PRACTICE ENHANCEMENT EXAMPLES Diabetes …

1 PRACTICE ENHANCEMENT EXAMPLES . Diabetes Patient Care Flowsheet A. ENHANCEMENT Objectives 2. ENHANCEMENT Author: Lisa Kwok A Diabetes patient care flowsheet facilitates the summary Acknowledgement: Fairview family Health of information on patients with Diabetes to improve the Network, Toronto, ON. management of their medications and other aspects of their disease state, which could lead to better health Health care providers in the PRACTICE site may approach outcomes for the patients. It also helps the physicians patients with Diabetes following their own template or incorporate and accomplish these objectives in their line of thinking. This can cause some information to be PRACTICE . missed or overlooked. A flowsheet can trigger more systematic thinking, which can ultimately benefit the As well, completing the flowsheet allows eligible patient by having all aspects of their disease state physicians at a PRACTICE site to bill for a special financial considered.

2 The flowsheet can help all members of the reimbursement related to Diabetes . PRACTICE follow the same line of evidence-based reasoning for the treatment of Diabetes . B. Tool or ENHANCEMENT Description A two-page form filled in by both physicians and the The flowsheet can be faxed to specialists or other health pharmacist, this flowsheet can also be placed on the care professionals involved in the management of care of PRACTICE 's shared drive and used electronically. Please see a patient. Informing all personnel involved with the care the end of this chapter for an example of a Diabetes of a patient, such as a community pharmacist, enhances patient care flowsheet. the patient's medication management. C. Medication Management Improvements A handout containing the patient's actual laboratory A Diabetes patient care flowsheet is a tool that values and their target levels can be created from the summarizes all medications patients are taking and flowsheet.

3 Having this information educates and pertinent medical information related to Diabetes on a empowers patients, and helps them understand the single piece of paper. This improves medication purpose of their medications. Benefits extend to other management by presenting information in one health professionals patients have contact with, because convenient and comprehensive list. the handout can be shown to or shared with them. When physicians complete the flowsheet and manage Patients can benefit from a Diabetes patient care their diabetic patients in this manner, they are flowsheet because it can serve as a guideline for reimbursed by provincial health insurance. individualized medication management for each patient, and as a prompt to encourage the pharmacist and Many patients with Diabetes do not realize the physicians into considering medications that should be seriousness of their disease. A flowsheet can trigger a prescribed for a person with Diabetes .

4 Areas of drug dialogue between the physicians and the pharmacist therapy that could be improved are observed more with their patients to encourage the patients' readily. Using first-line drug therapies as an example , is understanding of their disease, which could have a large there a good indication why a patient is not on an impact. Supplement the flowsheet with discussion with angiotensin-converting enzyme inhibitor (ACE-I)? the patients and patient education to ensure its potential is reached. 20 IMPACT PRACTICE ENHANCEMENT Guide Copyright 2006. All rights reserved PRACTICE ENHANCEMENT EXAMPLES . Diabetes Patient Care Flowsheet Drug therapy can be optimized in several different 2. Overall patient monitoring could improve by having all ways, depending on the needs of each individual patient. of the flowsheets of patients with Diabetes in a central Doses of existing medications can be adjusted (elevated repository where the progress of each patient could be or lowered), changes can be made in attempting to reach checked more easily.

5 It may also be easier for physicians various targets ( , blood pressure or cholesterol to observe trends occurring in each patient ( , disease targets), medications can be streamlined by removing improving or worsening). a drug that is not working well or is redundant, a new drug could be added or the dosing regimen can be The organization of the PRACTICE can potentially change simplified to improve the patients' compliance ( , if with the implementation of a Diabetes patient care a patient is taking a medication three times per day and flowsheet. Some changes may be observed in the is having difficulty doing so, the regimen can be changed manner in which the physicians PRACTICE as a flowsheet to once daily for that medication). becomes integrated into their daily routine, which can lead to changes in how the physicians manage their patients. Time may be used more efficiently because all I had one patient who was put on relevant information for a patient is contained in one document.

6 Compliance packaging. She benefited from it a lot and her Diabetes D. Development Process medication was reduced drastically. Physicians may be planning to create such a template and can use the presence of a pharmacist at their site This was very positive and rewarding as an opportunity to begin the process. In addition, a to be able to make a difference. pharmacist can suggest the use of a template to the IMPACT demonstration project participating pharmacist physicians of their PRACTICE site. Begin by researching different Diabetes management Patients may yield more benefits from a flowsheet tools available on the Internet. Ask peers and other because the monitoring of their disease state may contacts for a list of materials that can be accessed and improve. Because a flowsheet contains areas for the used for initial drafts. recording of certain laboratory values (hemoglobin A1c, lipids, etc.), the physician or pharmacist can gauge Hold a meeting with the PRACTICE site physicians to whether the patient is overdue for certain analyses.

7 Discuss the material found and any specific needs or Also, the pattern of laboratory values over time can be requests made by the physicians. The templates from observed. For example , if the laboratory values are not the Internet may have to be modified to incorporate close to the target levels and remain far from target over the needs of the physicians ( , more space needed time, this may trigger the physician to treat the patient for writing out medication names). Create a new form more aggressively. incorporating all the different areas requested by the physicians, and format it in a user-friendly way. Regular use of a Diabetes patient care flowsheet should result in more patients with Diabetes achieving their Ensure the form created includes the criteria required for targets with their glucose levels, blood pressure, reimbursement from provincial health insurance. cholesterol levels, etc. IMPACT PRACTICE ENHANCEMENT Guide Copyright 2006.

8 All rights reserved 21. PRACTICE ENHANCEMENT EXAMPLES . Diabetes Patient Care Flowsheet After a draft is created, hold a short meeting with the 2. Once a draft is finalized, store the flowsheet on the physicians to obtain feedback. Needs may vary by PRACTICE PRACTICE site's shared drive for future use. site. For example , some PRACTICE sites may request that the flowsheet is organized according to disease state, F. Overcoming Challenges while others may prefer that the patient medications and laboratory results are grouped together instead. Implementing a flowsheet may present some challenges. For example , adopting it may be slower than anticipated. Present each version and incorporate feedback into a new This can be overcome by using verbal reinforcement from one. It can be expected that at least three drafts will be the physicians at the PRACTICE site who are using the created, and require both formal and informal meetings flowsheet and who find it useful.

9 In addition, the with physicians. Depending on the PRACTICE site, the pharmacist can fill out the flowsheet and place it in the Diabetes patient care flowsheet can be distributed in hard patients' charts to prompt the physicians. copy (if the PRACTICE site is paper-based) or electronically. If the PRACTICE uses an electronic medical record (EMR). Because of the possibility of the creation of a large system, a paper Diabetes patient care flowsheet may be number of drafts through the revision process, it is difficult to implement, and vice versa. This challenge can suggested that a working draft be implemented at the be easily overcome by changing the format to one more PRACTICE site to determine how the Diabetes patient care people will use (either producing hard copies or putting flowsheet actually works in PRACTICE before making the file on a shared drive for electronic use). further revisions. The implementation process starts with this working draft.

10 It can be challenging when attempting to create a form that accommodates the needs of many different References and resources individuals. The revision process can be streamlined by creating a new draft only after a certain amount of A Diabetes patient care flowsheet incorporates feedback has been given, instead of creating a new draft information from the 2003 Canadian Diabetes for every suggestion. Association Guidelines, available at: Challenges that may be difficult to overcome It may not be possible to include everyone's suggestions The flowsheet can be an amalgamation of various flow and opinions, particularly if no consensus can be reached sheets available and can be modified for the PRACTICE site or if the suggestions are widely divergent. physicians. For example , see: (page 16). G. Facilitating Factors Involving physicians in the creative process by asking for E. Implementation Process their feedback and suggestions enhances and encourages the integration of the flowsheet at the PRACTICE .