Lessons Learned from the National Hansen's Disease HD Program: Increasing Awareness of HD Leprosy an

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Lessons Learned from the National Hansen's
Disease (HD) Program Increasing Awareness of HD
Leprosy and Care of the Diabetic Foot
Health Resources and Services Administration2008
Primary Health Care All-Grantee Meeting
June 23, 2008

• CDR John Figarola
• Chief Rehabilitation and Education Branch
• U.S. Department of Health and Human Services
• Health Resources and Services Administration
• Bureau of Primary Health Care
• National Hansens Disease Programs

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Diabetes

• 20.8 million people in the United States
• 60 to 70 have nervous system damage
• 15 develop foot ulcerations in a lifetime
• Within 3 years 60 of ulcerations recur and 10
  undergo amputation
• Amputation rate 1 per year
• 82,000 amputations a year in U.S.
• Cost of lower extremity complications 6
  billion/year
• Prevention programs could reduce amputations by
  50

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Foot Program vs. Standard Care
Horswell R. L., Birke J.A. and Patout C.A, 2003
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• The whole problem is really one of mechanics,
  not of medicine. The biological responses of
  these denervated limbs are qualitatively similar
  to those of normal limbs. It is the permitted
  pattern of mechanical stress that is different.

Paul W. Brand
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• Dr. Brand recognized that pressure
  insensitivity caused foot ulcers and that
  pressure could be reduced through proper
  orthotics and footwear.

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History of LEAP

• The Lower Extremity Amputation Prevention
  (LEAP) program was developed in 1992 at HRSAs
  National Hansens Disease Program in Carville,
  Louisiana. This comprehensive program is able to
  dramatically reduce lower extremity amputations
  due to neuropathy.
• 
  

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Lower Extremity Amputation Prevention Program

• I. Annual Foot Screen
• II. Patient Education
• III. Daily Self Inspection
• IV. Management of Simple Foot Problems
• V. Footwear Selection

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I. Annual Foot Screen
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Guidelines for Routine Management
Patient Education
Footwear
Self Inspection
Insoles
Risk Category
Follow Up Visits
every visit
off the shelf
daily
every visit
daily
every visit
daily
every visit
extra depth / custom
daily
Those with high risk feet should see their foot
care specialist on a routine basis as directed by
the risk category.
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II. Patient Education

• Demonstrate and practice foot care procedures
• Provide detailed foot care recommendations
• Request patient commitment to self-care
• Communicate a persistent message that foot
  complications can be avoided by self care

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III. Daily Self Inspection

• An individual who has lost protective sensation
  must regularly and properly examine his/her feet
  daily to visually detect signs of injury.
• Studies have shown that daily self-inspection is
  the single most effective way to protect feet in
  the absence of the pain warning system.

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IV. Management of Simple Foot Problems

• Simple foot problemsinvolve
• Skin
• Nails
• Callus
• Pre-ulcer

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Callus Care
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V. Footwear Selection

• Footwear plays a key role in prevention of
  plantar ulceration contributing to a reduction in
  lower extremity amputation in the diabetic and
  neuropathic population. Following a foot
  evaluation, the elements to consider for a
  successful footwear plan include
• Proper footwear selection based on foot risk
  category
• Footwear modifications
• Custom orthotics
• Patient compliance
• Regular footwear monitoring
• Footwear repair and replacement

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In-shoe Pressure Measurements
Potentially damaging barefoot pressures are
measurably reduced by footwear modalities shown
above.
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Therapeutic Shoe Bill Medicare Reimbursement
The footwear prescription must be filled by a
Podiatrist, Pedorthist, Orthotist,
or Prosthetist. Medicare claim form (HCFA 1500)
is submitted for reimbursement.

• Amount covered by Medicare
• (80)
• 100.80 for therapeutic
• extra-depth shoes
• 302.40 for custom-molded shoes
• 51.20 for inserts or modifications

• Total amount allowable
• (per year)
• 126.00/ pair for therapeutic extra-depth shoes
• 378.00 for custom molded shoes
• 64.00 for inserts or modifications

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Therapeutic Shoe Bill
If a patient qualifies, he/she is limited to one
of the following footwear categories per calendar
year
One pair extra-depth shoes plus three pair of
multi-density inserts
OR
One pair of extra-depth shoes that are modified
plus two pair ofmulti-density inserts
OR
One pair custom molded shoes plus two pair of
multi-density inserts (If the patient has foot
deformity that cannot be accommodated by a
depth shoe)
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Cohesive vision

• Create a team vision where everyone shares the
  same philosophy and communicates a consistent
  message to the patient
• Keep the patient informed and in the
  communication loop when decisions are made about
  his/her care

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Team Approach

• Primary Care Physician

Nurse
Orthopedist
Patient
Podiatrist
Therapist
Orthotist/Pedorthist
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Required Competency

• Biomechanics
• Mechanisms of loss of protective sensation
• Off-loading
• Orthotics and foot wear

• Wound management
• Nail trimming
• Callus trimming and buffing
• Patient education in self care

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Empower the patient

• Patients belief in their ability to effectively
  care for themselves
• Support groups

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Training

• Seminars
• On-line
• In-services
• Practicum
• Literature review
• Mentoring

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NHDP Educational Services

• Seminars
• Distance Learning
• Individualized Training Programs
• Educational Materials
• Website

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Seminars

• Management of Neuropathic Foot Problems
• Annually
• LEAP
• Casting, Splinting and Orthotics
• Wound Management

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Distance Learning

• Black Board
• Courses
• Discussion Board
• Post-test
• CEUs

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Individualized Education Programs

• Designed to meet the learning need of the
  applicant
• Foot Screen
• Foot wear/Orthotics
• Prevention of Disability
• Research

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Educational Materials

• DVDs
• Professional Educational Materials (Brochures and
  Pamphlets)
• Reprints
• Patient Education Materials

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www.hrsa.gov/leap/
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Monofilament Distribution

• To order a single filament http//www.ask.hrsa.go
  v/
• leapindividual.cfm
• To order a package of 10 single filaments
  http//www.ask.hrsa.gov/leapprofessional.cfm

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Summary

• An effective diabetic foot treatment program
  combines a multidisciplinary team trained to
  provide evaluation, treatment and patient
  education.
• Associated healthcare cost can be dramatically
  reduced by implementation of a comprehensive
  program.
• The National Hansens Disease Programs provides
  educational opportunities to assist in the
  development of a comprehensive diabetic foot
  treatment program.

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CDR John Figarola Chief Rehabilitation and
Education Branch U.S. Department of Health and
Human Services Health Resources and Services
Administration Bureau of Primary Health
Care National Hansens Disease Programs 1770
Physicians Park Drive Baton Rouge, LA
70816 Telephone [phone] Fax
225-756-3745 E-Mail jfigarola_at_hrsa.gov