Medical Groups’ Perspective on Population Health-Diabetes...
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Medical Groups’ Perspective on Population Health-Diabetes care Right Care Initiative November 5,2015 Parag Agnihotri MD Medical Director, Continuum of Care Sharp Rees-Stealy Medical Group San Diego
Transcript of Medical Groups’ Perspective on Population Health-Diabetes...
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Medical Groups’ Perspective on Population Health-Diabetes care
Right Care Initiative November 5,2015
Parag Agnihotri MDMedical Director, Continuum of Care
Sharp Rees-Stealy Medical GroupSan Diego
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Objective Diabetes Care at Medical Group
1. Patient Engagement2. Diabetes measure targets3. Prevention4. Technology
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#1 One effective way to engage patients in self management of their chronic disease is….1. Make sure to provide all ‘care instructions’ in
one session2. Present yourself as part of Care Team; one
who works with your PCP/office staff3. Provide generic education material4. My way or the highway
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Engage the PatientPartner with me
Form personal connectionFace to face interaction
Step by step wellness planCoordination of care across the
systemPatient specific education
materialShared care plans
Medication adherence reportingUse HIT to engage all patients not
just present
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Clinic embedded DM vs. Remote site Engagement Rate
SAMPLE Month Program Engagement Rates -Rolling 12 Months
Program Type Overall Eng Prev Month
Clinic Embedded Diabetes DM 68.5% 65.1%COPD 75.5% 75.3%
CHF 62.9% 62.4%Off site CKD 22.9% 22.9%
Complex Case Management 31.1% 31.8%Chronic Care Nursing 78.8% 78.3%
Senior Enhanced Care Management 57.2% 58.6%Off site LCSW Behavioral Health 29.2% 28.3%
Health Coaching 34.4% 26.6%Overall Engagement 52.1% 51.1%
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#2 Hitting the targets on process measures vs.
Measuring outcomesDo the RCT’s hit Targets?1
• From 3 target based RCTs of Diabetics 3 (with A1c
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SRS -Continuous Improvement Process ‘All or none’ Diabetes bundled care
Diabetic patients with A1c < 8%, 2 A1c, LDL
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Clinical Outcome Measures for Patients with Diabetes-6 years trend
0.1
40.6
9.1
21.4
0.3
42.7
8.6
20.0
0.3
34.8
6.4
14.3
0.4
30.6
4.4
9.7
0.2
29.3
3.7
9.9
0.3
33.7
3.2
10.9
0.2
31.0
3.5
9.8
New ESRD on Dialysis New Dx DM Retinopathy New Dx Acute Myocardial Infarction New Dx Stroke
Rate per 1,000 SRS Patients with Diabetes per Year2009 2010 2011 2012 2013 2014 2015
CY 2014 per 1,000 Members per Year: 13.302015 (Jan-Jun) per 1,000 Members per Year: 12.10
Reduction in Admissions per 1,000: 1.20Mean Cost of Stroke Hospitalization (HCUP) $20,000
Estimated Cost Savings for 2015 $487,584
Stroke Cost Savings in 2015
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#3 Moving from treatment to prevention
Cause for concern
% of Diabetics increasing
9 out of 10 people
With Pre-Diabetes do not know they have it.
Our Steps
Capture High BMI in EHR High BMI counseling – offer
Health coaching Promote awareness for
Diagnosis of Pre Diabetes Promote Metformin Weight Loss program
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Over 4 years average weight kept off was 50 lbs99 PATIENTS
Change‒ 50 lbs.‒ 19.4%‒ 5 mmHg‒ 2 mmHg‒ 8.6%
‒ 41.0%‒ 37.0%‒ 50.0%
96% of those with pre-diabetes (n=26) remained medication free at follow-up
94% of those with pre-hypertension (n=32) remained medication free
Measure Initial Follow-up
Weight 252 lbs. 202 lbs.
Total Cholesterol/HDL 3.61 2.91
Systolic Blood Pressure 128 mmHg 123 mmHg
Diastolic Blood Pressure 79 mmHg 77 mmHg
Fasting Blood Glucose 105 96
Cholesterol Medications 37 22
BP Medications 49 31
Diabetes Medications 18 9
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#4 Technology Tsunami
165,000 Health Care Apps
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People-Process-Finance-TechnologyBP not in control
High Risk ASCVD
Wireless BP cuff@ Home
Monitoring byPopulation Health RN,
Health Coach
Pharmacist review >3 anti HTN meds
Demonstrate Control
Communicate to PCP
1st choice: ACE-Inhibitor/Thiazide Diuretic combo
Feldman RD, Zou GY, Vandervoort MK, et al. A simplified approach to the treatment of uncomplicated hypertension. A cluster randomized, controlled trial. Hypertension. 2009;53:646–653Highly effective HTN t/t algorithm. Handler,J. Journal of Clinical Hypertension Dec 2013 vol 15:12 874-877
Grant $$
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Lessons learned • Embedded DM or Health coach or
as close to the practicePatient
Engagement
• Outcomes vs. process measure targetsMeasures
• Investment in Diabetes PreventionPrevention
• Technology can complement but not replaceTechnology
• Participate and share best practicesRCI learning collaborative
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Any questions [email protected]
mailto:[email protected]
Medical Groups’ Perspective on Population Health-Diabetes care�Right Care Initiative November 5,2015Objective �Diabetes Care at Medical Group#1 �One effective way to engage patients in self management of their chronic disease is….Engage the Patient�Partner with meClinic embedded DM vs. Remote site Engagement Rate#2 Hitting the targets on process measures � vs. � Measuring outcomesSRS -Continuous Improvement Process �‘All or none’ Diabetes bundled care�Diabetic patients with A1c < 8%, 2 A1c, LDL
