Ending Type 2 Diabetes One Exercise, Nutrition, and Gardening Class at a Time

Posts Tagged ‘OGTT Recruitment’

OGTT Sketch

In OGTT Screening on February 10, 2012 at 11:18 AM

Some drink the Glucola solemnly, obediently. It’s unclear whether they know the full extent to which we are testing their health status this morning. Others seem somewhat nervous, and still others chat away cheerfully until their name is called for the needle and flat orange sugar drink event.

The kids are restless, sucking on the backs of chairs as they watch the phlebotomy, or any sign of movement in the room.

The best is the tough guy with the mohawk. His name is called and he stays sitting, in a sheepish stand-off with the clinician’s assistant. And then, as he eventually pulls his tee shirt up over his tattooed forearm, he describes how much he hates needles.

Amazing how for style or nostalgia, an inked needle is welcome! And for an oral glucose tolerance test, it is so thoroughly resisted.

And yet resistant or not, bored or cheerful, nervous or curious, the 21 adults and their families present today will leave here with knowledge of diabetes, their risk, and some implementable-tools for improving the quality of their health. Cheers to them!

Tatoo!

OGTT!

Why OGTT Screenings Should Not Take Place Between the 1st and 5th Days of any Month

In OGTT Screening on December 9, 2010 at 5:32 PM

This past Saturday, 36 patients were scheduled to attend our OGTT screening. As per the usual protocol, our DPP staff called people at risk for diabetes weeks in advance. The head DPP provider also called to confirm their attendance a few days before the screening. Despite repeated efforts to ensure a full house, only 17 patients were in their chairs that December 4th morning.

As is the DPP’s custom, the lead provider took a few minutes at the close of the screening to consider what worked and didn’t work. She directed her attention to the attendance. While most of the DPP staff were perplexed, the clinic’s social worker was incredulous.

“Today is December 4th! What did you expect?”

Silence. No one understood what the social worker was getting at.

She sighed and made another attempt to explain, “It’s when everyone gets their checks.”

In Connecticut, state aid, including SNAP and other entitlements, is distributed on the first day of every month. Federal aid, SSI, arrives on the third. By then, the social worker continued to expound, people’s pantries, bank accounts, and access to credit, have dried up. It is on the first Saturday of the month, after their checks have arrived and the work week has slowed down, that many Fair Haven residents go grocery shopping, and run around town paying their light, electricity, phone bills.

“Not to mention, November was a 5-week month. Extra long, and extra hard.”

Needless to say, we won’t be scheduling OGTT screenings on the first Saturday of the month moving forward.

 

FHCHC DPP OGTT Billing Spreadsheet

In OGTT Screening on December 8, 2010 at 1:06 PM

The FHCHC Diabete Prevention Program maintains spreadsheets for all data to ensure research accuracy. This spreadsheet chronicles the relevant patient, billing, and insulin numbers for all OGTT screening attendees.

For a look at the whole billing flow, click here.

FHCHC OGTT Execution Checklist

In OGTT Screening on December 8, 2010 at 1:03 PM

This checklist is meant to guide DPP staff in conducting a successful OGTT screening.

FHCHC DPP OGTT Preparation Checklist: For the Brilliant at Heart

In OGTT Screening on November 26, 2010 at 11:44 AM

…at the start of the twenty-first century: We have accumulated stupendous know how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageabe. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government. Ant he reason is increasingly evisdent. : the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

That means that we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy – though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologes.

It is a checklist.

From: The Checklist Manifesto by Atul Gawande, 2009


Executing a group family-based OGTT screening is no simple task. Below is the checklist the DPP staff uses to ensure success.

Are You There? 2 Solutions for a Common OGTT Recruitment Breakdown

In OGTT Screening on November 9, 2010 at 4:23 PM

It’s been two weeks and Eva is making her third attempt to reach Sandra. Referred by her provider to get screened, Eva sits looking dejected in front of the referral note (click here for the OGTT recruitment write-up script).

Out of 20 referrals, Eva typically reaches five. The remaining 15 are unreachable – either not home or sporting a disconnected phone number. Eva leaves a message with those who have answering machines or someone capable of taking a message. Two or three will return her message. Now, what happens with the remaining 12 or 13 patients who were never spoken with after their provider wrote them an OGTT referral? Herein lies the rub.

A note is written on their referral form, and it is returned to the chart, filed away until the patients’ next scheduled PCP appointment. When is that appointment? Someday (indeed, elusive someday) in the future.

The problem with this scenario is not colossal: if the PCP has an urgent concern for the patient’s blood glucose level, they schedule an individual OGTT screening lab for that week as opposed to writing a group OGTT screening referral. An emergency, therefore, is not the problem. The main drawbacks of this system are as follows:

1) If the provider requests additional blood tests, like TSH, on that referral form, those requests are lost.

2) The elusive someday is truly elusive; for one reason or another the patient might not return to the clinic for years, by which time their prediabetes could easily have metamorphosed into type 2 diabetes.

A simple solution to this systems breakdown is to file the referral form into the referring providers’ folders after our Diabetes Prevention Program staff has finished with them, instead of into patients’ charts. Providers would then have the opportunity to see and, most importantly, react to the outcome of their referral request – whether that be to send a letter out themselves to those who were unreachable or note that the patient is scheduled for their screening.

Possible solution #2 is to attach a scheduling form to each referral form. In the moment that the provider chooses to refer the patient to a screening, a date and time would thereby be assigned. Both the scheduling and referral forms would get routed to the DPP office, and the DPP staff would take it from there, ensuring that the patient was set up to attend the screening.

OGTT Recruitment Write-up Script

In OGTT Screening on November 9, 2010 at 3:33 PM

This script is designed to serve as an OGTT recruitment guideline. It has been tested – DPP staff make up to 100 recruitment calls per week. The key here is that the simpler the message, the more return-calls the DPP tends to receive.

OGTT Recruitment Call Script for Individual Adults in English:

OGTT Recruitment Call Script for Individual Adults in Spanish:

OGTT Recruitment Call Script for Families or Individual Children in English:

OGTT Recruitment Call Script for Families or Individual Children in Spanish:

OGTT’s Evolution from Pilot to Paramount

In OGTT Screening on October 25, 2010 at 4:14 PM

There was a marked increase in the number of patients screened for diabetes and prediabetes when the Donoghue grant became operational. From 2006-2008 under the Connecticut Health Foundation’s initial grant, research was limited to hispanic women between the ages of 18-55 years old. Limited is not the best word, however. The number of Oral Glucose Tolerance Test (OGTT) patients perfectly matched the structures and resources available to the Fair Haven Community Health Center at the time.

During this initial 2-year period, OGTT screening referrals amounted to approximately 2-4 per week. Clinicians generated them conservatively, being new to the group-screening paradigm. One Diabetes Prevention Program staff member handled the entire referral to recruitment process. She stocked exam rooms with referral forms, collected filled-out forms each Friday. She called each patient within 3 weeks to schedule them for a screening, and filed the referral forms in patients’ charts herself. Mari also kept impeccable excel spreadsheets on all relevant numbers and names.

In 2004, when the clinic won a substancial Donoghue Foundation grant, however, this system needed to be expanded. Now, any patient that displayed a risk factor was offered a free diabetes screening. Having observed the previous two years’ success, clinicians were poised and ready to ramp up their referrals. And they did! Referrals went from the aforementioned 2-4 per week to 20-25 per week. The Diabetes Prevention Program had to hire another staff member who shared the referral and recruitment responsibilities. Once in a while there were so many referrals that Eva had to set aside entire series of workdays just to make referral calls. To meet the demand, the Diabetes Prevention Program also increased their screenings from one per month to three.  The success, therefore, of the initial two years of ‘limited’ access screenings established the program’s credibility and systematic foundation.

The Donoghue grant, however, made it possible for any patient at the Fair Haven Community Health Center, whether male female, child or adult, Balinese or African American, to get screened. Today, the DPP receives between 20-25 OGTT screening referrals per week, a major increase from the 2-4 one year ago.

OGTT Referral to Recruitment Flow Chart

In OGTT Screening on October 22, 2010 at 9:01 PM

Chronic Care Model: Tracking Chronic Disease with PECS

In About the Program on October 13, 2010 at 1:45 PM

The patient registry represented the clinical information component of the chronic care model, established at the Fair Haven Community Health Center when the clinic participated in the Health Disparities Collaboratives in the early 2000’s. The Collaboratives used the Institute for Healthcare Improvement’s Breakthrough Series to improve diabetes treatment and prevention nation-wide by utilizing three development stages: 1) learning model, where education and sharing best practices took place, 2) Chronic Care model, which included six components from self-management to clinical information systems, and 3) Model for Improvement, or implementing and testing new strategies. The clinical information systems as part of the second development stage, made tracking and targeting at-risk patients feasible. Taken from the Robert Wood Johnson Foundation, the intention of the clinical information component of the Chronic Care Model is to:

Organize patient and population data to facilitate efficient and effective care
Provide timely reminders for providers and patients
Identify relevant subpopulations for proactive care
Facilitate individual patient care planning
Share information with patients and providers to coordinate care (2003 update)
Monitor performance of practice team and care system

Effective chronic illness care is virtually impossible without information systems that assure ready access to key data on individual patients as well as populations of patients. 11, 12 A comprehensive clinical information system can enhance the care of individual patients by providing timely reminders for needed services, with the summarized data helping to track and plan care. At the practice population level, an information system can identify groups of patients needing additional care as well as facilitate performance monitoring and quality improvement efforts.
http://www.improvingchroniccare.org/index.php?p=Clinical_Information_Systems&s=25

Today, clinicians fill out an encounter form for every patient who has a chronic condition, or is at risk for chronic disease. Three FHCHC staff members regularly enter patient information into our central Patient Electronic Care System (PECS) that emerges from patient appointments and chronic-care related programs. PECS is designed to simplify tracking and managing chronic disease. When a patient has hypertention, for instance, the systolic and diastolic blood pressure data is highlighted in red on the form to bring the clinician’s attention to that data.

This is a sample of the front page of an encounter form.

10.2337/diaspect.17.2.102Diabetes Spectrum April 2004vol. 17 no. 2 102-106

Clinicians also add components to the basic PECS encounter form, which gives them specific information about the program or patient they are managing. Below are examples of these addendums.

The following two forms are for adults that attend OGTT screenings. The box on the first page is added to the basic encounter form. The second page is printed on the back of the basic encounter form. It is mostly used for billing but the data is useful when providers miss certain questions in the basic encounter form.

Page 1 Encounter Form Addendum  for Adult OGTT Screening:

Page 2 Encounter Form Addendum for Adult OGTT Screening:

Page 1 Encounter Form Addendum for Pediatric OGTT Screening:

Page 2 Encounter Form Addendum for Pediatric OGTT Screening:

Page 1 Encounter Form Addendum for Adult School-Based Health Center Care:

Page 2 Encounter Form Addendum for Adult School-Based Health Center Care:

Page 1 Encounter Form Addendum for Pediatric School-Based Health Center Care:

Page 2 Encounter Form Addendum for Pediatric School-Based Health Center Care:

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