BRIGHT SPOTS

[GUARDIANS FOR HEALTH]
[Overcoming challenges and resistance to change]
[Bright spot with Dr. Daniel Ngui]
[GUARDIANS FOR HEALTH is a non-promotional, brand-agnostic initiative coordinated by Boehringer Ingelheim.]
[SC-CRP-11873]

[Dr. Daniel Ngui, BSc (P.T), MD, CPFPC, FCFP, Family Physician] Some of the challenges that one can face when trying to implement this new model of chronic disease care is that you have to overcome some doubts of your team and team members because oftentimes,

there's a lack of training and lack of awareness of these new chronic disease models.

Oftentimes, there's a lack of proof of concept or lack of financial sustainability models that you will have to face.

Also, you may have to deal with some initial patient reluctance to work with a team because the patient may say, I want to see my clinician.

And so you have to overcome that by saying the team and your clinician will be seeing you and that way you can overcome that initial patient reluctance.

One other aspect you have to overcome is a health care providers resistance to change.

Many clinicians don't know about team-based care, they don't know how to best collaborate and work together. So you need to provide some education about that so that you can work together as a team.

From the patient experience perspective, I think that it's challenging trying out this new model, but what we've found is that when patients are called during the era of telemedicine during the pandemic, this was an ideal method and situation to integrate a new approach to chronic disease care.

Our patients appreciated the phone call or video conference letting them know that we cared about them and that we were still open to serve them.

Our patients appreciate the question, how do you think you're managing with your diabetes during the pandemic?

They really appreciate the opportunity to have extra education in a time where everyone was isolated.

When it comes to overcoming these challenges mentioned earlier of reluctance to adopt a new model for chronic disease management, it's important to implement ideas to overcome these challenges.

One is to provide opportunities for the team to access medical education about team-based care or about clinical practice guidelines through lunch and learn sessions through evening seminars or videos.

And even perhaps with a working group meeting put on by special interest groups such as Diabetes Canada Primary Care interest groups or Guardians of Health.

I think it's important that the medical team are made aware of the latest clinical practice guidelines, the latest landmark research and medications that can improve patient health outcomes.

It's vital that your team develop an internal culture of change. Understanding that everyone's working towards continuous quality improvement.

Looking back at our process and our evolution, the feelings of this initiative in general have been fantastic. It's been a long, interesting and rewarding journey.

I'm still continuing learning and trying to involve what we've been learning about. This entire process has been inspiring and self perpetuating.

I believe that the secret to sustainability may be having a team and having a team approach. The reason why is that we keep each other up to date with the latest clinical practice guidelines.

The latest research and awareness of the latest medications that can help our patients.

We are aware that we are trying to do everything together as a team and take on the responsibility of improving patient care together.

[Disclaimer
The members of the scientific planning committee acknowledge that their participation was made possible by sponsorship funding from GUARDIANS FOR HEALTH and Boehringer Ingelheim Canada Ltd.
The scientific planning committee was solely and fully responsible for developing all content and was involved at all stages of development to achieve scientific integrity, objectivity, and balance. As such, the content does not necessarily reflect the opinion of GUARDIANS FOR HEALTH, Boehringer Ingelheim Canada, or Boehringer Ingelheim GmbH]
[Guardians For Health logo]

[GUARDIANS FOR HEALTH]
[Implementing a Patient's Medical Home]
[Bright spot with Dr. Daniel Ngui]
[GUARDIANS FOR HEALTH is a non-promotional, brand-agnostic initiative coordinated by Boehringer Ingelheim.]
[SC-CRP-11874]

[Dr. Daniel Ngui, BSc (P.T), MD, CPFPC, FCFP, Family Physician] In terms of what we did in our office when thinking about a team based approach for diabetes,

what we what we said to our ourselves as a team is that we always need to think about using the right clinician at the right time for the right issue.

Everyone needs to agree on what the focus is and what the delegated tasks should be.

The team or our chronic disease CDM team, were focused on identifying the care gaps and then delegating the work of educating our patients and reaching out to our patients to other clinical pharmacists, other certified diabetes educators and allied providers in our office.

In doing so, we were able to have a very efficient method of identifying care gaps and providing the right clinician at the right time for the right issue.

I think that the challenge is that many clinicians may not be aware of this, there's no proof of concept of the financial survivability or sustainability of this model.

I think that a lot of clinicians may object because they will say, I don't really have access to a pharmacist, I don't really have access to a certified diabetic educator, or where do I find a allied health provider?

I think a lot of clinicians may doubt this because they will think that they need to have a dedicated exam room or space for team members.

But I want to say that it's possible to overcome these issues.

And what are the new things that are occurring for all physicians in our neighborhood is the development of the primary care network.

In this model, and I'm sure in other jurisdictions, there are interdisciplinary teams that other physicians can access, that we can refer to for example.

We can refer to social work occupational therapists, clinical pharmacists, Clinical Counselors and dieticians as part of our patient, medical network, and therefore, all clinicians can get access to a team.

So when it comes to choosing an ideal team member to be a chronic disease coordinator, there are many options. You could have a nurse in your practice, or you could have a super medical office assistant or you could have a trainee who could take on this role.

But in our experience, one thing to consider is that perhaps there's someone out there who is ideally suited to be a chronic disease quarter that you can partner with.

International medical graduates are ideal potential partners to be a chronic disease coordinator within your office.

It's often a win win arrangement where these international medical graduates are hoping to gain clinical experience and exposure to the healthcare system.

And as a clinician you are going to gain from working with them because they're medically trained, and they're already experienced dealing with chronic diseases.

So despite all those wonderful resources I mentioned before, a key idea is that you need to tailor your manual to your own individual clinic and your own individual situation and your own individual approach.

I think that for our clinic, what we did is we had our chronic disease manual, customized, which fit our local experience.

When you make your own manual you need to consider the local billing guidelines, making sure that this is a statement sustainable process.

You need to consider your own local clinical practice guidelines when it comes to diabetes.

And I think the overall overarching principle is that this is an iterative process.

And it's important that you as a team develop a culture of change. The team must be involved regularly and meet and you must incorporate the recommendations and move forward together.

Thank you for the question about where do you find the resources protocols, manuals for helping to train chronic disease coordinators?

Well, I think that it's important to first of all say there are lots of downloadable resources and with the resources provided to you through this initiative,

you'll get access to links for patient medical home toolkits to make you understand the concept of the patient medical home.

There'll be some best advice guides on chronic care management within the patient medical home best practices in terms of key base care and EMR usage.

And one instrumental article or seminal article was the ‘American Medical Association's six key steps to developing an efficient team based approach diabetes management’.

These are excellent resources that everyone should review.

[Disclaimer
The members of the scientific planning committee acknowledge that their participation was made possible by sponsorship funding from GUARDIANS FOR HEALTH and Boehringer Ingelheim Canada Ltd.
The scientific planning committee was solely and fully responsible for developing all content and was involved at all stages of development to achieve scientific integrity, objectivity, and balance. As such, the content does not necessarily reflect the opinion of GUARDIANS FOR HEALTH, Boehringer Ingelheim Canada, or Boehringer Ingelheim GmbH]
[Guardians For Health logo]

[GUARDIANS FOR HEALTH]
[Using a chronic disease coordinator to improve quality]
[Bright spot with Dr. Daniel Ngui]
[GUARDIANS FOR HEALTH is a non-promotional, brand-agnostic initiative coordinated by Boehringer Ingelheim.]
[SC-CRP-11876]

[Dr. Daniel Ngui, BSc (P.T), MD, CPFPC, FCFP, Family Physician] When it comes to the importance of continuous quality improvement and data monitoring quality, I think the beauty of working as a team is that you can all focus on continuous quality improvement.

You can all have multiple sets of eyes and brains double checking and monitoring the quality of the data that we enter, as well as working together to identify care gaps and recalling patients.

I think our CDM coordinator and team can help to do this work.

And as a team, we can help identify patients who have missing lab tests, who have more information required for learning about the ABCs of diabetes care,

and I think that as a team, what we found is this been a great way to identify patients who should be offered cardiorenal protective agents as part of the best evidence based recommendations.

I think as a team, it makes it sustainable for us to work together to regularly remove in a profile items. So the importance of data quality monitoring and management is paramount. And as a team, we can work on this ideally together.

Although it sounds like a lot of work, I think that what most clinicians don't realize is that it is possible with a team. 

Family doctors are so used to doing everything by themselves.

But we took a risk and we tried a new concept which is we invested in the manpower and created a role of chronic disease coordinator and thought about a distributed team based model.

When we hired a medical scribe/chronic disease coordinator, this individual was able to help improve documentation, of clinician visits, as well as focus in on using the EMR when clinicians were focused on clinical care.

I think when you think about a chronic disease coordinator, there's some requirements include being medically trained, being able to identify care gaps in terms of any chronic disease.

The chronic disease coordinator needs to be current and up to date with the latest guidelines and literature.

And I think that whoever you choose to be the chronic disease coordinator needs to have the aptitude and skills to use your EMR so that you can identify patients who are appropriate for recall for the team.

[Disclaimer
The members of the scientific planning committee acknowledge that their participation was made possible by sponsorship funding from GUARDIANS FOR HEALTH and Boehringer Ingelheim Canada Ltd.
The scientific planning committee was solely and fully responsible for developing all content and was involved at all stages of development to achieve scientific integrity, objectivity, and balance. As such, the content does not necessarily reflect the opinion of GUARDIANS FOR HEALTH, Boehringer Ingelheim Canada, or Boehringer Ingelheim GmbH]
[Guardians For Health logo]

[GUARDIANS FOR HEALTH]
[Introduction and challenges within primary care]
[Bright spot with Dr. Daniel Ngui]
[GUARDIANS FOR HEALTH is a non-promotional, brand-agnostic initiative coordinated by Boehringer Ingelheim.]
[SC-CRP-11877]

[Dr. Daniel Ngui, BSc (P.T), MD, CPFPC, FCFP, Family Physician] When it comes to my clinical practice journey and how it evolved, I think all clinicians start off as being inexperienced, very eager, and really wanting to do a good job.

My first experience was working for a health care team within a government run local health unit. I took on that job because I really wanted to understand my role as a family physician.

And I wanted to learn how to work with different health care team members. And eventually what happened is that I had to move off to a different private practice clinic.

I joined a community private practice to be with my father actually, who's a family doctor, who had established a clinic over 45 years ago.

What I learned from him was, I wanted to be as dedicated as him and I wanted to do a little twist and involve the traditional model of family practice.

When it comes to my approach as a family physician, I must say that two and a half decades goes by fast.

I'm still learning how to ideally lead a team, an interdisciplinary group of nurse practitioners, pharmacists, medical office assistants, medical trainees, and physicians. And our approach can be summed up as focusing on planned proactive care.

We use the EMR, we use search strategies that are incorporated on a daily basis. And we do that so that you can optimize efficiency and scalability.

What this does is it allows us to focus on chronic disease management. It allows us to focus on health promotion, and medical education for our healthcare providers and for our patients.

This really helps to empower both patients and healthcare providers.

Another way to describe my approach can be clearly understood by reading the 2018 Canadian Diabetes Association's clinical practice guidelines chapter on the organization of care.

This was an inspirational piece of work, and the author Maureen Clements et al., their group outlines some principles of the five R's and ways to organize diabetes care in a clinician’s daily practice.

The five R's are the following, recognize, register, resource, recall and relay. So when it comes to recognizing your patients with diabetes, you need to consider your patient's diabetes risk factor and screen appropriately for diabetes.

You need to register and develop a register of all your patients with diabetes so that you can ideally track care.

When it comes to the word resource, you need to support patient education and patient self management through the use of resources given to patients by interdisciplinary professional teams.

This could include family doctors, diabetes educators, registered dietitians, nurses, pharmacists, specialists and all of them focusing on self management support, helping patients to be linked with community services.

When it comes to relaying information. It's important that we facilitate and standardize information sharing between patients with diabetes, as well as the healthcare team members, and to make sure that we provide coordinated and timely changes.

When it comes to recall, the fifth ‘R’, we need to develop a system to remind and we and identify care gaps for our patients so that we can spend some one on one time with them, educating them and offering them the best possible options.

So when it comes to some challenges that primary care clinicians may face when managing diabetes, I think that as our populations age, many of our patients with diabetes will have multiple comorbidities, heart failure, chronic kidney disease, for example.

And I think that it's important that we take a holistic approach.

The other challenges that clinicians face depending on your jurisdiction, would be fee for service billing.

What's fee for service billing challenges as well is that we have very limited time to address patient’s multiple concerns.

Traditionally, there's been a lack of funding and training for team-based care. This is a challenge and barrier we must overcome.

Traditionally, there's been a lack of training for clinicians on how to best use electronic medical record, how to use our templates, how to use our EMR macros, and how to use our EMR searches, queries and dashboards to optimize chronic disease management.

Other barriers that we need to consider when it comes to approaching a different method of diabetes management is to be aware that there will always be patient inertia.

It may be due to a lack of awareness of patients of their conditions, it may be that they are not aware of how a team can work together on their diabetes management.

Another barrier may be clinician inertia within your own practices or within your own teams. This may come about because of a lack of awareness of the current guidelines or a hesitancy to implement the latest recommendations from the guidelines.

I think that another important barrier is actually our knowledge of the principles of population health management. What are the best practices in terms of managing a roster for example.

The other lack of awareness is on how to best work as a team, how to best manage your practice.

All clinicians have a lack of time and so we have a lack of protected time to focus on quality improvement and improving team workflows.

When it comes to considering the patient experience and the patient perspective, when I recollect about this new model, I think my very first patients got used to working as a team.

I think patients are always given an option of how they like to be managed and interacted with. And I think that it's important that every patient be given this as an option.

Patients who are new to this, do appreciate the systematic and deliberate approach. Many patients I found who have adopted and agreed with this approach have become better self managers.

In the end, you have to ask your patients what they prefer, and you need to individualize the approach.

[Disclaimer
The members of the scientific planning committee acknowledge that their participation was made possible by sponsorship funding from GUARDIANS FOR HEALTH and Boehringer Ingelheim Canada Ltd.
The scientific planning committee was solely and fully responsible for developing all content and was involved at all stages of development to achieve scientific integrity, objectivity, and balance. As such, the content does not necessarily reflect the opinion of GUARDIANS FOR HEALTH, Boehringer Ingelheim Canada, or Boehringer Ingelheim GmbH]
[Guardians For Health logo]

[GUARDIANS FOR HEALTH]
[Tips for a successful Patient's Medical Home]
[Bright spot with Dr. Daniel Ngui]
[GUARDIANS FOR HEALTH is a non-promotional, brand-agnostic initiative coordinated by Boehringer Ingelheim.]
[SC-CRP-11878]

[Dr. Daniel Ngui, BSc (P.T), MD, CPFPC, FCFP, Family Physician] When it comes to focusing on how to share this approach with others, one great way of doing this is through interdisciplinary continuing medical education.

So having a lunch and learn where there are different providers and professionals.

That is the best way to share team-based concepts to share cases where you're working on patients with diabetes cases, and it's a great way and efficient way to learn.

I think that when you are trying to share this with others, you need to make sure that they're aware that this new approach is something that they can take on in small steps and to allow them to work together in a team-based fashion on a consistent basis. 

For clinicians who are interested in adopting a new chronic disease model when they're aligning their practices with the principles of the patient medical home. Let me tell you about four key steps that clinicians can try to focus on.

Number one, if you simply work on cleaning up your Chronic Disease Registry, I think that's the first step towards understanding your chronic disease patients.

Number two, whether you or your team member has protected time regular set aside time for care gap analysis, I think that's an important first step towards identifying your chronic disease patients care gaps.

The third thing is to understand that you need to think about a systematic approach, making sure that you divide up recall campaigns and you work with you or your team to focus on key aspects that you're wanting to work on that month for chronic disease patients.

The other thing that clinicians can do is utilize technology to the max. Whether you use EMR templates macros, or telehealth to reach out to your patients with care gaps. You need to use technology to make this all happen.

With regards to the question of, does this model of chronic disease management and team based care apply to only diabetes care? My answer is no.

In our clinic, what we discovered is this concept works really well for other chronic conditions, whether it be COPD, asthma, congestive heart failure, hypertension management, patients with chronic disease, chronic kidney disease, ischemic heart disease, or dyslipidemia.

This focused approach on identifying care gaps and recalls works very well.

When you have different team members coming to visit to provide some assistance. For example, respiratory therapists came to our clinic,

we were able to use this integrated chronic disease recall approach with our colleagues coordinator to identify patients to come in for one on one assistance with their respiratory condition.

So it does work for other chronic conditions.

[Disclaimer
The members of the scientific planning committee acknowledge that their participation was made possible by sponsorship funding from GUARDIANS FOR HEALTH and Boehringer Ingelheim Canada Ltd.
The scientific planning committee was solely and fully responsible for developing all content and was involved at all stages of development to achieve scientific integrity, objectivity, and balance. As such, the content does not necessarily reflect the opinion of GUARDIANS FOR HEALTH, Boehringer Ingelheim Canada, or Boehringer Ingelheim GmbH]
[Guardians For Health logo]