The T1D Exchange Quality Improvement Collaborative (QIC) creates change packages by using data from the QIC to develop interventions that improve care and outcomes in T1D.

A change package is a published step by step guide any clinic can use to implement an intervention. The change package model builds on multiple clinics testing one specific change several times over and sharing the knowledge with every other participating QIC clinic. If data shows the change has made a positive impact on care, that change can be translated into a change package.

Much like a recipe, the change package model offers everything one site will need in order to implement that same change in their own practice in the effort to see the same improvements in care and outcomes for their patients with T1D.

Change packages are intended to be a pragmatic guide of best practices, testable ideas, tools, and strategies that can be adapted to a new setting, thereby accelerating implementation.

Instead of starting at square one with their own hypothesis and having to work through every step, the QIC enables other clinics to begin at a significantly more advanced stage. This means clinics following that particular change package’s comprehensive framework can rapidly apply a tested and proven method of improving care.

Clinical sites should consider the following to determine readiness to implement a change package:

  • Strategic alignment with institutional and division goals
  • Identification of a champion and motivated team who work together to accomplish change implementation
  • Consensus around the relevance of project aims and desire to implement change
  • Development of a specific, measurable, achievable, realistic, time-bound (SMART) aim
  • Personnel with skills to map existing clinical processes, identify potential failures and opportunities
  • Organizational willingness to try small tests of change (PDSA cycles); adapt what works and abandon what doesn’t
  • Personnel with analytic capabilities to measure and display data over time for learning
  • Infrastructure to spread successful interventions to eligible clinic population and sustain over time
  • Partnership with patients and families to increase patient engagement and readiness

“Being part of the QIC is like the hive mind,” says Nicole Rioles, Director of Clinical Partnerships and Population Health at T1D Exchange. “Instead of learning and knowing what you have in your own small space, your own clinic, you are gaining access to a huge system of knowledge.”

Examples Change Packages Distributed in 2020

The following are a brief overview of two change packages distributed in 2020 to clinics in the QIC.

“Access to Clinical Care”

Regular outpatient appointments and medication management are crucial for patients with type 1 diabetes, and the American Diabetes Association (ADA) recommendation is for pediatric patients to be seen at least four times per year.

Unfortunately, many patients fail to receive the services they need because of barriers to access, including issues such as: time of travel, cost of travel, the concern of missing work or school, transitioning from pediatric to adult care, and lack of childcare for other family members. There can also be challenges on the clinic side like long wait times until the next available appointment. While some clinics have a “patient navigator” appointed role that works with these underserved patient populations, many clinics do not.

This QIC Change Package serves to identify and re-engage patients who have been “lost to follow up” (LTFU), which refers to patients who were once active patients (or research participants) attending a clinic for regular follow up but became “lost” to routine appointments.

“Depression Screening”

Depression is a contributing factor to suboptimal health outcomes and is common among adolescents and adults with chronic health conditions, such as diabetes. When present, depression in adolescents with type 1 diabetes is associated with less frequent blood glucose monitoring, higher A1c values, and increased rates of diabetes-related hospitalizations.

Early detection of distress, or symptoms of depression makes referral for formal evaluation possible and has shown to be effective in primary care settings. Given the impact of depression on outcomes, patients with diabetes should be screened annually using age-appropriate screening measures and patients with positive screens should receive further evaluation and treatment as necessary.

This QIC Change Package offers extensive new guidelines for screening, scoring, and intervening in patients struggling with depression, ensuring that fewer patients “slip through the cracks” in the mental health screening process referred to as the “Depression Screening Tool Kit.”

The resources within this change package should equip additional sites with tools to accelerate adoption of a reliable depression screening process.

Improving the Lives of People with T1D

When change packages are adopted by other clinics, the impact on the treatment and outcomes for people with T1D is measurable.

Here are two examples of the QIC’s ability to improve T1D care across the country:

Increasing and Improving Continuous Glucose Monitor (CGM) Use

Ten diabetes centers in the T1D Exchange QIC successfully proved that we can improve CGM use through assessing and removing barriers to adoption, developing CGM patient education classes, and advocating for state Medicaid coverage. By understanding the best methods to increase CGM usage, we are one step closer to improving outcomes for all people living with T1D.

Many studies have demonstrated the clinical benefit of continuous glucose monitoring (CGM) in type 1 diabetes (T1D). Although favorable insurance policy changes have gradually increased the access of CGM nationally, widespread uptake has been slow.

Using the T1D Exchange’s QIC method of “Plan – Do – Study – Act (PDSA)” cycles to test and expand different interventions to increase CGM use in their respective centers, 8 out of 10 clinics improved CGM use significantly, particularly in patients aged 12 to 26 years old. This demonstrates that by using QI principles to test interventions and cross-learning, the T1D community can increase use of CGM devices.

Reducing the Proportion of Patients with HbA1c Levels Over 9%

Ten clinics in the QIC worked collaboratively on the goal of reducing HbA1c levels in high-risk patients — defined as patients with HbA1c’s over 9.0 percent.

Clinics shared respective data on a monthly basis and developed a set of 5 critical interventions to better support high-risk patients:

  • Support for glycemic management: assigning a patient navigator (PN) to increase support
  • Glucose monitoring: offering CGM education classes
  • Insulin management: offering insulin pump education classes
  • Patient-centered care: redesigning the overall clinic workflow
  • Access to clinic and psycho-social care: increasing depression screening & addressing social determinants

Being part of T1D Exchange’s QIC means not only contributing to the effort to improve national T1D patient healthcare but also significantly improving the care of your clinic’s T1D population. By working collaboratively across the country, the potential of improving the lives of those living with T1D is limitless.

Click here to read our “Breaking Down the Science” series and learn more about advancing health equity in T1D, including the 10-step framework developed by the T1D Exchange Quality Improvement Collaborative to address the literature gap on practical ways health care providers can address inequities.

Click here to listen to a panel discussion on Health Inequities in T1D care from the T1D Exchange that further highlights the importance of the T1D Exchange HEAL program.

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