Collaborative Diabetes CareCollaborative Diabetes CareMark G. Mitchell, OD, MBAMark G. Mitchell, OD, MBA

Reno, NevadaReno, Nevada

What my patients think of...What my patients think of...

==

What I think of...What I think of...

We need to change our We need to change our diabetes visits to work diabetes visits to work

better as part of the teambetter as part of the team

It's really important to system● Costs● Benefits of early intervention● It's an epidemic

8.5%World

10.9%US

>50%Tohono O'odham

Int Diabetes Federation 2013; Tohono O'odham Community Action

Prevalence

Demographics

African AmericanAfrican American Native AmericanNative American Hisp/LatinoHisp/Latino0%0%

5%5%

10%10%

15%15%

20%20%

25%25%

30%30%

ArizonaArizonaUSUS

10% of spending

10% of patients

QUALITY CAREQUALITY CARE

“All health professionals should be educated to deliver client-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”

Institute of Medicine, Health Professions Education: A Bridge to Quality (2003).

Sounds like Midwestern...

“All health professions schools have an obligation to educate future practitioners who are prepared both to assess and to meet the health needs of the public. This obligation entails…fostering greater inter-professional teamwork and collaboration.”

Macy Foundation, “Revisiting the Medical School Education Mission at a time of Expansion, 2009

DiabetesDiabetes

A great chance to collaborate and foster interdependence.

Oh...Oh...

And improve patient care.

Working togetherWorking together

Collaborative – includes concepts of shared responsibilities, shared decision-making, shared values, shared planning and intervention, and sharing of professional perspectives

Interdependent - mutual dependence rather than autonomous – arises out of common desire to address patient’s needs

• D'Amour, D., M. Ferrada-Videla, et al. (2005). "The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks." Journal of Interprofessional Care Supplement 1: 116-131.

Why don't they care?

Why don't they care?

● PCPs are trying to prevent:● MI, CVA, amputation, vision loss, etc● They are trying to follow current evidence-based

guidelines for– BP– Foot screening– Eye screening– Cholesterol– Education– And, it goes on and on

Why don't they care?

They're concerned with far more than the eye...

2013 US Costs2013 US Costs

US Primary Eyecare US Diabetes0

50

100

150

200

250

Bill

ion

s

Sources: Ken Research, American Diabetes Association

2013 US Costs2013 US Costs

US Primary Eyecare US Healthcare0

500

1000

1500

2000

2500

3000

Bill

ion

s

Sources: Ken Research, American Diabetes Association

2013 US Costs2013 US Costs

US Primary Eyecare US Healthcare0

500

1000

1500

2000

2500

3000

Bill

ion

s

Sources: Ken Research, American Diabetes Association

1%1%

We think of... They think of...

HEDIS

● Healthcare Effectiveness Data and Information Set ● NCQA ● Measure performance of health plans to allow

comparisons

HEDIS 2014

Out of 85 HEDIS measures

Only 2 eye measures

DM exams that's part of the Comprehensive DM Care measure

The other is glaucoma screening in older adults

What they really want from us?

IS IT TIME FOR IS IT TIME FOR LASER?LASER?

This isn't particularly collaborative.

We're small potatoes.

The Usual PCP Report

Do they have any DM findings?

What else have you done?

Do they need any tx?

When do they need to come back?

Who's the PCP?

MD

DO

NP

PA

Front desk staff?

Benefits of Medicine Collaboration

● Interprofessional relations● Valuable contribution of optometry students

● (we can't bill Medicare for their services anyway, why not put them in medicine clinic?)

● Oh, and the patients will benefit too● Save a visit● Get better care

Midwestern could be there...

● Collaboration● Optometry-Osteopathy

● A New Two O's

Diabetes care is comanagement

We are held to a medical standard

Same as ophthalmology

We need to do more.

Diabetes

● The standard of care is medical and involves:

● state of the art examination ● coordinated comanagement

with physicians● continuous patient

education ● timely referral when

complications occur.

● The timeliness of a referral is important, especially for patients with good vision and significant retinopathy. Failure to make a timely referral can result in litigation

The Diabetes Eye Visit

● a thorough history must be taken

● the examination should include:● measurement of visual acuity● refraction (as indicated)● tonometry and slit lamp evaluation● Dilated ophthalmoscopy and fundus biomicroscopy

● Ophthalmologists are sued by patients with diabetes more frequently than any other type of physician.

● Because loss of vision from diabetes is often preventable if timely diagnosis and treatment are provided, failure to refer appropriately can result in significant awards for damages.

Maybe if we help the PCP?Maybe if we help the PCP?

Maybe then they'll love us...Maybe then they'll love us...

What more could we do?

● Make the dilated eye exam more like their own office visit● BP, ask about compliance, any difficulties● Review medications● Go over self measurement logs...MDs don't have

time– And, reimbursement doesn't help

● Educate● Order screening blood tests for at risk patients

Get a blood test...

If at risk for diabetes or pre diabetes

Or...

● Have diabetes eye evaluations as part of a team effort with● Medicine● Podiatry● Education/Adherence● Blood draw

What more could we do?

Educate

● Optometrists should educate patients with diabetes concerning the risk of ocular complication and the need for periodic examination.

● Patients with retinopathy should be placed on a reasonable recall schedule or, if appropriate, referred to a physician.

● Recall schedules are based on the level of retinopathy observed.

ADHERENCE!

75% of patients don't take their medications as prescribed!

And, we're the ones who get sued?!

Source: M. Sokol et al., "Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost," Journal of Medical Care, 2005.

Return on Investment from Improved Medication Adherence: Diabetes

$1 more spent on diabetes medicines = $7.10 less spent on other services

Ave

rag

e A

nn

ua

l S

pe

nd

ing

R

ela

ted

to

Dia

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Adherence (%)

NONADHERENCE!

–Increases deaths, hospitalizations, and emergency room visits –Increases overall health care costs –Diabetes specific medications are not the only important thing

Patients, health care providers, and health care systems all play a role in creating the quality and outcome gap between current reality and optimal diabetes management.

Clinical Diabetes 2008;26:1 17-19.

Diabetes is a common and very costly chronic disease. There is broad-based agreement on how to manage diabetes, yet less than 40% of adults with diabetes achieve guideline-recommended levels of medical care.

Commonwealth Fund.

Change the exam a little

● Improve intraprofessional relations● Improve referrals to optometry● Improve patient care

The New Diabetes Eye Visit

● Vision, dilated exam, of course● Add blood pressure● More complete history

● Medication● Adherence/compliance● Any issues

● Education● Your choice on how extensive

The New Diabetes Eye Visit

● And, send a report● Send it right away...yes, right after or during visit● Consider other team members that might need it

– PCP, of course– Podiatry– Endocrine– Dental– Wound care– Even, the patient!

● MAKE SURE PATIENT IS IN THE LOOP

I can't do it!

● We have to...we're held to a medical standard● It doesn't take much time (and, you can train

your staff)● Standards for BP, glucose, a1c easy to learn● Patients accept this readily (they expect it!)● OK, so maybe education is hard, but we can

get better

The Business CaseThe Business Case

While there are questionable economic benefits for a health plan, there are real economic beneifts for private practitioners and other providers.

Increased referrals

Better interactions with PCPs

Increased recall effectiveness

More network opportunities

Faculty Development

Commitment to the value of IPE and IP collaborative practice

Knowledge of scope of practice of the professions

Effective teamwork skills

Teaching and managing large classes

Interactive learning

Small–group facilitating

What's best for the patient?What's best for the patient?

Working as part of the team.Working as part of the team.