ACPM National Diabetes Prevention Program Demonstration Projects

Transcription

1 ACPM National Diabetes Prevention Program Demonstration Projects Webinar # 2: Integrated Delivery Systems MaineHealth + South Nassau Communities Hospital October 23, 2018

2 Todays Presenters Author disclosure: No relevant financial affiliations from presenters The development of this presentation is supported by a five-year cooperative agreement (# 6 NU38OT ) between ACPM and the CDC Office of State, Tribal, Local, and Territorial Support (OSTLTS). The views expressed in this presentation are the authors and do not reflect the official policy or position of the CDC or the US government

3 Moderator MODERATOR: Heather Tindall Readhead, MD, MPH University Health Services (UHS), Primary and Urgent Care University of California, Berkeley

4 Agenda Welcome and Introductions of Speakers ACPM Diabetes Prevention Program Demonstration Projects Preventive Medicine Overview ACPM Overview National Diabetes Prevention Program ACPM and CDC Partnership ACPM Diabetes Prevention Program Demonstration Projects Grantee Presentations Participant Q & A Session

5 Todays Presenters MODERATOR: Heather Tindall Readhead, MD, MPH University Health Services (UHS), Primary and Urgent Care University of California, Berkeley DEMONSTRATION PROJECT GRANTEES Integrated Delivery Systems: MaineHealth Marin Johnson, MS Program Manager MaineHealth, Prevention and Wellness South Nassau Communities Hospital Lucille Hughes, MSN/Ed, CDE, BC-ADM, FAADE Director of Diabetes Education South Nassau Communities Hospital

6 Learning Objectives Explain key components the National Diabetes Prevention Program (National DPP) Identify processes for screening, testing, and referring patients with prediabetes to a CDC-recognized diabetes prevention program Evaluate screening and referral models and ways to develop, and operationalize these models

7 National Diabetes Prevention Program Demonstration Projects Heather Tindall Readhead, MD, MPH ACPM Faculty University Health Services (UHS), Primary and Urgent Care University of California Berkeley

8 What is Preventive Medicine? The Specialty of Preventive Medicine One of 24 specialties recognized by the American Board of Medical Specialties Only medical specialty that prepares physicians to care for both individuals and populations Board Certification Public Health/General Preventive Medicine 3-yr postgraduate training program that combines: A 1-year clinical internship 2 years of blended didactic (MPH), clinical and practicum training Occupational Medicine Aerospace Medicine Clinical Informatics 8

9 ACPM Vision and Mission Vision: ACPM will be the leading professional medical society for advancing preventive medicine, population and public health, and lifestyle medicine. Mission: ACPM supports efforts to improve the health of individuals and populations through evidence-based health promotion, disease prevention, lifestyle modification, and systems-based approaches to improving health and health care.

10 CDC ACPM National Diabetes Prevention Program (NDPP) Partnership ACPM partners with the Center fro Disease Controls and Prevention (CDCs) Division of Diabetes Translation to increase physician awareness, screening and referral to the National Diabetes Prevention Program (National DPP). The CDC-led National DPP is a partnership of public/private organizations working collectively to establish, spread, and sustain an evidence-based lifestyle change program for people with prediabetes to prevent or delay onset of type 2 diabetes.

11 Demonstration Project Overview From , ACPM lead and supported 9 demonstration projects funded by the CDC. Funding was provided through a competitive process. Award: $15,000 (for a 3 month time period).

12 Demonstration Project Overview Goals To support health care organizations/practices to develop and implement a protocol for screening, testing, and referring patients with prediabetes to a CDC-recognized diabetes prevention program, either through the EHR/EMR or by using another non-electronic approach. Case Studies Grantees have worked with ACPM to document their experiences and lessons learned as case studies to inform and teach providers and health care professionals.

13 Demonstration Project Overview ACPM National DPP Resource Center The resource center is provided as a one stop resource to equip physicians and health care professionals to increase awareness, screening and referral within their practice. It contains materials from the CDC, the American Medical Association, YMCA of the USA, Solera Health and other national partners. ACPM National DPP Advisory Council ACPM is fortunate to have 11 preventive medicine physicians that have expertise in the National Diabetes Prevention Program as part of our advisory council. The Advisory Council provides strategic guidance to our demonstration projects and toolkit development. ACPM Annual Conferences Award winners presented findings from their demonstration projects at the Diabetes Prevention Learning Institute at the ACPM Annual Preventive Medicine Conferences in 2017 and 2018

14 INTEGRATED HEALTH SYSTEMS South Nassau Communities Hospital Oceanside, NY Emory Healthcare System Atlanta, GA MaineHealth Portland, ME INDEPENDENT PRACTICE / ASSOCIATIONS Griffin Faculty Physicians Derby, CT Accent on Health Washington, DC Wheat Ridge Internal Medicine Wheat Ridge, CO FEDERALLY QUALIFIED HEALTH CENTERS Northeast Missouri Health Council Kirksville, MO Christopher Rural Health Planning Corporation Mulkeytown, IL AltaMed Health Services Los Angeles, CA Grantees

15 MaineHealth MMP Portland Family Medicine DPP Webinar 8/23/18

16 Obesity Prevalence >300,000 adults in Maine (total Pop: 1.3 Million) have PREDIABETES Fewer than half know it 2/3 of the adult patients in the MMP FMCs have either overweight (34%) or obesity (33%). CUMBERLAND COUNTY = 23.4% (Behavioral Risk Factor Surveillance Survey 2015) 16

17 Screening for Diabetes at MaineHealth Diabetes priority EHR build Practice Integration 17

18 MaineHealth NDPP Status MaineHealth is in Pending Recognition with the CDC Will not be eligible to consider to apply for Medicare reimbursement (MDPP) until Currently, there is a fee to enroll in NDPP ($250) - Scholarships are available - MaineHealth employees can attend at no cost free through WOW - A discounted class was offered in June for only $50. this didn t increase enrollment. - All classes are posted on 18

19 MaineHealth ACPM NDPP Grant Goals CLINICAL - Adapt workflow from STAT toolkit - Follow the ADA, CDC and USPSTF guidelines to screen patients for diabetes - Screening clinics INFORMATION TECH - Work with EHR IT to get Diabetes Risk Score in EHR EDUCATION and AWARENESS - Use ipad to assess risk and educate on NDPP - Prediabetes and NDPP marketing and awareness campaign 19

20 Clinical Work Flow Process 20

21 Clinical Work Flow Measure pre-visit huddle review If patient hasn t been screened in the past 3 years, complete POC HGA1C or order HbA1C or FPG during visit if: - If patient is >18 years with a BMI of >30 and has one risk factor - If patient is >18 with a Diabetes Risk Score of >5 - For all patients (of any weight) and is >45 years, - For all patients >40 years with a BMI>25 - Patients with a prediabetes diagnosis can be referred to NDPP *With funding from the ACPM Grant, outreach is being done for patients who don t have an office visit but EHR indicates patient should be screened. Screening Clinics have been scheduled to assist patients. 21

22 Act Fasting plasma glucose mg/dl A1C OGTT 2 hour Normal < 100 < 5.7 < 140 Prediabetes Diabetes > 126 > 6.5 >

23 Partner As a result of screening results, counsel patient re: diagnosis If screening results indicate normal, encourage patients to maintain healthy lifestyle If screening results indicate prediabetes, refer to diabetes prevention program (NDPP) - If blood sugars are declined, but patient is still an appropriate candidate for NDPP (BMI > 25 kg/m 2 or > 23 kg/m 2 in Asian Americans plus 1 risk factor), continue to refer to NDPP - Use SmartPhrase in EHR to prompt referral to be printed in After Visit Summary - Consider retesting annually to check for diabetes onset. If screening results indicate diabetes, confirm diagnosis and discuss appropriate treatment and next steps. 23

24 Methods Retrospective - Query report run in EHR to identify at risk patients - Letters and phone calls made Point of Care - Use workflow to screen, test and refer Screening Clinic - 4 screening clinics: Wednesday, 1/20 1-3pm; Saturday, 1/ am; Wednesday, 3/21 1-3pm; Saturday, 3/ am - Created more opportunity for patients to be screened who could not make an office visit - Patients attended who received letters, phone calls, saw marketing flyers or told at point of care 24

25 Outreach Efforts Dec March

26 Screening and Referral Results from Outreach 26

27 Screening Clinic 27

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31 Education and Building Awareness

32 Provider and Patient Education Include podcast on MaineHealth website for providers and patients Include Diabetes screening and referrals to NDPP training video for providers on MaineHealth For Healthcare Professionals page Team and Staff meeting at FMC to review screening guidelines and NDPP Developing tools to educate providers on DPP Podcast and public marketing campaign for patient awareness 32

33 Community Collaboration How can we work together to bring more NDPP classes to our communities? Partner with local organizations like the YMCA to reach our community members Train community members to teach NDPP within the MaineHealth system Provide technical assistance for NDPP coaches and participants Recruit eligible participants for NDPP Spread the word about NDPP, and make our communities the healthiest in America! 33

34 The Spread Increase NDPP enrollment Streamline provider referrals to NDPP system wide (in discussion with Solera) Disseminate system wide guidelines on when to screen for diabetes (using the Diabetes Risk Score in the EHR) All MaineHealth members and affiliates have cyclical NDPP classes to offer prediabetic patients throughout the state Disseminate Diabetes and NDPP awareness campaign system wide - waiting room posters patient postcards - provider checklists Prescription Pad - risk assessments NDPP one pager 34

35 Lessons Learned Providers limited awareness about when to screen and/or benefits of NDPP Lack of patient awareness on prediabetes/diabetes Outreach phone calls were unwelcome or incomplete majority of the time Outreach letters didn t include enough about risk factors for diabetes. Risk score should be separate from NDPP brochure (which was included) Lack of team based awareness in this preliminary phase of screening Errors in the report that can only be found in extensive chart review. EHR hiccups with getting the diabetes risk score to be accurate and delays in getting it in the appropriate report Delays in training staff on new physical activity question in EHR and using the diabetes risk score 35

36 Recommendations/Next steps - Patient Awareness Increase patients awareness for risk of diabetes and NDPP - Developing an awareness campaign to educate patients and providers on the importance of screening for diabetes and what NDPP is - Patient education in practices - Podcast on the importance of getting screened if risk factors are apparent and enrolling in NDPP - Use ipad in exam room for patient to assess their risk and view NDPP videos and MaineHealth podcast 36

37 Recommendations/Next steps: Outreach More comprehensive tracking system/simple database Include risk assessment with letter outreach Fine tune BI portal so chart review is not as cumbersome. Run report every 3-6 months 37

38 Recommendations/Next steps: Provider Engagement Develop 10 minute training video on referring patients to NDPP and the program itself Increase provider referrals to NDPP Podcast on the importance of screening and testing patients for diabetes 38

39 NDPP Scalability Plan: Key Components Marketing and Education Workflow and Outreach Training Partnerships Infrastructure 39

40 NDPP Scalability Plan: Initial investment sustains growth over time Marketing materials may be modified to accommodate regional contacts Increase Lifestyle Coach talent pool and streamline onboarding Coach salary is stable even as more participants enroll in classes Automate referrals using EHR (warm hand-off) Utilize software (Smartsheet) to operationalize data and information exchange between coach and NDPP Program Coordinator Establish Business Agreement with State of Maine to bill Anthem insurance for employee participation in the NDPP - Goal is to gain more local business partnerships to offer employee wellness program participants NDPP Prepare to receive preliminary recognition and become Medicare Supplier in

41 NDPP Update: Enrollment and Referrals Partner with a provider champion in each MH member region to increase patient referrals to NDPP Participants call NDPP Program Coordinator and are screened for eligibility, motivation to change, etc. Collect a waitlist of interested participants and establish a class based on demand (minimum of 8 participants to start a class) - Aim for at least 2 classes to begin per region each year (total of 14) Offer onsite NDPP classes for State of Maine employees if demand is high Utilize a system SmartPhrase in EHR to auto-fill patient s After Visit Summary with referral information for the NDPP Utilize marketing materials to promote NDPP 41

42 Questions? Marin Johnson, MS MaineHealth Program Manager, Prevention and Wellness Christina Holt, MD, MSc Primary Care Physician; Research Director; Program Director, Maine Medical Center Leadership in Preventive Medicine Residency Dept of Family Medicine, Maine Medical Partners, Portland Family Medicine Center Emily Keller, MD Preventive Medicine Fellow, Maine Medical Center 42

43 American College of Preventive Medicine National Diabetes Prevention Demonstration Program Lucille Hughes DNP, MSN/Ed, CDE, BC-ADM, FAADE Director Diabetes Education Angelie Singla, LMSW Director, Corporate, Foundation, Government Relations South Nassau Communities Hospital

44 Rapid Participatory Assessment (RPA) 655 patients identified in New York Medical Partners (NYMP) ACO 240 providers in NYMP ACO 55 Primary Care Providers Quickly narrowed project focus to two NYMP ACO primary care practices Process survey conducted Fall 2017 Manual process Not sustainable Captured only small cohort in need

45 Process Improvement Process flow chart updated (slide 7) Marketing efforts (flyers) (slide 6) Collaborative effort with ACO, practice staff, and IT Developed EMR identifiers A1C 5.7 now identified in RED Direct referral to DEC created in Athena EMR for both prediabetes and clinical diabetes. Personal call to patient made upon arrival or referral Next step is to identify BMI 25 in RED as well (We are aware BMI criteria of 23 for Asian Americans) 45

46 Barriers and Solutions Only A1C data was available to clinicians A1C color coded, BMI to soon be added Direct electronic referral process implemented Lack of awareness among physicians and office staff regarding program, criteria, roll and expectations for each employee Education provided to all/ they became part of the solutions Launched program in the Winter during evening hours Second cohort began September 5, 2018 and during the daytime hour Time consuming data entry Data Analysis of Participants System (DAPS) 46

47 AADE s Data Analysis of Participants System (DAPS) A complete data tracking and analysis tool that saves time and money, ensure accuracy of entry data, help you meet CDC Recognition Standards, and provide intelligence that can boost marketing efforts. Real-time reporting and analysis of program and participant data in a dashboard format Analysis at the individual and program level, benchmarked against CDC Recognition Standards. One-click export into the CDC-required report format Cloud-based, HIPAA compliant.

48 DAPS 48

49 DAPS 49

50 Scalability and Sustainability Include additional ACO practice sites Began discussions with YMCA leadership (May 8) Met at SNCH DEC to discuss scalability at SNCH and throughout Long Island with a collaborative approach using their Lifestyle Coaches YMCA long history with CDC and National Diabetes Prevention Program (NDPP) YMCA has already submitted CMS provider application YMCA update as of August 2018 Program Director facilitating at this time Closed Facebook Group 50

51 Program Flyer 51

52 Program Flyer 52

53 Process Flow Then and Now 53

54 Electronic Referral Order Example: no patient identifiers included 54

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56 Q & A Session

57 Thank you CME Evaluation and MOC information will be ed shortly More information visit: