Effective delivery of Diabetes Self- Management Training through telehealth enabled services

Transcription

1 Effective delivery of Diabetes Self- Management Training through telehealth enabled services Katie Farrell, RD, CDE Manager Diabetes Education CHI Franciscan Health Lana Adzhigirey RN MN CPHQ RN Program Administrator VHS CHI Franciscan Health April 16, 2016

2 Patient and Population Health Perspective 2

3 Disclosure Katie Farrell declares that during the past 12 months neither she or any member of her family, has had another financial interest in a corporate organization providing support to this continuing medical education activity. Lana Adzhigirey declares that during the past 12 months neither she or any member of her family, has had another financial interest in a corporate organization providing support to this continuing medical education activity. 3

4 Learning Objectives Demonstrate how a telehealth-enabled diabetes management program can be integrated into diabetes education centers Discuss outcomes and lessons learned about patient engagement, in-home technology, and program staffing Summarize the patient, clinician, health system, and payer benefits associated with a telehealth-enabled diabetes management program 4

5 CHI Franciscan Overview The premier health system in Pacific Northwest Presentation Title 5

6 System of Care Services across our patient s care continuum Acuity Virtual Health Services & Clinical Operations Center 6

7 Virtual Health Services Care Transformation Services - Growth

8 Consumer Clinical & Administrative Support Legislature Policy & Procedures Information Analysis Shared Knowledge Technology Health Outcomes Virtual Healthcare Model Framework Care Transformation Services - Partnership Patient Navigation Services (Operators, Interpreters, Central Staffing) Hospital Patient Monitoring Services (Telemetry, Virtual ICU, Virtual Companion) Care Transformation Services (VUC, Chronic Disease Mgmt, Post Discharge Care ) Telehealth Consults (Provider to Patient, Provider to Provider, Patient to patient, Community ) Other Services (New and developing)

9 Virtual Diabetes Management The Vision Being diagnosed with diabetes is like being placed in a raft and thrown in the middle of the ocean with two oars. 9

10 FHS Patient Centered Care Model Example Care Transformation Services - Growth Patient Engagement Care Continuum 1. Patient education program coordination 2. Patient experienceservice recovery coordination Care Transition Post Discharge 1. Calls: all discharged patients (Inpatient, ED, SDS, etc) 2. Follow up care (dc instructions, fu appointments, meds) 3. Option for remote monitoring for 30 days 4. Option for Virtual Follow up visits by PCP Health Promotion Chronic Disease Program 1. Same as care transition but 60 days 2. Expand to multiple chronic conditions 3. Additional ds specific modules: Virtual Diabetes Management CDE, health coaches Access to Care Population Health 1. Virtual Urgent Care to decrease avoidable ED costs 2. Patient Access Team: Connect general population with Primary Care 3. Predictive Analytics?

11 Innovation What we THINK it is: 11

12 Innovation What it REALLY is: 12

13 Innovation The typical first response: 13

14 Diabetes Care 14

15 Most people with diabetes do not get education in that first year of diagnosis Fewer than 7% of persons received DSMT within 1 year after diagnosis with diabetes. mlmm6346a2.htm?s_cid=mm6346a2_e 15

16 Diabetes Management 3 year retrospective claims analysis of 4 million covered lives, average cost savings $135 per month of those who completed DSME YET DSME use remains very low Diabetes Self-Management EducationTraining Reimbursement Toolkit,

17 VDMP: Virtual Diabetes Management Program The challenge is reaching those who do not receive diabetes education. We had an opportunity with CHI division of innovation, to try a different way of delivering education. 17

18 Technology changed faster than we could plan our program 18

19 Virtual Diabetes Management Program VDMP 19

20 So many reasons to quit! We lost our virtual health care provider partner, once we overcame that obstacle, another major roadblock. 20

21 Just Start One of our team members (Tina) at a critical decision making point reminded us 21

22 Extensive Planning Workflows Workflows Workflows And then Just Start! 22

23 Virtual Diabetes Management Program: VDMP Implement a Virtual Diabetes Management Program and enroll patients with diabetes that is difficult to control Provide them with home monitoring equipment and 1:1 coaching for 6 months Improve Hgb A1C results and compliance with DM pathway 23

24 VDMP March December 2014 Last patient to enroll equipment install: July 8, 2014 Every patient enrolled for 6 months Final enrollment: patients completed program 3 unenrolled One at patient request Two for non-participation 14 Gender Age Range (years) 10 Average Age (years) 37 to Male Female 24

25 VDMP Most patients made significant improvements in diabetes self-management, lifestyle behaviors, and adherence to their care plans: Diet Activity Medications Glucose monitoring Health maintenance rate improved from 52% to 85% (20 measures) 25

26 VDMP: Virtual Diabetes Management Program VDMP Results 9.51% 7.18% HgbA1c Pre HgbA1c Post Notes: Absolute Reduction: 2.33% Relative Improvement: 25% Goal: A1c less than 7% (BS 150) Behavior change making a huge impact on diabetes control 26

27 Improving Blood Glucose Trends 27

28 Virtual Diabetes Management Alerts 110 alerts 9 alerts Total BG Alerts Hypo BG Alerts Hyper BG Alerts 5 minutes after I checked my blood sugar, got a call immediately. Got upset at first, then realized it was good to have someone on your shoulder. Alerts 28

29 Remote Home Monitoring Challenges: Significant technology challenges Cellular not a reliable approach for all patients Lessons Learned: Adds significant clinical value Patients learning improves (diet, activity and taking medications) Contributes to rapid behavior changes Identifies co-morbidities Cellular glucometers appear to be reliable Auto data reporting much more reliable than self- reporting Teachable moments, real time learning very valuable, Recommendations: Re-examine how patient BPs are monitored and managed Work toward reimbursement for telehealth services Continue to look for creative ways to reach people with diabetes 29

30 Virtual Diabetes Management Case Study 2. Patient Interviews Patients rated program highly overall: avg #1 Value: Creating accountability for their actions; encouraging them to change; reassuring them that someone cares There were ZERO unplanned hospitalizations, ER or Urgent Care visits related to diabetes Four previously unknown cases of HTN identified 30

31 VDMP: Virtual Diabetes Management Program Lessons Learned Why was it so difficult to enroll participants? Time commitment Unsure about all the types of technology that we would be using Fear of the unknown: both providers and patients Staffing constraints Started with patients of 2 physicians, ended with 11 physicians Reason patients did enroll: Wanted to refocus on their health Help getting back on track Doctor recommended it Accountability 31

32 VDM3 Virtual Diabetes Management, Monitoring & Maintenance 32

33 Continue to follow VDMP participants VDM3: Virtual Diabetes Management, Monitoring and Maintenance 30 minute phone call with CDE once per month 33

34 #2 VDM3 Follow up for subpopulation of VDMP Hgb A1C levels per Participant One of the patients has lost 50 pounds in the past 9 months and has discontinued all of his diabetes medications (while maintaining an A1c of 6.5%) Participant Dropp ed out Before Pre- VDMP Intake Discharge Post-VDMP Now VDM Mid Program VDM3 Discharge patients Monthly phone calls BG monitoring Increased activity Weight loss

35 VDE Virtual Diabetes Education 35

36 Partnership with HealthSlate VDE: Virtual Diabetes Education 36

37 Partnership with HealthSlate 1:1 CounselingCoaching Education and Skills Development Self-Management Tools Peer Support 37

38 1:1 CounselingCoaching The 1:1 counseling provided virtually by CHI Franciscan CDE Communication tools to include: video, writing on patient s screen, pictures sent from phone and text messages Patient uses smart phone or tablet; CDE uses PC 38

39 VDE Scalability Assessment As discovered in a previous Virtual Diabetes Management Pilot, high touch, high intensity programs though effective (significant decrease in HgbA1 over a six month period in 22 patients) are not easily scalable This VDE program offers a broader, more inclusive selection criteria, lower touch and lower intensity approach This approach allows for greater scalability by reducing equipment requirements to a tablet or a smartphone with access to the Internet 39

40 VDE Selection Criteria 40

41 VDE Recruitment Strategy Outpatient Recruitment A Diabetes Registry list pulled to identify patients who meet the criteria Patients will be identified by the Franciscan PCP andor his or her clinic staff using the enrollment criteria as specified A personal letter will be sent from the primary care provider telling the potential enrollee about the opportunity to participate 41

42 Hgb A1C VDE Detailed results 14.0% 12.0% 10.0% VDE Results Patient reports phone issues Patient seeing endo, started GLP-1 8.0% 6.0% 4.0% 2.0% 0.0% Initial A1c 11.6% 10.0% 9.8% 9.7% 8.9% 8.6% 8.2% 8.2% 8.1% 8.0% 6.9% Follow-up A1c 9.2% 8.1% 6.4% 7.3% 9.1% 7.6% 8.8% 7.0% 6.6% 42

43 Hgb A1C Virtual Diabetes Programs Comparison Results 12.0% Hgb A1C Comparison 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% VDMP VDM3 VDE Traditional DE Pre 9.7% 8.0% 8.6% 8.5% Post 6.9% 7.3% 7.8% 7.5% 43

44 Same Great Care Delivered in a new way 44

45 How do we get paid? Reimbursement strategies 45

46 Reimbursement Implications Who has the answers? 46

47 All Charges and Reimbursement for Diabetes related services CY2014, grouped by Unique patients, with Facility and Pro charges, reimbursement com Patient assigned to most recent payor Virtual Diabetes Management PRELIMINARY Cost Savings Patient Group Patients ChgMonth PymtMonth VDMP Patients 22 $1, $ High Risk (A1c >8.0) 490 $2, $ Other Diabetes Patients 43,585 $2, $ Grand Total 44,097 $2, $ Charge Savings VDMP vs. High Risk 45.0% VDMP vs. All Diabetes Patients 50.0% Payment Savings (includes all payer with very different rates) VDMP vs. High Risk 36.3% VDMP vs. All Diabetes Patients 49.6% 47

48 Yeah, but how much does this cost? Hypothetical example 48

49 And who is paying? Who could be paying? Approached 7 major payers Typical response: This is incredible Typical follow up: Let s meet again soon A better approach - legislation 49

50 American Medical Association Adopts Telemedicine Policy to Improve Access to Care for Patients June 2014 "Whether a patient is seeing his or her physician in person or via telemedicine, the same standards of care must be maintained. Telemedicine can strengthen the patient-physician relationship and improve access for patients to receive health care services remotely as medically appropriate including care for chronic conditions, which are proven ways to improve health outcomes and reduce health care costs. AMA President Robert M. Wah, M.D., June 2014 Accessed online on May 7, 2015 at 11-policy-coverage-reimbursement-for-telemedicine.page 50

51 An Act Relating to Telemedicine Passed in 2015 Regular Session Washington state telemedicine law: SB 5175 Health plans must reimburse providers for healthcare services delivered to a beneficiary through telemedicine for the following three reasons: - If the plan would normally over that healthcare service if it were provide in person - If the service is medically necessary - If the service is recognized as an essential health benefit under the Patient Protection and Affordable Care Act 51

52 Telemedicine bill 6519 passed the Senate If passes all, will be effective as of Washington State Telemedicine law: SB 6519 Home added as an originating site - 3) An originating site for a telemedicine health care service subject to subsection (1) of this section includes a: (a) Hospital; (b) Rural health clinic; (c) Federally qualified health center; (d) Physician's or other health care provider's office; (e) Community mental health center; (f) Skilled nursing facility; ((or)) (g) Home; or (h) Renal dialysis center, except an independent renal dialysis center. State Collaborative to ensure telemedicine services are reimbursed 52

53 The pineapple juice bill You could go online and learn all you want but until you have someone to work with, it s really hard. Like reading about engines but you don t really learn until you get your hands on it. 53

54 54

55 Diabetes Self-Management Education and Training Among Privately Insured Persons with Newly Diagnosed Diabetes United States, Weekly November 21, (46); Rui Li, PhD 1, Sundar S. Shrestha, PhD 1, Ruth Lipman, PhD 2, Nilka R. Burrows, MPH 1, Leslie E. Kolb, MBA 2, Stephanie Rutledge, PhD 1 (Author affiliations at end of text) A systematic review with meta-analysis of 21 studies comparing group-based DSME with standard diabetes treatment, participants with Type 2 diabetes randomized to the group-based intervention showed improvement in clinical, lifestyle and psychosocial outcomes (14). In a three year retrospective claims analysis of 4 million covered lives, which included 250,000 Medicare beneficiaries, there was a reported Medicare average costs savings of $135 per month among those beneficiaries who completed a DSME program (15). Tomky, D. (2013). Diabetes Education: Looking Through the Kaleidoscope. Clinical Therapeutics, Chen, L., Chuang, C. et al. (2013). Evaluating self-management behaviors or diabetic patients in a tele-healthcare program: longitudinal study over 18 months. Journal of Medical Internet Research, 15 (12), e

56 Katie Farrell Lana Adzhigirey 56