Multidisciplinary vision: expanding new horizons in diabetes care

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Multidisciplinary vision expanding new horizons
in diabetes care

• Janice Zgibor, RPh PhD
• Director of Evaluation
• University of Pittsburgh Diabetes Institute
• Assistant Professor of Epidemiology
• University of Pittsburgh Graduate School of
  Public Health

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Questions

• What proportion of people with diabetes have
• Controlled BP (lt130/80mmHg)?
• LDL at the goal level (lt100 mg/dl)?
• A1C at the goal level (lt7)?
• What proportion have met all three?

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Questions

• What proportion of people with diabetes have
• Controlled BP (lt130/80mmHg)? 40
• LDL at the goal level (lt100 mg/dl)? 36
• A1C at the goal level (lt7)? 49.8
• What proportion have met all three? 7.3

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Diabetes Healthcare In the United States

• Current healthcare system in a state of flux
• A gap exists between the healthcare that the
  public has and the care that it should have
• Healthcare system is fragmented
• Rooted in acute/episodic care
• Not equipped to handle epidemics of chronic
  disease

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Epidemiologic Transition
Omran, A. The Epidemiologic Transition A theory
of the epidemiology of a population change.
Milbank Q. 197149509-538.
Non-Communicable Disease
Mortality Rates
Health System
Infectious Disease
Time
More information available at http//www.pitt.edu/
super1/lecture/lec0022/007.htm
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The Paradigm Shift
Acute Care
Focus prevention Care coordinated
Focus illness Care fragmented
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Quality of Care
the degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional knowledge

• Three types of quality problems
• Overuse
• Under use
• Misuse
• Four main reasons for inadequate quality of care
  in the U.S.
• Growing complexity of health care science and
  technology
• Increase in chronic conditions
• Poorly organized delivery system
• Constraints on information technology

Committee on Quality of Health Care in America,
Institute of Medicine Crossing the Quality
Chasm A New Health System for the 21st Century.
Washington D.C., 2001
8
Adapted from The First National Report Card on
Quality of Health Care in America, RAND Corp.
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Health System Rankings

• U.S. health system ranked 37th in the world based
  on
• Level of population health measured by
  disability-adjusted life expectancy
• Health disparities within the population
• Health system responsiveness consisting of
  patient satisfaction and how well the system acts
• How well people of various socioeconomic status
  find that they are being served
• Distribution of the health systems financial
  burden
• Highest ranking health systems France, Italy,
  Spain, Oman, Austria, and Japan

Committee on Quality of Health Care in America,
Institute of Medicine Crossing the Quality
Chasm A New Health System for the 21st Century.
Washington D.C., 2001
10
7
Adapted from The First National Report Card on
Quality of Health Care in America, RAND Corp.
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Quality of Care for People with Diabetes in the
United States

Adapted from Saaddine JB Ann Intern Med. 144
465-474, 2006
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Quality of Care for People with Diabetes in the
United States
Adapted from Saaddine JB Ann Intern Med. 144
465-474, 2006
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Percentages of Adults with Recommended Levels of
Vascular Disease Risk Factors in NHANES III
(1988-1994) and NHANES (1999-2000)
Adapted from Saydah S.H., et al. JAMA 291
335-342, 2004
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The Rule of Halves
Among all people with diabetes
Only 6 would have a successful outcome
50 are diagnosed
If 50 of them receive care.
and 50 of those achieved treatment targets
and 50 achieved desired
outcomes
Adapted from Novo Nordisk Changing the Cost and
Benefits of Diabetes
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Cost Differentials for Adults with Diabetes Over
a 3 Year Period
300
Adapted from Gilmer et al. Diabetes Care 28(1),
2005
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Organization of Diabetes Care in the United
States (What it should be)

• Evidence-based, planned care
• Reorganization of practice
• patient as the most important member of the team
• Attention to patient needs
• Access to clinical expertise
• Supportive information systems

Crossing the Quality Chasm, IOM, 2001, 28-29.
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Organization of Diabetes Care in the United
States (What it is)

• Care is often not based on evidence, but
  experience and training
• Seldom is there a team approachcare is mainly
  driven by the physician alone
• Care delivery is primarily paternalistic with
  little attention to patients behavioral needs
• Limited access to diabetes specialists
• Poor information systems

Crossing the Quality Chasm, IOM, 2001, 28-29.
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Potential Solutions

• More effective prevention and management
• 50 of mortality from the 10 leading causes of
  death is attributable to lifestyle behaviors that
  cause or complicate illness
• Model of chronic illness care which is
  evidence-based, population-based, and
  patient-centered
• Implementation of chronic illness model into
  clinical practice

Glasgow R.E., et al. The Milbank Quarterly
79579-612, 2001
Renders C.M., et al. Diabetes Care 241821-1833,
2001
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Examples of expanding new horizons in diabetes
care at the University of Pittsburgh Diabetes
Institute
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University Center Primary Care Practice 1 and
Practice 2
Prime Care Primary Care Practice
?
Falk Clinic ?
135,000
General and
Internal Medicine
?
Childrens Hospital East
?
Partners in health Primary Care Practice
Childrens Hospital Johnstown
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Chronic Care Model
Community
Health System
Health System
Organization of Healthcare
Resources and Policies
Decision Support
Delivery System Design
Clinical Information Systems
Self- Management Support
Informed, Activated Patients and
Caregivers
Prepared, Proactive Practice Team
Productive Interactions
Improved Outcomes
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Health System Community

• UPMC board initiative
• Support from all departments
• Finance
• Information systems
• Physician practices
• Presentations to top leadership
• Corporate Communications
• Pittsburgh Regional Initiative for Diabetes
  Education (PRIDE) http//www.prideofpa.org

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Chronic Care Model
Community
Health System
Health System
Organization of Healthcare
Resources and Policies
Decision Support
Delivery System Design
Clinical Information Systems
Self- Management Support
Informed, Activated Patients and
Caregivers
Prepared, Proactive Practice Team
Productive Interactions
Improved Outcomes
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Clinical Information Systems(EMRs and
Registries)http//www.chcf.org/documents/chronicd
isease/ComputerizedRegistriesInChronicDisease.pdf

• There is a registry with real-time data.
• Care reminders and feedback.
• Proactive population-based care.
• Individual patient care planning.
• Identifies gaps in care.

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AADE 7 Self-Care Behaviors Outcome System

• Purpose
• Assess
• Gather
• Track
• Aggregate
• outcomes measures of behavior changes from
• diabetes self-management education (DSME)
• First tool of its kind to gather the evidence to
  support the use of DSME in improving patient
  outcomes

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Information Technology

• Affords opportunities to
• Support DSME practice and follow up
• Gather, track and aggregate data
• Continuous feedback
• Comparative reports to peers
• Clinical information
• Reimbursement

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Chronic Care Model
Community
Health System
Health System
Organization of Healthcare
Resources and Policies
Decision Support
Delivery System Design
Clinical Information Systems
Self- Management Support
Informed, Activated Patients and
Caregivers
Prepared, Proactive Practice Team
Productive Interactions
Improved Outcomes
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Decision Support(the right care at the right
time)

• Evidence-based guidelines are used into daily
  practice.
• Healthcare team members are trained on the
  guidelines.
• Patients own the targets.

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Chronic Care Model
Community
Health System
Health System
Organization of Healthcare
Resources and Policies
Decision Support
Delivery System Design
Clinical Information Systems
Self- Management Support
Informed, Activated Patients and
Caregivers
Prepared, Proactive Practice Team
Productive Interactions
Improved Outcomes
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DSME Paradox

• DSME follow-up is crucial and effective
• Currently, poor reimbursement practices for DSME
• Medicare only pays for 2 follow-up visits/year

Solution??
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ADA Recognition for Education Programs
University of Pittsburgh Diabetes Institute
Advisory Committee
Prior to 2000
n ADA Recognized n Not ADA Recognized n Pending
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ADA Recognition for Education Programs
Presently
University Center
Northwest
VA Pittsburgh
Braddock
CHP Johnstown
CHP East
CHP Main
Bedford
South Side
Horizon Shenango
Horizon Greenville
Gen. Internal Med
St. Margaret
Shadyside
Passavant
Lions _at_ McKeesport
Lee
Magee
Falk Clinic
n ADA Recognized n Not ADA Recognized n Pending
27 PRIDE programs recognized by the ADA
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Reimbursement Challenges

• Missing certificates
• Staff neglected to submit charges
• Wrong codes were entered
• Billing on 1 hour frames instead of 30 min.
• Insurers ignored charges

Siminerio L, Piatt G, Emerson S, Ruppert K, Saul
M, Solano F, Stewart A, Zgibor J. Deploying the
chronic care model to implement and Sustain
diabetes self-management training programs. The
Diabetes Educator, volume 32 (2) 1-8, 2006.
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DSMT Reimbursement and Educator Salary at 8 UPMC
ADA Recognized Programs (January 2002-June 2004)

Siminerio L, et al . The Diabetes Educator,
volume 32 (2) 1-8, 2006.
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Chronic Care Model
Community
Health System
Health System
Organization of Healthcare
Resources and Policies
Decision Support
Delivery System Design
Clinical Information Systems
Self- Management Support
Informed, Activated Patients and
Caregivers
Prepared, Proactive Practice Team
Productive Interactions
Improved Outcomes
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Is this where we are going????
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Diabetes Educators in the Primary Care Setting
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Delivering Diabetes Education at the Point of Care

• One CDE started in 4 primary care practices
  identified to have a high volume of diabetes
  patients - 2003
• Two CDEs presently in 17 primary care practices -
  2008
• Available on diabetes days
• CDE must meet the needs of the practice.
• Met with physicians to determine best methods for
  communication and documentation
• ADA Medical Standards of Care and the National
  Standards for DSME used to provide consistency
  and benchmarking
• All DSME sessions were based on the empowerment
  approach
• Allowed CDEs to finally be able to bill for their
  services!

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Temporal Trends in A1c and LDLc Levels in
Patients who Receive Point of Service Diabetes
Education (POSE) Compared to those who did not
receive POSE in Four Primary Care Practices,
January 2003 December 2006

• A1c Levels

• LDL Levels

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Therapeutic management Nurse-directed protocols

• Approved protocols for glycemic, hypertension and
  cholesterol management
• Nurses used these protocols in therapy
  management
• Currently taking place in high-risk Hispanic
  communities
• Significant improvement in provider processes and
  patient outcomes

Davidson, M., et al Effect of nurse-directed
diabetes care in minority populations Diabetes
Care, 2003.
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Conclusions

• Educators in primary care
• Increased access
• Improved clinical outcomes
• Obtained recognition
• Reimbursement for services
• Opportunities for therapeutic management

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Group Medical Visits
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Why group visits?

• Current level of access ? good care.
• Patient satisfaction is the key to success
• Better patient-provider communication is needed.

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Advantages for patients

• Reduced isolation
• Peer education
• Slower pace
• Increased satisfaction
• Guideline implementation
• and adherence
• Increased time with provider

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Advantages for providers

• Patient retention
• Fewer ER visits/admissions
• Billable
• Increased satisfaction
• Guideline implementation
• adherence
• Efficiency
• Less isolation

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What is the evidence?Outcomes of Group Medical
Visits an example

• Population
• Kaiser Permanente Pleasanton, CA
• Age 16-75
• Poor glycemic control (gt8.5 or no test in
  previous 12 months)
• Methods
• Group (cluster) visit monthly for 6 months
• Diabetes nurse educator, psychologist,
  nutritionist, pharmacist

Sadur, CN, et al, Diabetes Care. 22(12)
2011-2017
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What is the evidence?Outcomes of Group Medical
Visits an example

• Results
• Lower A1c
• -1.3 vs -0.22
• Decreased admissions
• Increased satisfaction with diabetes care
• Quality
• Responsiveness
• Convenient and easy access
• Increased self-efficacy

Sadur, CN, et al, Diabetes Care. 22(12)
2011-2017
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Diabetes Educators and Primary Prevention
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Diabetes Educators Primary Prevention

• Challenges
• Numerous referrals
• No reimbursement
• No track record
• Solutions
• Have skill set
• Recognized in community
• Trusted resource

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Diabetes and Cardiovascular Disease Risk
Reduction Program in a Hospital-Based Diabetes
Education Setting

• Diabetes Prevention Program

• Modified Diabetes Prevention Program

• 16 sessions over 24 weeks
• Individual counseling
• Food pyramid
• Fat intake
• Brief introduction to a pedometer

• 12 weekly sessions over 12-14 weeks
• Group classes
• Healthy food choices
• Emphasis no fat intake and calories
• More emphasis on a pedometer

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Diabetes and Cardiovascular Disease Risk
Reduction Program in a Hospital-Based Diabetes
Education Setting

• Diabetes Prevention Program

• Modified Diabetes Prevention Program

• 16 sessions over 24 weeks
• Individual counseling
• Food pyramid
• Fat intake
• Brief introduction to a pedometer

• 12 weekly sessions over 12-14 weeks
• Group classes
• Healthy food choices
• Emphasis no fat intake and calories
• More emphasis on a pedometer

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Proportion of Subjects who Decreased at Least One
Parameter of the Metabolic Syndrome at 3 and 6
Month Follow-Up

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Average Weight Loss Following a modified Diabetes
Prevention Program
lbs
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Review

• Outreach into the Community
• Novel systems to redesign delivery of care
• Team approach with the patient as the captain
• Use of benchmarks to establish gaps in care
• Technology
• Data repositories, patient registries, clinical
  information systems
• Primary prevention
• Reimbursement

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The Pay Off

• UPMC has redesigned the way in which diabetes
  care is delivered in order for these positive
  outcomes to be sustained
• Empowerment approach
• Point of service education
• CDE reimbursement
• Educators deliver primary prevention
• UPMC Health Plan (insurer) has begun initiatives
  to reimburse for primary prevention efforts

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The Curricula

• Innovative Tools and Practice Models in Diabetes
  Care
• Guidelines and Standards of Diabetes Care
• Decision Points in Therapy
• Insulin Pumps and Software Training, Best
  Practices and Practical Experience
• Training on Pump and Meter Technology
• Putting It All Together Patient Cases
• Chronic Care Model
• Communicating With Patients and Families
• Reimbursement for Diabetes Care

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Acknowledgements

• Linda Siminerio, RN, PhD, CDE
• Janice Zgibor, RPh, PhD
• Sharlene Emerson, MSN, CDE
• Diane Luther, BSN, CDE

Portions of this research was sponsored by
funding from the United States Air Force
administered by the U.S. Army Medical Research
Acquisition Activity, Fort Detrick, Maryland,
Award Number W81XWH-04-2-003 . Review of
material does not imply Department of the Air
Force endorsement of factual accuracy or
opinion.