Joseph Kim, MD, MPH, MBA:
Can you introduce yourself Dr Bracken and give us a high-level overview of your quality improvement (QI) project?

Colten Bracken, MD, FAAFP:
My practice sits in a small town in southern Utah, and it 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, so I have a vested interest in taking care of my patients here because this is the little town where I grew up. In addition, we are designated as a rural health clinic. The practice itself consists of myself, a family medicine–trained physician, and 2 nurse practitioners who help with the workload. We have been open since approximately 2021. We started from scratch, building this thing from the ground up, including the building. So this has been a labor of love and a work in progress.

Our quality improvement (QI) project is a little bit unique in that we were starting from scratch. A lot of our patients were not in the habit of coming in to see their healthcare professional (HCP), and in particular from the diabetes standpoint, there was not great control of their diabetes. Many had elevated A1Cs that were greater than 9.0%.

We came into this community and established this clinic to discover that we needed to reinforce a lot of good habits and tactics to take care of our patients’ diabetes and achieve the results that we wanted. Ultimately, we looked at our community and saw that there were problems in terms of not receiving great care of their diabetes and taking note of the high obesity rate. Therefore, we asked ourselves what we could do as a clinic to increase the number of patients with managed diabetes. That is the high-level point of what we were trying to accomplish here.

Joseph Kim, MD, MPH, MBA:
It sounds like there was a real opportunity that you saw needing to be addressed. Can you tell us about your goals and the aims of the QI project? And how did you establish those aims as you started your QI journey?

Colten Bracken, MD, FAAFP:
That is a great question. I had a little bit of background in QI through my medical school training. I had not done many specific projects on my own, so this was a great opportunity to not only do it myself but get my staff involved to help them learn some of the tools of QI.

At the start, we brought it back to the basics by doing some things like a root-cause analysis and fishbone diagrams to determine the low-hanging fruit. What are some of the things that we can tackle right off the bat that are going to have a great impact on our patients' control of their diabetes? One of the things we identified early on was that patients were not returning for their follow-up appointments. For example, we would see patients with an A1C of 10% and then tell them exactly what we were going to do in terms of their care. We would say that we needed to see them back in 3 months, if not sooner, to recheck their A1C. After 6-9 months passed, the patient would return to our doorstep and still have a terrible A1C. With this pattern, we identified a need to streamline the follow-up process, which was one of the big things that we used to tackle this problem. We found that putting a greater emphasis on the importance of follow-up for our patients induced a big change and made a difference.

Joseph Kim, MD, MPH, MBA:
In terms of tracking those follow-up visits, was that all built into your electronic health record (EHR)? Or did you have to use a different practice management software or method altogether?

Colten Bracken, MD, FAAFP:
We used a couple of different methods to ensure that the follow-ups were happening. First, our EHR has built-in functionality that allows us to order a follow-up visit that would then generate system reminders. So patients now receive reminders about their appointments, and we also receive a reminder that the patient needs to be seen.

But we found that this solution alone was not enough. Therefore, the care manager became a big part of this project and really took off. We had a care manager role before this, but she was not fully functioning in the practice. We did not have a great direction for her. So we got her into this QI project and she ran with it. Now the case manager is embedded in our other subsequent projects.

With the case manager, we had her running reports on the first of the month to determine which of our patients with type 2 diabetes (T2D) had an A1C greater than 9.0% and who is then due for follow-up visits. Then she made phone calls to the patients to remind them of their follow-up appointments. We found that by her doing a warm phone call, patients would return to the office. Nobody ever said no to her when she called, which was great.

Joseph Kim, MD, MPH, MBA:
Yeah, it is that human touch that is so important. And I think that just having that person on the team and empowering her with that role is also critical.

Joseph Kim, MD, MPH, MBA:
You also started increasing your documentation of obesity as a diagnosis as a part of your QI project. Can you tell us about that?

 

Colten Bracken, MD, FAAFP:
Because we were starting from the ground up, we had no patient records. We really had a carte blanche here as far as all of our patients who started to come to our practice. We had to establish and document all of their problem lists and their health history. For the first few years, that actually was quite daunting. And with every patient who came in, there was quite a bit of paperwork and documentation that needed to be done.

We found that even with the good job that we were doing, a lot of things were falling through the cracks, in particular diagnosing obesity. You could ask, “Why does that even matter? What does it matter if you actually put ‘obesity’ on the patient’s problem list?" There is a philosophy that I like that is often attributed to W. Edwards Deming, who is a father of quality improvement: "What gets measured gets improved.” We found that just by simply documenting the presence of obesity (ie, a BMI of greater than 30 kg/m²) and putting that in the patient’s chart, it brought up more conversations. We did have a few ask why “obesity” was noted in their charts, so we explained to them that it is a medical diagnosis. That it was not intended to be offensive. But by documenting obesity in patients’ charts, it got addressed more often than before. We originally thought that we were doing a pretty good job of discussing weight management and counseling. It was not until we started documenting every patient with a BMI of 30 kg/m² or more that we took notice of the improvement by addressing that.

Joseph Kim, MD, MPH, MBA:
The treatment of obesity and diabetes can sometimes comprise the same strategies or agents that can address both conditions. Did you find any synergistic effects of improving both obesity and diabetes care? Were you able to define tactics to address both of those conditions at the same time?

Colten Bracken, MD, FAAFP:
They need to be treated hand-in-hand. If you have patients with obesity and T2D and you are only focusing on their diabetes, you are missing out on half of their treatment. They go hand-in-hand because if you can address obesity through weight loss, then that is going to directly affect patients’ T2D. We know this, but often HCPs get so focused on one’s A1C that they lose track of treating patients as a whole.

A perfect example, and I got her permission to share this, is that my mother-in-law has T2D. We were able to get her off a significant number of her diabetes medications because we helped her lose a substantial amount of weight. The direct correlation of addressing her obesity resulted, in turn, with helping improve her T2D significantly.

We found that by emphasizing both conditions in this QI project, patients took notice. They could see that we were putting more emphasis on these issues and that this was important to us. Then it became important to them, and they built off one another. I think that there is absolutely some synergy in addressing both obesity and T2D together.

Joseph Kim, MD, MPH, MBA:
Can you tell us how you were able to get your staff involved in these QI efforts? Did you assign certain tasks to them or give them additional responsibilities as you went through this journey?

Colten Bracken, MD, FAAFP:
That is a great question because buy-in is critical to any QI project. You must have your staff buy in, otherwise there is only so much you can do by yourself. Fortunately for us, I became the champion of this project and pushed it from the get-go. As the owner of this small practice and its medical director/ only physician, it was a lot easier to gain staff buy-in. I did not have to get buy-in from upper-level management or any other parties involved because I was the single, main party involved. That made it a little bit easier in that regard.

We hold regular staff meetings. And part of those staff meetings is dedicated to discussing our efforts and metrics to keep those in the forefront of everybody's mind. We published some of this information around our clinic so we could see how we are doing.

We also assigned specific roles. Certain people were responsible for calling patients. It was ultimately my care manager's job to ensure that was getting done, but she would assign some of that work to our receptionists. We had standing orders in place so that if patients came in for a sore throat but had not had their A1C checked in the last 3 months, the medical assistants were empowered to automatically check their A1C and then bring it up in that visit. We really got everybody—from the receptionists and care manager to the medical assistants and all other HCPs—involved from the get-go. We talked about it regularly and found that getting everybody engaged produced results. This also got them excited, and the staff enjoyed seeing the benefits of this project. We could see tangible improvements in patients’ A1C and the documentation of their obesity in their patient charts. Success begets success; the more we were doing, the more excited the staff got about the project.

Joseph Kim, MD, MPH, MBA:
It is definitely a continuous journey with ongoing improvement. You mentioned the care manager role. Is that person still overseeing patients with diabetes and obesity primarily or have you added on additional chronic conditions? What is the current scope of the job responsibility?

 

Colten Bracken, MD, FAAFP:
We had her on staff before and gave her this specific responsibility of being a chronic care manager. Initially, it was a gamble we took to designate somebody full time away from clinical practice, if you will. From a practice management standpoint, I worried that the role was not going to generate revenue. In hindsight, making a full-time chronic care manager has been one of the best things I have done for my practice.

She was involved in this diabetes and obesity QI project at the start and has been incredibly influential as she continues to work on the project. Since then we have had her branch out and she is now involved in chronic care management services that go hand-in-hand with diabetes and obesity care. That responsibility includes her calling patients regularly and setting up appointments for them. She even does home visits sometimes and completes vitals checks. Being in a small community, patients love her and trust her. And she is just an extension of me. So having her on staff has been beneficial to my patients. In addition, we can bill for chronic care management, so she is paying for herself. It is improving the quality of our care without costing the bottom line anything, which is fantastic.

Recently, we have been branching out to have patients use more remote patient monitoring of blood pressure, glucose levels, and oxygen levels, which provides us extra equipment in our toolbox. We are able to take better care of our Medicare population, in particular, as those patients are aging and their health is only getting worse. There are only so many primary care providers out there. So the more I use a role like the chronic care manager, the better I feel I am able to manage our little population here. She has just been instrumental.

Joseph Kim, MD, MPH, MBA:
Tell us about some of the challenges that you faced in implementing this QI project and how you were able to navigate those.

Colten Bracken, MD, FAAFP:
I think the hardest part was keeping everybody’s interest. Like I said, we have regular staff meetings to keep up with metrics. I read a book recently about the “infinite game,” which is the idea that we are not trying to win or lose here; we are trying to continue to play this game and improve over the long run. We do not suddenly fix patients’ A1C and then we are done. We fix their A1C and must continue to monitor and manage it. Setting the mindset that this is a continual process is critical. There is not an end result, which is a difficult concept for any human to conceptualize.

Then some more nuts and bolts things. It was difficult with our EHR, and we finally figured out some of that. Using the accurate data that we wanted required something of a learning curve. For example, we had to figure out where to get the right reports, and how do we get the right number of patients in those reports? Getting that raw data from our EHR took some learning.

Then there are always challenges in terms of trying an intervention that would not pan out to be effective. We had to go back to the drawing board in these cases, which is part of the Plan-Do-Study-Act cycle. The interventions are supposed to be continuously ongoing toward that improvement you want to see. The first one may not work well, and that is okay. You learn from it, you study it, you assess it, and you do something different the next time. 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.

Joseph Kim, MD, MPH, MBA:
It sounds like you have a great team in place and the roles and responsibilities clearly defined. You are providing better care for your community. And speaking of the residents, what are some of the biggest barriers to care for them?

Colten Bracken, MD, FAAFP:
We are in a rural, primarily agricultural community. The community itself is maybe only approximately 2000 people, but our catchment area is closer to 6000 or 7000 people who feed into the schools and the grocery stores surrounding the clinic. We find that there is a certain amount of health literacy that people struggle with. Like I said, there had not been great medical care out here before we arrived. There is a lot of misinformation out there and a lack of good medical advice. People here turn to the internet for information, and heaven knows what they find there. It has been a challenge to educate patients on proper ways to care for their T2D, obesity, and other health issues.

Access to specialists is another challenge. Let us say that patients need to see a cardiologist or go for an eye exam for their diabetes. They must travel at least an hour to get to the closest city where there are specialists available. Although that may not seem like such a great distance, sometimes it is a serious hardship for those who are on limited incomes or who do not have the means to make it down there. We are in a resource-limited area, which makes it challenging for our patients.

Those are probably the biggest burdens that patients struggle with around here. They make do. And many people have just done without unfortunately for a long time. It is the old farmer mentality of just rubbing some dirt on the wound and it will get better. It is unfortunate that this mentality has dominated here for a long time, but it is getting better. I would like to think that we are making a difference here, but there are still long ways to go for a lot of people here.

Joseph Kim, MD, MPH, MBA:
I really appreciate these insights. The final question that I have is, “What advice would you give to other practices or institutions looking to implement a similar QI project?”

Colten Bracken, MD, FAAFP:
Based on my experience over this last year, you really do not know what you do not know. I thought we were doing a great job and taking good care of our patients. And we were, we were trying to. It was not until we dove deep into some of the measures and numbers that it was clear we could be doing better. So I suggest others take a step back to study or measure themselves. We are caring HCPs who want what is best for our patients, but sometimes there is a better way to do it. Learn from others, too. A key component of this project was hearing from other clinics that were involved in the same type of QI projects and learning from their successes and failures.

A mantra that I learned in medical school is that no one is big enough to be independent of others. Medicine is a team sport. Therefore, the best thing for us is to learn as much as we can from others and always strive to be better. We can always be better, as good as we are as HCPs now. There is always room for improvement. Just get out there, do it, and get involved.