Appendix A - Program & Service Details(complete a new sheet for each program/service)

Program/Service Name:

Diabetes Program

New/Existing: ☐ Newx Existing Clinical Practice Guidelines finalized for Program/Service?☐Yes☐No

Type:x Chronic Disease Management☐ Health Promotion☐ Prevention Priority Addressed (choose the one most appropriate):

☐Acute/Episodic Care ☐ Seniors Care x Diabetes ☐Obesity/Nutrition☐ Smoking/Addictions

☐ Mental Health☐ Lung Health ☐ Heart Health☐ Other -

Provider / FTE
RD / 0.1
PA / 0.1
RN-EC / 0.1
RPN / 0.05
MD / 0.8

Planned Staff Involvement (FTE):

Marathon Diabetes Clinic (MDC)

Collaboration with other organizations for program/service:

High Level Description & Goals
(2014/15) / 1)Target Number of Patients, and
2)Target Population
(2014/15) / 1)# of Patients Served
2)Patient Encounters**
(2013/14) / Activities
(2014/15) /
  • Performance Measures
  • Corresponding Targets
  • Actual Measure
(2013/14) /
  • Performance Measures
  • Corresponding Targets
(2014/15) / Planned Quality Improvements
(2014/15)
Improve DM control and self-management using the Canadian Diabetic Association Guidelines
  • Increase number of patients with current lab work
  • Increase number of patients with A1c ≤ 7
  • Increase number of patients with eye exam recorded in past two years
  • Increase number of patients with identified DM provider and MDC DM Clinician
  • Improve communication between MDC and MFHT and charting
/ 1) 490
2) Patients with diabetes / 1) 417
2) 882 /
  • Continue recall for patients with overdue DM labwork
  • In collaboration with MDC, continue to offer regular and intensive DM follow up to patients to achieve better DM control
  • One community DM clinic in each community in our catchment area
  • Continue to identify MDC clinician and MFHT DM provider on patient chart
  • Contract IT specialist to create new DM flow sheet in EMR using template created in 2013/14
  • Pilot and revise new flow sheet based on feedback
  • Focus on ways to improve % patients having foot care charted in flow sheet
  • Continue quarterly tracking of outcomes
/
  • % patients with A1c in past 12 months
  • 90%
  • 85%
  • % patients with ACR in past 12 months
  • 65%
  • 61%
  • % patients with A1c ≤ 7 in past 12 months (those with A1c result)
  • 60 %
  • 54%
  • % patients with eye exam recorded in past 24 months
  • 90%
  • 60%
  • % patients with DM provider and/or DM Clinician identified in the chart
  • 100%
  • 94%
/
  • % patients with A1c in past 12 months
  • 90%
  • % patients with ACR in past 12 months
  • 65%
  • % patients with A1c ≤ 7 in past 12 months (those with A1c result)
  • 60%
  • % patients with eye exam recorded in past 24 months
  • 90%
  • % patients with foot exam recorded in past 12 months
  • 60% (current measure 33%)
  • % patients with BP ≤ 130/80
  • 55% (current measure 25%)
  • % patients with DM provider and/or DM Clinician identified in the chart
  • 100%
/
  • Complete new user-friendly DM flow sheet for EMR
  • Survey patients and providers re: satisfaction with program and flow between MDC and MFHT
  • Assess reasons for low % patients with recorded foot exam in past 12 months (foot exam not done, or not recorded?) and identify ways to improve in this area
  • Establish protocol for only valid BP measures to be entered into the EMR
  • Work with local First Nations to identify ways to improve DM follow up and management

Stories and Highlights (2013/14)
  • Increased number of patients with A1c in last 12 months from 78% to 85%
  • Increased number of patients with identified DM provider and/or MDC DM Clinician from 90% to 94%
  • Phone calls made to all patients with last A1c test done over 12 months ago
  • Through manual chart review, increased % patients with recorded eye exam in past 24 months from 43% to 60%
  • Increased % patients with LDL ≤ 2 from 42% to 53%
  • Template for new improved DM flow sheet created
  • Chart and graphs created to easily track DM outcomes

*For new programs/services, do not complete the shaded cells

**Patient encounters may include but are not limited to in-person appointments, telephone contacts, OTN and home visits. Group sessions should count each participant in each session as a patient encounter.

Programs share the following characteristics: a) specific patient group, b) meaningful, measurable objectives/indicators, and c) outcome measures/indicators that allow the FHT to determine whether the objectives have been achieved