July 2007

Save the Date for PRISM 3
You are invited to attend our last Practice Improvement Series Meeting (PRISM) for 2007 on September 20th from 7:45 a.m. -3:30 p.m. at the Harraseeket Inn in Freeport. The theme for this upcoming session is Patient-Centered Care. There is no cost to attend and CME credit is available. All sessions are open to all office staff, including physicians, RNs, CNAs, MAs, patient service representatives, practice managers, and others!

PRISMs are designed to help primary care and pediatric practices improve care and outcomes, learn new disease-specific information, create more efficient office systems, and succeed in pay for performance programs.

The keynote speaker for PRISM 3 is Bill Schwab, MD from the University of Wisconsin School of Medicine and Public Health. He will present "Recognizing Patient and Family-Centered Care" and two workshops on a similar topic. Dr. Schwab is a Professor at the University of Wisconsin School of Medicine and serves as Director of the University of Wisconsin Family Medicine Residency Program at Madison. He is a nationally respected clinician, educator and policy consultant on chronic illnesses and disabilities from a family-centered perspective. He was honored as Family Physician of the Year by the Wisconsin Academy of Family Physicians in 1999.

PRISM 3 will also include a Motivational Interviewing Skills Workshop with Andy Loman, LCSW. This session represents a great opportunity to build skills that you can use to create stronger relationships with your patients. This session will be presented from 9:20 a.m. until 12 p.m. and requires pre-registration.

In addition to Dr. Schwab's presentation, PRISM 3 will include a two-part workshop on using an EMR in your patient and family-centered practice. Titled Communicating and Computing in the Exam Room, the session is presented by the Institute for Healthcare Communication. Also, PRISM 3 will include: an introductory session on understanding how to use the Planned (Chronic) Care Model, Patient-Centered Care: What's Happening in Maine, Spiritual Care of Patients, More Lean Design, Patient to Patient: Self-Management Support, COPD guidelines and many more!

Reserve your space soon! PRISM 3 is filling up fast. To register for PRISM 3 and/or the Motivational Interviewing Skills Workshop, please email mhlc@mmc.org or call 207-541-7558.

MaineHealth Clinical Integration Announces NEW Educational Brochures
MaineHealth's Clinical Integration Division is pleased to announce its NEW patient brochures, which are ideal for display in patient waiting areas. Brochures are available on the following topics: gestational diabetes, diabetes, cardiovascular health, heart attack, asthma, and depression.

You can order these brochures (in packets of 25) at http://www.jsmccarthy.com/mainehealth. If you need a user name and password, please contact Elizabeth Lambert at lambee@mmc.org. The site also has a wide range of patient and provider education materials. If you are already a registered user of this online program, simply sign in and choose the brochures and tools of your choice!

For more information about Clinical Integration's new brochures and communication materials contact:
Julie Osgood, MS
Program Director, Clinical Integration
465 Congress Street, Suite 301
Portland, ME 04101
Phone: 541-541-7515
Fax: 541-7547
Email: osgooj1@mmc.org

Save the Date for the Health, Culture and Literacy Conference in Freeport this October
Save the Date!! Nearly half of all Americans have trouble understanding and acting on health information, resulting in poor outcomes and billions of wasted dollars. Come learn about why and how to correct this problem at the Health, Culture and Literacy Conference coming up on October 26, 2007 at the Hilton Garden Inn in Freeport from 8:30 a.m. to 3:30 p.m. Anne Fadiman, best-selling author of "The Spirit Catches You and You Fall Down" about the Hmong population in California, will be the keynote speaker. Workshops will include: Diverse Populations in Maine, Cultural Competency in Rural Settings, Informed Consent and Health Literacy, Health Literacy of American Adults, Getting Started in your Office Setting. You will leave with evidence-based tools and resources to improve your ability to communicate healthcare information more effectively. Continuing education credits and scholarships available. For more information, please click here. For a copy of the Save the Date postcard, please click here.

Diabetes Tools NOW Available to your Patients
The TARGET Diabetes Program is pleased to present an informational brochure and poster on Gestational Diabetes for your waiting and exam rooms to help inform your patients about the importance of being tested for Gestational Diabetes. You can view these tools by going to the TARGET Diabetes website. You may also order them via MaineHealth's online ordering program by contacting Elizabeth Lambert at lambee@mmc.org to become a registered user of the program.

Kristina Scrutchfield
TARGET Diabetes Program Manager
465 Congress Street, Suite 301
Portland, ME 04101
Phone: 541-7534
Fax: 541-7547
Email: scrutk@mmc.org

Maine Center for Diabetes Withdraws from Rosiglitazone Trial
The Maine Center for Diabetes Staff would like to thank the physicians and other providers who showed interest and referred patients for the Rosiglitazone trial. In light of the new information and FDA warning on Rosiglitazone, the Maine Center for Diabetes has withdrawn from this trial. For more information, please contact us.

John Devlin, MD
Cynthia Hull, CCRC
Julie Barnes, R.D., CDE
175 U.S. Route 1
Scarborough, Maine 04074
Phone: (207) 885-7710
Fax: (207)885-7528
Long Distance: 1-800-248-1043

ICD-9 Code for Pre-Diabetes
For those offices in need of the ICD-9 Code for Pre-Diabetes, it is 790.29.

2007 ADA Standards of Care for Dilated Eye Exams
The American Diabetes Association recommends the following for dilated eye exams for diabetic patients:

• Adults and adolescents with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 3-5 years after the onset of diabetes.
• Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes.
• Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist. Less frequent exams (every 2-3 years) may be considered in the setting of a normal eye exam. Examinations will be required more frequently if retinopathy is progressing.
  ~Diabetes Care, Volume 30, Supplement 1, January 2007~

If a dilated eye exam is done and is normal, clinicians may elect to schedule the follow up exam for patients with type 1 and 2 diabetes in 2 years.

To help support accurate reporting of dilated eye exam results, the MaineHealth Clinical Improvement Registry (CIR) now offers a drop down menu for recording results of retinal eye exams. Each CIR result is programmed to correlate with the appropriate interval for the patient's next eye exam. Patients with "no diabetic retinopathy" will be listed on reports as needing the exam bi-annually (every 2 yrs). Patients with any other (i.e. "abnormal") result recorded will be listed in CIR reports as needing the exam yearly. Also, remember the CIR will continue to report patients as needing an eye exam annually UNTIL results are entered into the results field of the CIR. Please click here for a detailed picture of the changes to the menus in the CIR.

Here are additional tools that may help you talk with patients about the importance of having a dilated eye exam:

• The ADA website has patient education information on their website by clicking here.
• There is a letter in the CIR for patients reminding them to have their eye exam
• Use the self care report from the CIR to remind patients their eye exam needs to be done

If your practice uses another registry or an EMR you may want to inquire about how this information is being tracked.

THE CARE TRANSITIONS INTERVENTION: A Quality Improvement Pilot
The Care Transitions Intervention (CTI) is an evidence-based program developed by Eric Coleman, MD, MPH, and his team at the University of Colorado Health Sciences Center. The overriding goal of the CTI is to improve care by providing older patients and their caregivers with the support and tools that promote knowledge and self-management of their condition. This patient-centered intervention is designed to improve quality and contain costs for patients with complex care needs as they transition across settings from hospital to home.

A Transition Coach, who is a registered nurse, encourages self-management and direct communication between the patient/caregiver and primary care provider. The coach meets with the patient and family caregiver in the hospital, makes a home visit and provides three follow-up phone calls during the 4-week intervention.

CTI focuses on the following four areas: medication self-management; use of a dynamic patient-centered record; timely primary care and specialist follow-up; and knowledge of "red flags"- indications that their condition is worsening and how to respond.

MaineHealth Elder Care Services completed a CTI Quality Improvement Pilot at Maine Medical Center in April 2007. It was a collaborative effort between four organizations: Maine Health Elder Care Services, Maine Medical Center (MMC), University of Southern Maine (USM) and HomeHealth Visiting Nurses of Southern Maine (HHVNSM).

Thirty-eight patients completed the Care Transitions Intervention. They experienced improved self-management knowledge and skills, primarily in the areas of medication management, condition/disease management, and greater confidence about what was required of them during the transition and beyond. Encouraging patients and their caregivers to assert this more active role in their care transitions also resulted in reduced re-hospitalization. The readmission rate within 30 days of discharge was 8% (3 /38) for any diagnosis and 3% (1/38) for the same diagnosis. The readmission rate for comparable diagnoses at Maine Medical Center is 14%.

Contact the Partnership for Healthy Aging at pfha@mmc.org or 775-1075 for information on Care Transitions.

Peggy Haynes, MPA
Director of the Partnership for Healthy Aging
465 Congress Street, 7th Floor
Portland, ME 04101
Phone: 775-1095
Email: haynem@mmc.org

Addressing youth obesity: How YOU can play a role
Nearly one in third of Maine children are at-risk for overweight or overweight. Most alarming is the high probability of an overweight child becoming an overweight adult. While national leaders and public opinion polls call on physicians to take an increased role in prevention and early recognition of pediatric overweight, significant gaps exist in the ability of physician practices to respond to this crisis. However, it is important to recognize that providers are one very important part of a diverse strategy to promote healthy weight.

Currently nineteen physician offices, both pediatric and family practice, from around Maine have chosen to participate in the second round of the Maine Youth Overweight Collaborative (MYOC). Building upon the successful strategies from MYOC1 (clinical delivery system design changes and community engagement), MYOC2 aims to substantially increase the ability and effectiveness of physician practices in Maine to prevent and manage youth overweight. This goal of MYOC2 will be accomplished by providing practice teams with needed training and tools, and assisting them in strengthening their linkages to community partners.

As part of MYOC2 physicians offices are asked to do the following to address youth overweight in their office:

• Promote prevention and healthy lifestyles for children and families, regardless of weight through the use of a consistent evidence-based message: 5-2-1-0
1. 5 fruits and vegetables per day
2. 2 hours or less of recreational screen-time per day
3. 1 hour or more of physical activity per day
4. 0 limit sugar sweetened beverages and encourage water and low fat milk
• Assess and classify weight status of all children:
1. Accurately measure height and weight
2. Calculate Body Mass Index (BMI)
3. Plot BMI on BMI growth chart
4. Classify weight status as:
1. <5%ile = underweight
2. 5-84%ile = healthy weight
3. 85-94%ile = at-risk for overweight
4. 95-98%ile = overweight
5. 99%ile
• Conduct an appropriate medical evaluation on children who are overweight or obese
1. Order appropriate laboratory tests
• Assess behaviors and attitudes
1. Use a behavioral risk assessment that targets diet and physical activity behaviors and attitudes (e.g. 5-2-1-0 waiting room survey)
• Assess readiness for change around healthy behaviors
1. Use brief focused negotiation and motivational interviewing techniques

Using the PHQ-9 as an Outcome Measure
Many of you are now in the habit of using the Patient Health Questionnaire (PHQ-9) as a way to diagnose depression in your patients. The PHQ-9 has been validated for that purpose. It offers you a measure of severity of symptoms at diagnosis which can help you determine the appropriate initial treatment approach.

In addition to its use in diagnosis, the PHQ-9 has also been validated as a management tool, to help you assess whether treatment is working and whether your patient has reached his/her treatment goal. As is true for the Hgb A-1-C for diabetes, the PHQ-9 offers a way to assess disease severity and a measure that you and your patient can follow to see how they are doing with their depression.

Here are some tips for using the PHQ-9 to monitor outcomes of care:
1. Consider a PHQ-9 score of 10 or higher to be positive for depression – some refer to this as 'clinically significant depression'.

2. Whether you choose active treatment or watchful waiting, a score of 10 or higher should be followed up with another PHQ-9 in 4-6 weeks.

3. Assessing Treatment Response:
Click here for a table of this information

4. The treatment goal is a score of less than 5, which is referred to as 'remission'. Appropriate treatment should lead to 50-67% of patients reaching remission.

5. For patients who do not reach remission in spite of appropriate treatment for their depression, including involvement of mental health specialists, reasonable treatment goals include reducing the PHQ-9 score below 10 and/or reducing the score by more than 50% from baseline.

6. Many of the people who do not reach remission have other mental health co-morbidities such as anxiety disorders or substance use disorders. Recognizing and addressing those increases the likelihood of remission.

For more information about using the PHQ and treating depression, see the e-learn modules 1 and 2 by clicking here.

User name: welcome
Password: welcome

Reference List:

1. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737-1744.
2. Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Med Care. 2004;42:1194-1201.

Neil Korsen, MD
Cynthia Cartwright, RN, M.Ed.
Caring for ME Depression Program
39 Forest Avenue
Portland, ME 04101
Phone: 662-3529
Fax: 662-3118
Email: cartwc@mmc.org

Cardiovascular News: Better Treatment, Lower Risk Factors Caused Drop in Cardiac Deaths
A recent study published in the New England Journal of Medicine and highlighted under Cardiology News in the American College of Physicians newsletter examines the dramatic decrease in deaths from cardiovascular disease over the two decades from 1980-2000, and finds that the improvements are due to BOTH better medical treatment of acute disease, AND better control of cardiac risk factors. The research sought to uncover the reasons why the death rate for coronary artery disease was cut by almost half between 1980 and 2000. It found better medical treatments, like revascularization for chronic angina, accounted for 47% of the drop, while reduced risk factors like smoking accounted for 44% of the decline. The full article may be accessed online at NEJM online with the ACP newsletter summary available at ACP online.

For more information about this topic or the Cardiovascular Health Program at MaineHealth, please contact:
Cindy Richards
Program Manager, Cardiovascular Health Program
465 Congress Street, Suite 301
Portland, ME 04101
Phone: 541-7545
Email: richac2@mmc.org

MaineHealth Website Shortcuts to Asthma
Got asthma? Get shortcuts to the AH! Asthma Health website. Providers can use the following: http://www.mainehealth.org/AH. There is also a shortcut to the webpage for patients http://www.mainehealth.org/asthma. Now it's easier to find the resources that you need to support your patients with asthma.

Also, the AH! Asthma program is pleased to provide links to the new translations of the Asthma Control Test (ACT) that are available on the webpage for providers. The ACT is a validated, self-administered test which was developed by physicians to be consistent with current national asthma guidelines and to help provide a quick assessment of a patient's asthma control. The Asthma Control Test is available in Spanish, Korean, Russian, and Mandarin for people 12 years and older and in Spanish for kids 4 -11 years old .

For more information about this topic or to find out more about MaineHealth Clinical Integration's Award Winning AH! (Asthma Health) Program, please contact:

Donna Levi, MS
AH! (Asthma Health) Program Manager
Maine Health, Clinical Integration
465 Congress St. Suite 301
Portland, ME 04101
Phone: 207-541-7566
E-mail: levid@mmc.org

Upcoming Living Well Class
The MaineHealth's Partnership for Healthy Aging is offering a six week Living Well Program to assist patients with self managing their chronic illness. The class is being held in Scarborough from July 27 thru August 31st. For more information about the program click here.