basics to start.

Follow up will be by PCP and Team RN.

January 14, 2009 West Cluster Meeting Notes

Present: Becky, Mark, Sherrie, Sarah, Kelly, Timieko, Star, Ashley and Doug

Becky presented a new PCER list; East Cluster has narrowed their list and it could be color coded if we wish; this can be decided upon later.

A note “letter sent” can be entered on the “G” drive so as not to bother the patient again for at least 6 months.

Discussion about ways to help cut down opportunistic care- have patient bring letter in to visit (note it in the letter), calls to patient to come in for fasting labs if they are having a PE or due for such labs soon.

New Diabetic Red folders are located in the nursing area of the West cluster at the top holder on the wall where the incoming folders are from the Business office. Diabetic cards are in the folders. Star put flyers for the new RN class in each folder.

Discussion about diabetic group visits. Dr. Knopp is interested. ? Saturday group visits.

Meeting is adjourned approximately 2:20pm.

Star Morales, CMA

CORE MEETING Minutes December 2nd 2008 8:00-9:00am

Agenda that was discussed

Injection Room
1. Call Center will start making appointments for CORE
So far everything the most part are working well. Go live date is January.
We will re-evaluate later.

2. Consent forms and yellow cards are not being filled out before coming to
CORE
We have seen some improvement from East and West Cluster. North
Wing still sends patients over (about 50%) with yellow cards/ consents.
Immunization forms not filled out. However, we have seen Improvement..

This appears to be more of an education issue and we will ask Becky to put on
Agenda for the next all staff Nurse meeting

3. Immunizations:
New vaccine (pentacel) now has Dtap-HIB-Polio. The Staff have voiced concerns
About giving too much HIB, however this issue was discussed with Shiji. Who
Said that it wouldn’t be a problem and to go ahead and give the pentacle.
Another issue that was brought up is the Zostervax. Patients have been coming
In requesting the injection, however there is a nation wide shortage. The vaccine
should be available in June or July.

In the mean time Cindy is keeping track of the all patients that want the Zostervax
Vaccine. Pat suggested that GH send out a flyer telling the patients when the
Vaccine is available.

Some questions were brought up about getting the Zostervax vaccine and preventing
Any chance of getting shingles? Here are some facts that I got from the CDC website:


General Questions about Shingles Vaccine

Is there a vaccine to prevent shingles?
Yes Is. CDC recommends Zostavax for use in people 60 years old and older to prevent shingles. This is a one-time vaccination. Zostavax does not treat shingles or post-herpetic neuralgia (pain after the rash is gone) once it develops.

How effective is the shingles vaccine?
In a clinical trial involving thousands of adults 60 years old or older, Zostavax prevented shingles in about half (51%) of the people and post-herpetic neuralgia in 67% of the study participants. While the vaccine was most effective in people 60-69 years old it also provided some protection for older groups.

I have more information that I got off the CDC. Let me know if you want it

December 31, 2008 West Cluster Meeting Notes

Present: Becky, Mark, Sean, Kelly, Doug, Sarah, Timieko and Star

Becky introduced the BRN Flow Nurses Outreach Responsibilities sheet which is shared form the East wing. Discussion about staff signing orders, standing orders for lab view (sometimes patients have other labs that need to be drawn but are not released for lab view that day and then pts have to come back for another draw). Discussion about can lab personnel be trained to ask questions about if pt is diabetic or has cardiac disease and then check a clinic wide HEDIS list narrowed down for just these things and then draw an extra tube or ask MD or nursing staff to order …. More discussion later.

Hemoccults can be used once a year after age 50 instead of flex sigs if patient has no family history of colon cancer.

? Epic upgrade so lab can look at other lab s that may need to be drawn around the time they are in. Can ask Kris Moore on 1/7/09.

Please label injectable medications with the date you open the vial.

Label food in fridge; will try to clean out once a month.

Can refer appropriate patients to Sean Robertson, RN for Case Management via Epic secure message.

Meeting closed approximately 2:20pm

Star Morales, CMA

CORE MEETING Tuesday, December 30th, 2008

Topics for discussion:

8:00- Injection room
1. TB Screening- some confusion on documentation process. Core staff denied confusion; they felt it was probably a flow staff that worked in the injection room. Pat agreed to educate the LPN’s on TB protocol.

2. Injection Charting Errors- Most errors come from forgetting to put the asterisk in front of the lot number when they are charting on pediatric patients. We will start tracking on a monthly basis to see if the same errors are being made.

8:25 Immunizations
1. Count: daily, weekly and monthly- staff feel that counting immunizations only need to be done bi-monthly.
2. Ordering system- the staff were concerned that Bobbie is the only person that knows how to order Immunizations- We will start training all core staff so that if someone is sick or on vacation, the count will still get done on time
3. Bobbie will put together all the information that is needed and put in a Sherpa. The Sherpa will also contain the instructions for charting them in Epic.
4. The matrix has been changed again. The new one address’s procedures that are done in the core. Copies have been made and distributed to all core staff. Pat will train flow staff LPN’s who float to the core. This information will also go in the Sherpa.

8:40 Levine
1. We would like Dr. Levine to attend our meeting once a month. Dr. Levine also like this idea and will be at our next meeting on 1/6/09
2. Some topics that we would like to discuss with him are: ordering immunizations, wound care, and we would like to set up a weekly or bimonthly meeting with him to discuss our difficult wound care patients.

8:50 Dressings
1. Need a time to get caught up on new products and old products. (when to use them, why we use them and how to use them) this will be done through a 15 minute

North Cluster meeting minutes 1/5/09

Ongoing Focus:

Nurses:
1. encourage my group health use
2. 100% fluoride for WCC 6mo-3yrs
3. note same day HEDIS outliers for providers

Providers:
1. 100% AVS
2. act on same day HEDIS outliers

New to do:
Becky: look into paps, mobile mammo (see below)
Mark: look into PCR's/PAR's bringing up and offering MyGroupHealth brochures on check in
Nurses: note vitals refusals, lay out BP cards if BP's higher than target
Providers: special attention to BP's
____________________________________________
Present: Anna, Becky, Diane, Jason, Lakisha, Liz, Mark, Shiji, Ted (Yay! This is the closest we've come to a perfectly attended meeting since October)
Absent: RN

Leaders: Jason and Liz

A. Pushes for AVS's and fluoride have been good. Keep up the good work.

B. Attention to MyGroupHealth signups has been waning because of business. Will try to re-focus. Mark will also check with front desk folks to see if they are offering MyGroupHealth brochures to people when they check in. If not, will start.

C. Liquid nitrogen - being left open. Will pay attention to closing valve tightly. No splash nozzle was ordered a long time ago.

D. would like mobile mammogram schedules posted in rooms again. Also will request more dates

E. reminder for appropriate vitals at every visit, including weights. If pt refuses - please note that for provider. 1 trick is to offer to weigh pts with them standing backwards so that they don't have to see it themselves.

F. unclear why our numbers are so poor with our paps. Unclear if the overide modifiers in Epic actually turn off the HEDIS measurement. Becky will look into this.

G. HTN seems like a good big measure to target.
1. Reminders that nurses and providers repeat BP's if they are elevated (everyone is doing this already).
2. BP cards. Have a big stash of BP wallet cards in all the rooms so that we can hand these out routinely. Recommend that nurses put one of those on the table if they notice an elevated BP. This will serve as a reminder to the doc that this needs addressing and lead to more education and self surveillance for pts.
3. will ask Shannon to come talk with us at our next meeting about her role in the eBP study and how we can adapt that for our own cluster purposes and who would do her role in this.

DM Class dot prhase

From Jason Wong: "I just made a new departmental smart phrase so all of us have access to it already. I have found this phrase helpful to give to pts on their AVS because they are rarely able to plan far enough ahead to register for one on the spot."

.1pidiabetesclass
(per my usual naming convention, 1 is for our department, pi is for patient instructions)
________________________________

I recommend that you call or go to the front desk and register for our diabetes class or group visit sometime soon for more education and information about diabetes:

- the class led by a nutritionist is the 2nd Tuesday of the month 10am - noon.
- the group visit led by a nurse is every 2nd Friday of the month 3pm - 4:30pm.

They are both free, but you need to register in advance to make sure the class is not too crowded.

CORE MEETING Minutes Tuesday, January 5th 2009

Topics for discussion:

8:00- Dr. Levine

1. Doctors putting in orders: core staff voiced concerns that Doctors aren’t consistently writing orders for the patients that they bring over to core. This does not include drop in’s. Dr. Levine agreed and will speak to doctors.

2. Core/Dr. Levine meetings with core staff to discuss wound care patients:
A. Doctor Levine agrees that a meeting is necessary. He will look at his schedule and let us know what day will work for him. These meetings will be bi-monthly, Start and end time has not yet been decided.
B. Pat brought up that there should be 1 doctor in the clinic that will become “the wound care” Doctor. Dr. Levine stated that he has been working on it. He also pointed out that you can not force a doctor to assume that position.

3. Drop in’s and the impact it has on the core: Pat has been tracking drop in’s on a monthly basis. Looking at what day of the week we get the most drop-in. This is being done so that the core can be up-staffed on high volume days.

4. Cindy brought up discussing patients and HIPPA Law. She reminded us that if she can
Hear us talking, so can all of the patient’s that are sitting in the lobby.. It was a great reminder for us (staff feel that they do good and then we start to slip again). Core agreed that we need to cognizant of where we talk regarding patients, as well as the volume of our voice.

8:30 New Matrix Changes: New coding for injections and CORE procedures.
We ran out of time to discuss this. Will be placed on the agenda for our next meeting

8:50 Immunizations :
We also ran out of time to discuss this. Will discuss at next meeting

January 7, 2009 West Cluster Meeting Notes

Present: Becky, Mark, Sean, Doug, Sarah, Ashley, Kelly, Timieko, Esma, Star

Speakers: Kris Moore, M.N., R.N., Coordinator Population Based Care, Michelle Seelig M.D., Medical Director, Clinical Information Systems: Best practices of HEDIS Measures

Meeting held in North Annex, Burien clinic.

Questions about how to use the tool for opportunistic care for making quick headway.

Reports are always 3-7 weeks behind so check EPIC first before contacting patients on the list to see if care has already been received.

Where should we target first?
DM and heart care are number 1
Cancer (Breast, cervical and colorectal) is number 2
Childhood immunizations are number 3

If patients are not able to take ASA provider can add this to the problem list.

If a child is off on the regular immunization schedule, they can add “Alternative Immunization Schedule” to the Problem List.

There are different age cutoffs for different measures, but most are under age 80.

Discussion about labs, when lab orders are available to the lab, patients having to get multiple labs drawn because of this……

Birthday letters come out of their office and we can contact them if there is an exception.

Contact Kristine Moore through Outlook or Epic;
Contact Michelle Seelig through Outlook or Epic

Meeting closed at 2:30PM

Star Morales, CMA

East Cluster Meeting Minutes, January 7, 2009

A very well-attended meeting today!

Flow

• We reviewed our immunization discussion from last week, which concluded that only children under 4 years old must go to CORE for shots. However, we have no reliable system for delivering immunizations in the clusters, as MAs are prohibited from doing so. Sheila reports today that CORE does not expect clusters will do their own shots if clusters are busy. If clusters are flowing efficiently, cluster flow staff should do their own injections. (Note: this last bit was clarified further by Sheila on Jan 9).
  
• Regarding our original flow document. This is several pages long and quite complex. It sits in a notebook, and no one could be expected to review it regularly to recall what the nursing flow job is. So, is there a disconnect between that "formal" document and the day-to-day work our nurses are doing? Cheryl responded that there are still quite a few variables in the day, floating staff and provider preference differences make our standardization work more challenging.
• Blood pressure. Could we eliminate some re-work by deferring blood pressure measurement until the patient has been seated for a few minutes (end of nursing assessment)? We agreed to do this and discuss it next week.
• An FYI: our new Occupational Medicine provider starts soon (February?), and will see both Occ Med cases and commercial driver's license certification visits.

Quality

• New PCER reports are out. They feel lighter.
• As a clinic, we are up 1%, which is a big move for a big population! We're at 70%, goal is 75%. We're on our way.
• We agreed to have Becky deliver PCER reports next month with just the priority items we have identified (see last week's notes).
• Levine has asked to be held accountable to deliver a sample HEDIS letter in seven days. The clock is running. Tick tock.
• Dr. Butler's flowstaff, working in Katie's absence, should absolutely be doing HEDIS outreach. Katie comes back Feb 2!
• Sherrie's DM classes start soon! Every second Friday of the month, she'll spend 90 minutes (from 3-4:30p) with a group of up to ten patients with diabetes. She'll review their clinical data with them and use this as a way to do facilitated, group teaching around issues of self-managment. Jason Wong has created a dot phrase we can use in our AVS notes, and Wellesley will see if it is BRN-wide, or can be made so.