Resident Quality/Performance Improvement Projects

Diabetes mellitus is a common chronic disease affecting about 20 percent of the AMO’s adult patient population. The AMO developed and continues to refine a comprehensive and multidisciplinary diabetes management program that has twice earned the ChristianaCare President’s Award for Excellence, most recently in 2014. Efforts of the attending physicians, residents, nurses and embedded diabetes educators continue to improve patient outcomes for a number of key measures, most significantly by controlling blood sugar (HA1c) among these patients. Over a one-year period, 25 percent of patients achieved good glycemic control with a mean reduction in HA1c of 0.6 percent (p=0.005). During that time, the overall rate of glycemic control increased from 63.7 to 70.8 percent. Additionally, performance improvement was achieved in 6/7 diabetic measures including two important intermediate outcomes (glycemic and LDL control goals).

The team developed its own unique, evidenced based algorithm for managing hypertension and standardizing care among patients whose blood pressures averaged 160/100 or greater over the previous year. The program incorporates patient education and blood pressure home monitoring with cuffs provided by the AMO; medical management to identify and treat underlying, secondary problems; medication reconciliation with the aid of a clinical pharmacist; and motivational interviewing to help patients adhere to their medical regimen. In FY14 more than 170 patients were part of the hypertension education and monitoring program.

The Huddle is a daily, scheduled, informal meeting between the provider and the medical assistant to prepare for the needs of patients during an upcoming clinical visit to the AMO. A standardized huddle checklist/form promotes greater process uniformity and efficiency. Since the Huddle was instituted, both the number of diabetic foot exams completed and pneumonia vaccination rates have increased, showing significant increases in the rate of improvement each month. The team presented a poster on the Huddle at the Society for General Internal Medicine annual meeting in April 2014.

By increasing the use of fecal occult blood tests (iFOBT/POCT) the Med-Peds practice at Wilmington Hospital Health Center contributed to an improved colorectal cancer screening rate (60%) with a goal to reach 75%, the current Delaware average. Future plans include collaboration with ChristianaCare labs to facilitate distribution of iFOBT take home kits for patients.

Pro-active scheduling of dental appointments by the Primary Care Practice at the Wilmington Hospital Health Center led to increased numbers of fluoride applications (198 fluoride applications from July 2013 to June 2014) and to establishing a dental home for 27 children. A target goal is to help at least 50 percent of children without a dental home to visit a new dentist and to expand participation in the program to other ChristianaCare primary care practices with pediatric patients.

The Adult Medicine Office increased the rate of HIV screening in adult patients from 21 to 34 percent. There have been 4 new cases of HIV detected. Among these, 48 adolescents were screened for HIV (about 105). Target goals are to increase the screening rate in adults to 50 percent and in adolescents to 25 percent.

With a goal to capture 100 percent screening for autism (M-CHAT) and pediatric general development (PEDS) with appropriate referrals for abnormal findings, the Med-Peds residents have used these tools to perform 576 autism screenings (with 5.4% abnormal) and 318 PEDS screenings (41% abnormal).

Promoting the availability of “walk-in” appointments and bilingual services is designed to increase the rate of screening mammograms for women. Currently, the screening rate for women over age 50 at the Wilmington Hospital Health Center is 53% (73% nationally). Efforts continue to expand access to mammogram appointments.

Since implementation in March 2014, more than 50 diabetic patients have been seen at the Wilmington Eye Clinic. Efforts are underway to coordinate complete data entry for these patients for access by the Primary Care Practice.

The purpose of this program is to educate residents and attending physicians about the care of patients with chronic, non-cancer pain and to develop a team approach to pain management. A number of AMO patients are managed on prescription opiate medication at high doses (>100 mg of morphine sulfate equivalent). Residents are collecting data for analysis on patient responses to the program as well as provider attitudes about treating chronic pain.