Transforming Diabetes Care

1(c)

Transforming Diabetes CareProgram Content

• Product training to enhance care

• Applying the Chronic Care Model to diabetes care

• Reimbursement through improved coding

• New standards, guidelines and decision points in therapy

• Changing behaviors in healthcare

2(c)

Transforming Diabetes Care How adults learn…

Problem solving,

role playing,

case studies,

myths and truths,

downloading,

testing, injecting,

“pumping”

What I hear,

I forget;

What I see,

I remember;

but what I do,

I understand.”

~ Confucius, 451 B.C

3(c)

• What proportion of people with diabetes have…

– Controlled BP (<130/80mmHg) – LDL at the goal level (<100 mg/dl) – A1C at the goal level (<7%)

• What proportion have met all three?

4(c)

• What proportion of people with diabetes have…

– Controlled BP (<130/80mmHg) 40%– LDL at the goal level (<100 mg/dl) 36%– A1C at the goal level (<7%) 49.8%

• What proportion have met all three?

7.3%

Sayday, et al JAMA 2004; 291:335

5(c)

Informed,ActivatedPatients andCaregivers

ProductiveInteractions

Prepared,Proactive,Practice Team

Improved Outcomes

Delivery System Design

DecisionSupport

Clinical Information

Systems

Self-Management

Support

Health SystemResources and Policies

CommunityHealth Care Organization

The Chronic Care Model

6Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]

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Looking at Our Practice: Questions we should ask ourselves

• What aspects of the model can we adopt?

• Which guidelines will we follow?

• How do we make sure our coding is correct?

• Who in our community do we involve?

• Would we benefit from a diabetes registry?

7(c)

Meet Joel Henderson and his family

– 43 yr old obese male– Type 2, HTN, dyslipidemia, sleep apnea– Family hx - heart disease, depression– A1c 8.6% – BP 146/96 – Chol 192

Admits his diabetes is not a priority Busy stressful life“My wife worries about my diabetes for me”Understands family history and risksAdult daughter and granddaughter recently moved back home“I really don’t know what questions to ask.”

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Chronic Care Model

Pillars of Care

Self-Manage-ment

Support

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

CommunityResources

9© Johnson & Johnson Diabetes Institute, LLC 2009

Community Resources and Collaborations

• Local Malls (for ‘mall walking’)• Public Library• Local Restaurants • Beauty Salons• Barber Shops• Parks & Recreation Dept.• Visiting Nurse Organizations• Literacy Volunteers of America• American Diabetes Association• Local Senior Centers• Local Health Care Providers

• Churches• Service Organizations• Housing Authority• Grocery Stores• Schools• Local Worksites• Media

10(c)

Chronic Care Model

Pillars of Care

Self-Manage-ment

Support

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

CommunityResources

11© Johnson & Johnson Diabetes Institute, LLC 2009

Self-Management Support

• Joel’s role includes: – Testing his blood glucose – Learning food’s effect on his glucose– Begin exercising regularly

• Our role includes:

– Assessing his readiness to make these changes

– Provide visits and perhaps referrals that support his efforts such as:

• Medical Nutrition Therapy• Diabetes Self Management Education

– Provide support

12(c)

Self-Management Support Medical Nutrition Therapy Referral

Joel and his wife learn:• Relationship between his food

choices and his glucose control

• Value of SMBG in helping him

make food choices

• Effects of exercise on glucose

control

13(c)

Self-Management Support Changing Behavior

Our role:Assess where Joel is on the road to change

Work to motivate him to change behaviors Tools that can help: Importance and Confidence Rulers

“Joel won’t change his eating habits.”

“Joel isn’t getting enough exercise.”

“I can’t seem to get through to him!”

14(c)

Chronic Care Model

Pillars of Care

Self-Manage-ment

Support

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

CommunityResources

15© Johnson & Johnson Diabetes Institute, LLC 2009

Benefits of SMA

• Improves access to good care

• Improves patient satisfaction

• Improves patient-provider communication

Delivery System Design Shared Medical Appointments

16(c)

Sample Agenda

I Introductions

(15 min)

II Self-management education

(30 min)

III Interactive with HCPs

(30-40 min)

IV Q&A on topic

(15 min)

V 1:1 visit time

(30-45 min)

Table

Table

Dry Erase Board

Coffee Water Tea

Pts Enter

Patients Dr. Cabral Behaviorist Phyllis

Documenter

Table Nurse

Joel might benefit from A Shared Medical Appointment

17(c)

Benefits of Shared Medical Appointments to our practice include:

Fewer ER visits/admissionsPatient retentionIncreased satisfactionEfficiencyLess isolation

CLEVELAND CLINIC JOURNAL OF MEDICINE, VOLUME 71, NUMBER 5, MAY 2004

18(c)

Chronic Care Model

Pillars of Care

Self-Manage-ment

Support

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

CommunityResources

19© Johnson & Johnson Diabetes Institute, LLC 2009

Treat to Target

A1c BP Chol LDL/HDL TG

ADAAmerican Diabetes Association

< 7% 130/80 < 200 <100*>40 men

>50women

<150

AACEAmerican College of Endocrinology

< 6.5% 130/80 < 200 <100*>40 men

>50women

<150

* CVD < 70

20(c)

The Price our Patients pay….

‘Avoidable Glycemic Burden’

“…a hypothetical patient progressing from nonpharmacologic treatment through sulfonylurea or metformin monotherapy to combination oral agent therapy….would accumulate nearly 5 HbA1c-years of total burden >8.0% and about 10 HbA1c-years of total burden >7.0%. The latter figure exceeds the mean reduction in glycemic burden (9.0 HbA1c-years) achieved over 10 years by the U.K. Prospective Diabetes Study”

Brown, J. et al Diabetes Care 2004;27:1539

Brown, J. et al Diabetes Care 2004;27:1536 21(c)

2009 ADA/EASD Consensus Algorithm

Early Insulinization

22

DIABETES CARE, VOLUME 32, NUMBER 1, JANUARY 2009: 200

(c)

Early Insulinization

Barrier

• Frequent Hypoglycemia

• Weight gain

• Needle phobia

• Guilt and failure

• Time to titrate

Solution

• Analogue insulins

• RD consult, metformin

• “Adam’s technique”, an insulin injection technique

• Explain progressive nature of diabetes

• “Do it yourself” algorithms prescribed by the healthcare professional

23(c)

• Using evidence based guidelines– Define targets and algorithms

• ADA, AACE, Staged Diabetes Management etc

• Regular updates

As an office, we need to defineDecision Support resources for us

24(c)

A decision point…

Joel is now on max doses ofmetformin and glyburide. His A1C is 7.0% today.

What is the likelihood that it will be above 7.0% on his next visit in 6 months?

25(c)

Brown JB, et al. Diabetes Care 2004;27:1538

Duration of control….

26(c)

Decision Points involve a number of factors

– TARGET• What is the goal you are shooting for?

– METHOD• What is your choice of therapy to get there?

– TIMING• When do you decide it isn’t working? • How often do you make changes?

27(c)

Chronic Care Model

Pillars of Care

Self-Manage-ment

Support

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

CommunityResources

28© Johnson & Johnson Diabetes Institute, LLC 2009

Clinical Information Systems

• EMRs

• Diabetes Registry

• Real time data

• Identifies gaps in care

• Care reminders and feedback

• Individual patient care planning

• Proactive population-based care

29(c)

Reimbursement

Barrier• Identifying all billable

moments

• Not getting reimbursed for diabetes education

• Not paid for preventive counseling -“Diet and Exercise”

• Knowing what can be billed on the same day

• Cannot bill for MNT + DSMT on same office visit

Solution• Find a coder to identify

billable moments

• ADA Recognition will open doors

• Always get a referral for DSMT and for MNT

• Get referrals for additional hours of MNT if requested from the professional for treatment changes

30(c)

Key Learnings

• Recognize barriers and provide solutions to:– Treat to target

• Early insulinization

– Reimbursement• New approaches

– Changing behaviors• Assessing readiness

31(c)

How will we change our practice?

As a practice, which of these key learnings should we implement ?

And when do we begin ?

32(c)

33(c)