The Role of the Diabetes Educator within the Patient-Centered Medical Home & Future Roles

Transcription

1 The Role of the Diabetes Educator within the Patient-Centered Medical Home & Future Roles Linda M. Siminerio, RN, PhD, CDE Professor of Medicine University of Pittsburgh School of Medicine & Nursing

2 Objectives Present the evidence in support of the diabetes self-management education (DSME) and support. Describe the role of the educator in the patient-centered medical home (PCMH). Discuss opportunities for diabetes education in an era of health reform.

3 Diabetes Nursing 1972 Diabetes education Administering insulin Urine testing Giving a meal plan

4 The need for education John ( )

5 The Call for Self-Management: Why? Diabetes Epidemic Lifestyle Disease and Decisions 98% patient/ 2% physician affect on glycemia Shortage of endocrinologists, primary care physicians and certified diabetes educators. 17,700 in US for 25 million people New Mexico 184 CDEs for 2,085,538 population.

6 Team Care: Differences in A1C Quality Improvement Strategy No. of Trials Shojania KG, et al. JAMA. 2006;296: Favors Intervention Favors Control Team changes 26 Case management 26 Patient reminders 14 Patient education 38 Electronic patient registry 8 Clinician education 20 Facilitated relay of clinical information 15 Self-management 20 Audit and feedback 9 Clinician reminders 18 Continuous quality improvement 3 All interventions Difference in Post-Intervention A1C (%)

7 The evidence: Therapeutic management nurse-directed protocols Approved protocols for glycemic, hypertension and cholesterol management Nurses used these protocols in management Intervention in high-risk Hispanic community Significant improvement in provider processes and patient outcomes Davidson, M., et al Effect of nurse-directed diabetes care in minority populations: Diabetes Care, 2003.

8 HbA1c (% ± SD) outcome measure

9 Hospitalization Rates and Charges

10 Nurses Self-Reported Responsibilities Provide a feeling of security and hope Discuss compliance and self-management Act as intermediary between doctor & pt Brief doctors about possible complications/ psychological problems Talk to their families Patients receiving support (%) Siminerio, L et al. US Nurses Perceptions of Their Role in Diabetes Care: Results of the Cross-national Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabetes Educator, 2006.

11 Nurses Willing to Take on More Responsibility Funnell, Peyrot, Rubin, Siminerio: Steering toward a new DAWN in diabetes management. The Diabetes Educator, Journal Supplement for Continuing Education, 2005.

12 Physician Reports on Team Care "There should be better communication within the diabetes management team." "There should be better access to psychologists or psychiatrists for referral." "More qualified nurseeducators/specialist diabetes nurses should be available." Agree (%)

13 Health Care Outcomes Continuum Immediate Outcomes Learning Knowledge Skill Acquisition Intermediate Outcomes Behavior Change Post-Intermediate Outcomes Improved Clinical Indicators Long Term Outcomes Improved Health Status

14 The evidence: Education Improvements in knowledge does not translate behavior change Improves A1C by 0.76% Benefits decrease over time-requires ongoing support Is effective and cost-saving Team-Based Care Best predictor of improved glycemia Effective communication is key Access to a nurse associated with improved outcomes

15 The Pittsburgh Regional Initiative for Diabetes Education (PRIDE) Program is committed to providing diabetes outreach services to western Pennsylvania communities.

16 Pittsburgh Regional Initiative for Diabetes Education (PRIDE) 1. Examine Access 2. Reaffirm Models for Delivery 3. Population Health 4. Innovation

17 Pittsburgh Regional Initiative for Diabetes Education (PRIDE) 1. Examine Access Are we reaching people with education?

18 Education Services in UPMC Database Those who received education: All patients studied n=12,745 (100%) DSME only n= 1,512 (12%) MNT only n= 0 (0%) DSME and MNT n= 672 (5%) Neither DSME or MNT n= 10,561 (83%) Ruppert, K, Siminerio, L, Stewart, A, & Songer, T. Diabetes education services and health care charges in a large health system database. ADA, Suppl

19 Risk Factors, Co-Morbid Conditions, Participation and Physician Referrals to a Rural DSME Program Diabetes Patients N=265 Never received a referral (76%) (n=123) Those who received referral (n=72) 83% attended DSME Ruppert, K., Uhler, A., Siminerio, L. Examining Risk Factors, Co-Morbid Conditions, Participation and Physician Referrals to a Rural DSME Program, Diabetes Educator, 2009.

20 Proportion of Diabetes Patient Behavioral Risk Factors (n=162) Risk Factors Percentage Current smoker 17% Hypertension 85% Hyper-lipidemia 78% BMI 30 kg/m² 65% > 2 risk factors 92%

21 Co-morbid conditions and education Percentage % Number of co-morbid conditions Education No Education

22 Pittsburgh Regional Initiative for Diabetes Education (PRIDE) 1. Explore Access 2. Reaffirm Models for Delivery How do we promote access?

23 IS THE OFFICE THE PLACE? 525,600 minutes/year versus 45 minutes/ 3-4 visits/year

24 Patient Centered Medical Home

25 Redesigning Practice

26 A1c Reductions in PRIDE Clinics (1385 Patients)

27 Pittsburgh Regional Initiative for Diabetes Education (PRIDE) 1. Explore Access 2. Reaffirm Models for Delivery 3. Population Health How can we better utilize population outcomes?

28 Glucose to Goal Identify Practices in Community Meet with practices to determine methods for identifying high risk patients, e.g A1C >8%, frequent readmissions, recent hospital d/c. Determine methods for communicating with patient, e.g. letters from practice, phone calls, referral from physician, etc.. Establish schedule for program, e.g. days, location, staffing Communicate schedule to practices Deliver program Bill for DSME Refer to DSME Collect and report data

29 Services include: Insulin starts Assistance with patient medication management Developing and supporting nutrition and activity plans Instruction and interpretation of self-monitoring of blood glucose (SMBG) Providing risk reduction strategies, foot care, prevention of hypo- and hyperglycemia, sick day management, etc. Additional time needed to identify barriers and problem-solve

30 Self Management Diabetes Self- Management Education (DSME) Lays foundation Provided by health professional Provides and links clinical advice Develop goals Self-management support (SMS) Ongoing Supports follow-up Can be provided by community, health workers and peers Advocacy, community connections, support behavior and goals

31 PRISM STUDY Patient Reinforcement Impacts Self-Management University of Pittsburgh and Penn State Hershey Medical Center 3 PA Regional Sites Diabetes Self-Management Education (DSME) Educator SMS Peer SMS PCP - SMS Usual SMS

32 Benefits of Diabetes Education in Primary Care Change in clinical outcomes with diabetes education Diabetes Education (0-6 weeks) CMI, Inc. FQHC PSU Median Change [p-value] Median Change [p-value] Median Change [p-value] HbA1c (%) 0.6 [.0001]* 1.1 [.0001]*.35 [.0001]* SBP (mm/hg) NS NS NS DBP (mm/hg) 2.5 [.005]* 3.6 [.02]* NS HDL (mg/dl) NS NS NS LDL (mg/dl) 8.5 [.04]* 11 [.01]* NS tchol (mg/dl) 8.7 [.05]* 13.3 [.009]* NS 32

33

34 Pittsburgh Regional Initiative for Diabetes Education (PRIDE) 1. Examine Access 2. Reaffirm Models for Delivery 3. Population Health 4. Innovation

35 Telemedicine for Reach, Education & Treatment (TREAT)

36 Benefits of TREAT: 1) Rural nurse gains therapeutic management expertise with the support of specialist 2) Patient receives the benefit of intensified management 3) Local primary care provider has a referral program for challenging patients 4) Have demonstrated high satisfaction & improvements in A1C

37 Educator & Insurer Local insurer employees CDEs to train and support health plan: Practice based care managers Work with high risk patients Telephonic health coaches Discharge transition case managers

38 Partnership Sharing Informa#on Se?ng Expecta#ons Ac#vated, engaged pa#ents Trained Healthcare Professionals Pa#ent- Centered Outcomes Forging a New Partnership

39 If you don t like change, you are going to like irrelevance even less.

40 Questions?????