Diabetes Care for High Risk Populations: Lessons from a Community Based Program

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Diabetes Care for High Risk Populations
Lessons from a Community Based Program
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Software Screen
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Todays Speakers
Marie Laboissonniere RN Med CDOE
CVDOEand Susanne Campbell RN MS St Joseph
Center for Health and Human Services Providence,
RI
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Learning Objectives

• Participants will be able to
• Describe resources available that enable
  uninsured/vulnerable patients to obtain
  medications, supplies and material support
  needed to work toward positive treatment
  options.
• Identify strategies to maximize internal/external
  resources to provide patients with nutritional,
  mental health and additional chronic care
  services.
• Identify educational and peer support
  opportunities to engage patients in taking a
  significant role in managing their own care.

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The Diabetes Resource Center (DRC)

• Established in 1991 to meet the needs of people
  with diabetes who
• Have limited or no resources
• Are under or uninsured
• Have diabetes-related needs for
• Medications
• Accessing primary care, specialty care, mental
  health and case management services
• Diabetes education

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Primary Goals

• Patients will be able to manage their condition
  and improve clinical outcomes through access to
  
• Primary Care
• Podiatry, Ophthalmology
• Medications
• Diabetes Supplies
• Mental health and case management
• Nutritional services
• Individual and group education

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Main Partners

• Rhode Island Dept of Health Chronic Care
  Collaborative (Diabetes and CVD)
• Colleges and Universities (student interns for
  pharmacy, nutrition, nursing, medical
  assistants)
• Funders (Blue Cross/Blue Shield, Rhode Island
  Foundation, Churches . Private Charities)
• Systemetrics (Pharmacy Assistance Software)
• Drug companies
• CMS-contracted QI Organization (Quality Partners
• Private physicians that donate time
• Volunteers (registry data entry, patient follow
  up)
• Peer Navigator (Rhode Island Parent Information
  Network)

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Challenges

• Growing number of uninsured patients
• Employing professional staff that speak Spanish
  (RD, Social Worker, RN)
• Less grant funding opportunity with downturn in
  economy
• Place to come for free care
• Free standing registry
• Patient engagement and follow through
• Reimbursement for services

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Changes Reduce Expenses, Improve Efficiency

• Integrated the DRC into the Adult Primary Care
  Program
• Implemented group diabetes classes (including
  mental health )
• Implemented peer support group
• Implemented small group education
• Automated the Pharmacy Assistance Program (PAP)
• Coordinated purchased supplies with PAP
• Added Primary Care model requirement to access
  other support services

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Changes Team Expansion/Integration

• Co-located and integrated mental health
• Expanded team to include RD, social worker,
  Clinical Nurse Specialist, and peer navigator
• Expanded relationship with Universities
• Expanded community partnerships (exercise,
  tobacco cessation, nutrition)
• Expanded program to other chronic care conditions
  
• Collaboration with acute care Diabetes Center
  for Excellence

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Changes Reimbursement

• Became ADA certified site and State recognized
  CDOE site
• Hiring RD who is can be reimbursed under Medicare
  and Medicaid
• Becoming a Patient Center Medical Home
  Insurances paying more per member/month and pay
  for performance

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What Patients Need

• Medications/strips
• Pharmacy Assistance Program seeing 200 patients
  per month
• Increasing need for grant funded insulin and
  supplies
• Increased need for Pharmacy samples

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What Patients Need

• Mental Health
• Resources for Basic Living Needs
• Treatment for anxiety and depression
• Peer support, particularly for Latino population
• Navigating the health care system

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What Patients Need

• Access to Care
• When becoming uninsured
• When discharged from Hospital/ER
• Earlier identification of pre-diabetes and
  diabetes
• Life Style Change Education, especially for
  nutrition and managing conditions
• For management of chronic mental health
  conditions and co-morbid conditions

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Strategies

• Medications/strips
• Obtained grant through Rhode Island Foundation to
  pilot bilingual Chronic Care Support position
• Implemented Pharmacy Assistance Program
• Implemented Systemetics software
• Improved clinical outcomes (total cholesterol,
  LDL levels and HbA1c)
• Reduced expenses for grant purchased medication
  and supplies

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Strategies/Patient Resource Information

• For information on Pharmacy Assistance software
  (Systemetics) contact 888-593-1085 or
  info_at_rxassistplus.com
• For patients with insurance and high co pays,
  call Patient Advocate Foundation Co-Pay Release
  at 1-866-512-3861 (prompt 2 case management).
• Abbott and Roche offer glucose test strips, and
  meters for people who qualify for their program.
• For Abbott products Call 1-800-222-6885 or
  visit www.abbottpatientassistancefoundation.org
  
• For Roche products visit www.accuchek.com and
  go to patient assistance program

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Strategies Mental Health

• Obtained funding from Blue Cross/Blue Shield of
  RI for Project Access
• Blue Angel Mission to integrate mental health
  and medical services
• Hired a bi lingual LICSW and CNS
• Contracted with Psychologist for team support and
  patient grand rounds
• 320 patients screened by staff at Point of Care
• Physician/patient discussion and referral for
  case management, individual clinical
  intervention, support group

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Strategies Mental Health

• Integrated social worker into Diabetes Education
  classes
• Implemented follow up peer support group
• 452 patients with diabetes screened at point of
  care
• 39 referred (60 Latino 49 uninsured)
• 72 improvement in HbA1C after interventions
• 59 established self management goal

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Strategies Nutrition

• University Partnerships URI Nutrition Science
  Program-student interns to obtain experience
  counseling patients with diabetes at no cost to
  patients
• Students providing educational resource packets
• Reduced RN CDOE staff and replacing with RD
• RI Neighborhood Pilot Project referrals to St
  Joes for medical, nutrition, education and
  pharmacy assistance referral to Neighborhood
  partners for exercise, nutrition, social services
  and support groups

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Eye/Podiatry

• Hospital Collaboration MD volunteer as part of
  staff privileges
• Once a month podiatry clinic
• Once a month eye clinic (including specialty
  referral and treatment)
• Increased referrals at earlier identification at
  point of care take off socks, monofilament
  testing

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Strategies/Education

• Obtained a grant from Rhode Island Foundation to
  start diabetes education classes (on site and off
  site)
• Followed at ADA application guidelines when
  setting up program
• Obtained ADA recognition status for long term
  sustainability
• Partnered with hospital staff to provide
  Community Health Fair with over 200 people
  attending

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Strategies/Education

• Small patient group instruction for common
  skills-insulin injection and blood glucose
  monitoring
• Large group instruction for comprehensive
  diabetes education
• Telephone follow up to assess blood glucose
  patterns and titrate insulin to achieve blood
  glucose goals
• Follow up patient engagement to check on coping
  skills

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Strategies/Staff Education

• Staff nurses to obtain CDOE certification, and
  Tobacco Cessation Certification
• Nurses obtained CVD certification to expand from
  Diabetic Resource Center to Chronic Care Resource
  Center
• Partnered with Quality Partners for Chronic
  Kidney Disease resource education
• Integrated standards of care into the clinical
  note

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Strategies/Limited Resources

• Drug companies Education for staff, patients
  and medication samples and strips helped to
  underwrite costs of health fair
• Workforce Volunteer Program (AHEC) Placement of
  students and volunteer for career exploration and
  work experience (registry support, pharmacist
  student, medical assistant, nutrition
• Peer Navigator Program Provides staff who can
  offer individual assistance for basic needs
• Churches and small foundations
  medication/strips

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Future Plans

• Obtain Level 1 Patient Medical Home Status to
  position ourselves for better reimbursement
• Electronic Medical Record
• Expand to Pre-Diabetes
• Shared Medical Visit Pilot
• Shared Nutrition Visits
• Group follow up after CDOE classes

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Future Plans

• Through a Block grant, working with community
  groups to work on access to fresh fruits and
  vegetables in community markets and policy
  changes to address social determinants of health
• Working with SNAP program to offer on site Food
  Stamp application assistance

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Questions / Discussion
?
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• Have additional questions?
• Please contact us at info_at_rxassist.org