Quality Improvement in Obesity Care: How to Integrate Comprehensive Diabetes Management

Joe Kim (CCO): Today, joining me is Dr Bracken, who is going to be speaking to us about quality improvement in obesity as well as in diabetes. Thanks, Dr Bracken for joining us today. Let us start off by telling us about your practice.

Dr Colten Bracken (Utah Valley Family Medicine): Awesome. Well, thanks for having me. My practice sits in a small town in Southern Utah. We are designated as a rural health clinic. Our practice is a run of the mill primary care practice. We do primary care visits from birth all the way to death. It is in my hometown, actually. I have a vested interest in taking care of my patients here just because this is the little town that I grew up in.

It consists of myself, a physician, family medicine trained, and then I have 2 nurse practitioners that also work here in my clinic to help the workload. We have been open since about 2021. We started from scratch, built this thing from the ground up, including the building. It has been just a labor of love and a work in progress, that is for sure.

Joe Kim: That is great to hear. I know that you all have done some quality improvement work around diabetes and obesity. Tell us about that work, about the project, as well as we can start with some of the high levels of the results that you achieved, and then we will dive deeper into some of the specific aspects of that work.

Dr Bracken: Yeah. Our project was a little bit unique in that we were starting literally from scratch. A lot of our patients were not in the habit of coming in to see the doctor and particularly from the diabetic standpoint there was not a lot of great control of their diabetes in terms of their A1Cs were quite elevated, greater than 9%.

We came into this community, we established this clinic, and really had to reinforce a lot of good habits and tactics to take care of their diabetes to try to get the results that we wanted. Ultimately, it was trying to look at our community and see, hey, there is some problems here in terms of not great care of diabetes, quite a high rate of obesity. What can we do as a clinic to increase those numbers? That is really the high level point of what we were trying to accomplish here.

Joe Kim: I think it sounds like there was a real opportunity, you saw that need. Tell us about the ways that you determined, like what were the goals and the aims of the project? How did you establish that as you started that QI journey?

Dr Bracken: Yeah, that is a great question. I had a little bit of background in quality improvement through my medical school training. I had not really done a whole lot of specific projects on my own. This was a great opportunity to not only do it myself, but also to get my staff involved and to help them learn some of the tools of quality improvement.

Initially, we got down to the basics and we did some things like a root cause analysis. We constructed fishbone diagrams to try to get at what are some of the low hanging fruit? What are some of the things that we can tackle right off the bat that is going to have a great impact on our patient's control of their diabetes?

One of the things we identified early on was that patients were just not coming back for their follow-up appointments.

We would see somebody, for instance, and their A1C would be 10%, and we would say, "Okay, this is what we are going to do. We need to see you back in 3 months, if not sooner, and then we are going to recheck your A1C," and 6 to 9 months later they would show back up on our doorstep and still have a terrible A1C. We identified, gosh, we need to streamline the follow-up process and which was 1 of the big things that we used to tackle this. We found that just by doing that alone putting a greater emphasis on this for our patients that made a big change. That made a big difference.

Joe Kim: In terms of tracking those follow-up visits, was that all built into your electronic record? Did you use different software like practice management software, or was there a different method altogether?

Dr Bracken: Yeah, so we utilized a couple of different methods to ensure that follow-ups were happening. First of which was just in our EMR. We use Athena, and it does have a functionality built in there to where we could order a follow-up visit which would then generate system reminders so the patient would get reminders. We would get reminders that the patient is needing to be seen. That was part of it. But we found that was not even quite enough in and of itself. We really utilized a care manager which was a big part of this project and really took off.

We had a care manager before this, but she was not fully functioning. We did not have a great direction. Getting into this project really got her running with this and then other projects that we have subsequently done.

What we did is we had her start running reports every single month on the first of the month to say, "Okay, who are our patients with type 2 diabetes? Who has had an A1C that is been greater than 9% and who is then due for follow up visits?” Then she made actual, physical phone calls to the patients and said, "Hey, it looks like you are due for your appointment. Why do not you come on in?" We found that by her actually doing a warm phone call, people came in. Nobody ever said no to her when she called, which was great.

Joe Kim: Yeah, it is that human touch, that is so important and that is great to hear. I think just having that person on the team and really empowering that person with that role. I think 1 of the other things that you all also did was really increasing that documentation of obesity as a diagnosis. Can you tell us about that and what led to that?

Dr Bracken: Yeah. Again, where we were starting from the ground up, we had no patient records. We really had carte blanche here as far as every single patient that came to see us, we had to establish and document all of their problem lists, all of their health history, and so for the first few years of being open, it was quite daunting.

Every single patient that came in, there was quite a bit of paperwork. Quite a bit of just documentation. We found that as good of a job as we were doing, a lot of things were falling through the cracks, particularly diagnosis of obesity. You could say, "Gosh, why does that even matter? What does it matter if you actually put that on the problem list?"

There is a quote that I like from Edwards Deming who is 1 of the fathers of quality improvement. He says, "What gets measured gets improved." We found just by simply documenting the presence of obesity, a BMI of greater than 30, and putting that in their chart, that brought up more conversations. We even had a few people of coming in and saying, "Hey, I saw that you said I was obese in my chart. What is that all about?" We had to explain to them, well, this is a medical diagnosis. This was nothing offensive.

Just by putting that in their chart and documenting it, it got addressed more often than it was before. We thought we had been doing a pretty good job of discussing weight management and counseling, whatnot. Until we actually started documenting every patient with a BMI of over 30 with obesity, we noticed we were not doing as quite a good a job as we are doing now of addressing that.

Joe Kim: I know that often the treatment of obesity and diabetes, like there is sometimes it is the same treatment or the same medication that might address both of those. Did you find either synergistic effects of improving both obesity care and diabetes? Were you able to essentially come up with tactics to address both of those conditions at the same time?

Dr Bracken: Yeah. They really need to be treated hand in hand. If you have an old patient with obesity who also has type 2 diabetes, and you are only focusing on the diabetes, you are really missing out on half of their treatment. They go hand in hand in terms of if you can help with obesity, it is going to directly impact the type 2 diabetes. We all know this, but oftentimes we just get so ingrained in focusing on the A1C that we lose track of, "Let us treat the whole patient as a whole."

Perfect example of this, and I got her permission to share this, but my mother-in-law has type 2 diabetes. We were able to get her off of a significant number of her diabetic medications because we were able to help her lose a substantial amount of weight during that same period of time. The direct correlation of helping her obesity then in turn worked on helping her diabetes control significantly. We found that by putting an emphasis on both of these in this project that we were doing, by documenting it and bringing it to the forefront of our conversations, the obesity, but also focusing on the care of their diabetes, we found that people noticed that. People could see, gosh, you guys are really putting a lot more emphasis on these issues. We can tell that this is important to you. Consequently, it became important to them and it just built off of each other. I think there is absolutely some synergy in addressing both of these problems together.

Joe Kim: Tell us how you were able to get your staff involved in these QI efforts and how you either assigned certain tasks to them or gave them additional responsibilities as you went through this journey.

Dr Bracken: Yeah, and that is a great question because that is a big part. Any QI project, you have to have your staff buy-in. Otherwise there is only so much you can do by yourself. Fortunate for us, I became the champion of this project and really, really pushed it from the get-go. As the owner of this small practice and as the medical director and the only physician, it was a lot easier. We did not have to get buy-in from upper level management or any other, parties involved just because I was the party involved. That made it a little bit easier on that regard.

From the get go, we started holding regular staff meetings. We already held regular staff meetings, but specifically part of those staff meetings was dedicated to discussing our efforts, discussing our metrics, just keeping it in the forefront of everybody's mind. We published some of this information around our clinic so that we could see how we were doing.

Then we assigned specific roles. Certain people were responsible for calling patients. It was ultimately my care manager's job to make sure that was getting done, but then she would assign that to some of our receptionists to do. We had standing orders in place so that if somebody came in for a sore throat, but we could see, "Hey, they had not had their A1C done in 3 months." That my medical assistants were empowered to automatically check an A1C and then bring it up in that visit.

We really got everybody from the receptionist to the medical assistants, to my care managers, to all of the providers involved from the get go. We talked about it regularly and we found that getting everybody engaged, for 1, it produced results. Then for 2, it actually got them excited about it. They liked seeing the benefits that this was doing. That we could see actual tangible improvement in people's A1C and the documentation of their obesity in their charts. Success begets success and the more we were doing, the more excited the staff got about the project.

Joe Kim: So far we have been focusing heavily on the positive, which is great. Tell us about some of those challenges as well as how you were able to navigate around them.

Dr Bracken: Yeah, the hardest part I think is keeping interest from everybody. Like I said, we had the regular meetings and we kept up on the metrics and we posted everything to try to keep it. I read a book recently about The Infinite Game in terms of, we are not trying to win or lose here. We are trying to continue to play this game, and we are trying to continue to improve for the long run. This is not something that all of a sudden we fix their A1C and then we are done. We fix their A1C and then we still have to monitor that and manage that.

Setting that mindset that this is a continual process. There is not an end result here and that is difficult with any human just creating that mindset. Then some more nuts and bolts things, it was difficult with our EMR and we finally figured some of it out, but just getting the accurate data that we wanted took quite a bit of a learning curve to figure out, okay, where do we get the right reports and how do we get the right number of patients?

Just getting that raw data from our EMR took quite a bit of learning. Those are probably, I think, the 2 biggest things. There is always challenges in terms of like, we will try an intervention and then find that was not very effective. We had to go back to the drawing board, and that is part of those PDSA cycles that they are supposed to be continuously ongoing towards that improvement.

The first 1 may not work very well, and that is okay. You learn from it. You study it and you assess it and you do something different the next time. It probably just continuing that mindset of this is a never ending project. We never get finished with this which is sometimes hard in our typical finite mindset, but we are getting there. I will not say that we are perfect at it, and we are still learning. It is an ongoing process, but we are better than we were a year ago, I can tell you that.

Joe Kim: Yeah, it is definitely that continuous journey, ongoing improvement. You mentioned the care manager, I would like to learn a little bit more about that person's role. Is that person still overseeing primarily diabetes and obesity, or have you added on additional chronic conditions? What is that scope of responsibility at this time?

Dr Bracken: We had her on staff before and we gave her this specific responsibility of being a chronic care manager basically. Initially, it was a little bit of a gamble just to designate somebody full-time away from clinical practice, if you will. They are not actually engaged with the patient on a day-to-day rooming patients. From a practice management standpoint, I worry that initially she was not going to generate in revenue. That was she going to be profitable. In hindsight, gosh, making a full-time chronic care manager has been 1 of the best things I have done in my practice.

She initially was involved in this diabetes and obesity project and has been very, very influential and she continues to do that. We have had her branch out and are now involved in chronic care management services which just go hand in hand with this diabetes care and obesity care.

That involves her calling patients regularly, setting up appointments for them. She even does home visits sometimes and does vitals checks and being in a small community people love her and they trust her and she is just an extension of me. It has been very beneficial to my patients. Then being able to bill for the chronic care management, she is actually paying for herself. It is improving quality and it is improving care for my patients without really costing my bottom line anything, which is fantastic.

Then we have just recently been branching out into more remote patient monitoring, blood pressures, blood sugars, oxygen levels, those types of things, which again, just provides us 1 extra tool in our toolbox to be able to really better take care of our particular Medicare population that it is they are aging and their health is only getting worse. There is only so many primary care doctors out there. The more I use someone like April, who is my chronic care manager, the better I feel like I can manage our little population here. She has just been very instrumental.

Joe Kim: Yeah, it sounds like you have got a great team in place and with all those roles and responsibilities clearly defined, you are providing better care for that community. Speaking of that community, what would you say are the biggest barriers to care for them?

Dr Bracken: We are in a very rural primarily agricultural community. The community itself is maybe only about 2000 people, but our catchment area is closer to 6000 or 7000 that feed into the schools and the grocery stores in our clinic. We find that there is a certain amount of health literacy that people struggle with.

Like I said, there had not been really great medical care out here for a long time before we arrived. There is a lot of just misinformation out there in the lack of good medical advice. People turn to the internet and we all know heaven knows what that people can find there. That has been a challenge to educate people on proper ways to care for their diabetes and obesity and other issues.

Access to specialists is another 1. Let us say, somebody needs to get in to see a cardiologist or go for an eye exam for their diabetes or whatnot, they have to travel at least an hour to get down to the closest city where there are specialists. While that is not a great distance, sometimes that is a pretty big hardship for some of our patients who are on limited incomes or, just do not have the means to make it down there and the time and whatnot. We are in a resource limited area, which makes it challenging for our patients.

Those are probably the biggest ones that people struggle with around here. They make do, and a lot of times people have just done without unfortunately for a long time. It is the old farmer mentality of you just rub some dirt and it is going to get better. Unfortunately, that is what has happened for a long time and it is getting better, and I would like to think we are making a difference here but there is still long ways to go there for a lot of people here.

Joe Kim: The last question that I have is, what advice would you give to other rural focused healthcare providers, rural clinics, people working in similar types of environments when it comes to improving obesity and diabetes care for their populations?

Dr Bracken: Yeah, I would say, just from my experience and this last year of really diving into this a lot more is you really do not know what you do not know. I thought we were doing a really good job and I thought we were taking great care of our patients and we were, and we were trying. Until we really started to dive into some of the measures and some of the numbers and really look at, gosh, maybe we could be doing better. Sometimes just taking a step back and actually studying it and actually measuring things to say, "Yeah, we are very caring providers and we want what is best." Sometimes there is a better way. Learning from others. Part of this big project was hearing from other clinics who were involved in the same type of quality improvement projects and learning their successes and their failures.

One of the big mantras that I learned in medical school from the Mayo Clinic is that no one is big enough to be independent of others. Medicine is a team sport, and so the best thing is just to learn as much as we can from others and to always try to be better. We can always be better, as good as we are as providers. There is always room for improvement. Just get out there and do it. Get involved.