Michigan s Diabetes Prevention and Control Program & National Kidney Foundation Michigan: A Successful Partnership

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1 Michigan s Diabetes Prevention and Control Program & National Kidney Foundation Michigan: A Successful Partnership Dan Diepenhorst, MI DPCP diepenhorstd@michigan.gov Linda Smith-Wheelock, NKFM lsmith-wheelock@mkfm.org

2 Kidney Disease in Michigan More than 940,000 Michigan adults have CKD and most are unaware of their condition. Approximately one in eight Michigan adults over the age of 20 has CKD. The number of people with CKD continues to grow as the number of people with uncontrolled diabetes and high blood pressure grows. 70% of CKD cases caused by diabetes and high BP can be prevented or delayed.

3 An Epidemic of Kidney Disease Stage 5: GFR <15 Stage 4: GFR Stage 3: GFR n=300,000 n=400,000 n=7,600,000 Stage 2: GFR 60 89* n=5,300,000 Stage 1: GFR 90* n=5,900,000 * Clinical Practice Guidelines for CKD Am J Kidney Dis. 2002;39(suppl 1):S17 S31. * GFR = glomerular filtration rate (ml/min/1.73 m2); *with kidney damage

4 ESRD: Risk by Ethnicity Racial Differences in ESRD in US from * * Odds Ratio * reference 0 White Black Native Asian *P < * United States Renal Data System (USRDS) 2000 Annual Data Report

5 New Cases of Kidney Failure in Michigan Per million Per Million Per million National Average 0 New Cases per Million Detroit 1st Wayne Qtr County Michigan

6 CKD: Delayed Referral to Nephrologist * A Stack. Am J Kidney Dis. 2003;41:

7 CKD: Reasons for Delayed Referral to Nephrologist CKD is under-recognized Failure to screen pts at-risk Fear of loss of control over pt PCPs unaware of incremental benefits of earlier referral Fewer ER visits (pulmonary edema) Significant healthcare cost savings Lack of education regarding CKD management * R Sesso, AG Belasco. Nephron Dial Transplant. 1998;11:2417. DW Eadington. Nephron Dial Transplant. 1996;11: RJ Schmidt, et al. Am J Kidney Dis. 1996;32: P Jungers, et al. Kidney Int. 1993;41:S170 S173.

8 Michigan s CKD Strategic Plan A Partnership Between MDCH And NKFM that established our Roadmap

9 CKD: The Michigan Initiative 1. Develop an early CKD identification process 2. Screen and prevent CKD in patients who are atrisk encourage early referral for nephrology consult 3. Educate primary care physicians about diabetes, hypertension and CKD 4. Focus on Managed Care for Health Care System Change 5. Be in the community where people live, work and play with primary and secondary prevention programs.

10 CKD: Screening and Prevention Identify at-risk medical populations Hypertension Diabetes Metabolic syndrome 1 st degree relatives of ESRD pts CKD history often neglected during Hx Identify at-risk ethnic groups Hispanics African-Americans American Indians (Native Americans) * United States Renal Data System (USRDS) 2000 Annual Data Report

11 CKD Programs in Michigan Since early 1990 s, collaboration with two units of the MDCH: Diabetes Prevention and Control Program Cardiovascular Disease, Nutrition and Physical Activity Section

12 Primary Prevention Healthy Hair Starts with Healthy Body Dodge the Punch Barber Shop Program Healthy Families Start with You All programs use lay health educators and focus on healthy lifestyle changes such as exercise, healthy eating, smoking cessation and the importance of doctor visits. HH and DTP reach primarily African-Americans School Education Programs such as Kids and Kidneys and Kids Interested in the Care of Their Kidneys

13 TM We Care About More Than Your Hair A Campaign of the National Kidney Foundation of Michigan

14 Healthy Hair Program Goal: To prevent kidney disease by raising awareness of its 2 primary causes: hypertension and diabetes and to encourage healthy lifestyle choices Hair stylists in salons are trained as lay health educators Two health chats are the centerpiece of the intervention Risk assessment Discussion of importance of healthy lifestyle Encouragement to make positive changes

15 Outcomes from Primary Prevention Programs: Healthy Hair Healthy Hair has reached over 23,500 beauty salon clients with health education since Surveys show that 64% of clients took a positive health step such as eating more nutritiously, increasing physical activity or stopping smoking. In a review by the Agency for Healthcare Research and Quality in 2008, Healthy Hair was given an evidence rating of moderate.

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17 Dodge the Punch Program Developed as the male counterpart to the Healthy Hair program Barbers are trained to become lay health educators in their barbershops Two health chats are the centerpiece of the intervention (as with Healthy Hair) Risk assessment Discussion of importance of healthy lifestyle Encouragement to make positive changes

18 Outcomes from Primary Prevention Programs: Dodge the Punch Has reached over 4,200 African- American barbershop clients since % of clients indicated that they had made at least one healthy lifestyle change.

19 Healthy Families Start with: YOU A Promising Partnership

20 Healthy Families Program A multi-generational community-based health education program Promotes the adoption of healthy nutrition and physical activity habits Target population: preschool-aged children and their low-income parents. Uses Head Start family service coordinators to discuss the importance of nutrition and physical activity with Head Start parents.

21 Regie s Rainbow Adventure Regie s Rainbow Adventure is the children s intervention Head Start teachers read these stories to emphasize the importance of eating fruits and vegetables that are the color of the rainbow Children also create healthy snacks and play games related to the stories Stories are shared with parents so that good nutrition becomes a family goal

22 Testimonial from Healthy Families Program Wanting to be a healthy role model to my three young children, I joined the Healthy Families program. I was motivated to set healthy family goals and have lost over 20 pounds.

23 Healthy Families Outcomes

24 Outcomes from Primary Prevention Programs: School Education Kids and Kidneys and Kids Interested in the Care of their Kidneys Have educated over 1 million elementary, middle school and high school students since 1998 Emphasize kidney disease prevention, nutrition and exercise Statewide evaluations have demonstrated a 20% knowledge gain with students

25 Secondary Prevention NKFM s Kidney Early Evaluation Program (KEEP) Provides free kidney screenings using glomerular filtration rate to measure how kidneys are filtering waste from the blood. Also screens for diabetes and high blood pressure

26 Secondary Prevention: PATH PATH (Michigan s name for the Stanford Chronic Disease Self-Management Program) Since 2006, NKFM has been at the forefront of implementation and spread of PATH From 2007 to 2008, Michigan saw an 82% increase in participants completing a PATH workshop PATH outcomes: Improved exercise, symptom management and general health, and fewer emergency room and outpatient visits (See Stanford Ed web site)

27 Number of people completing PATH Workshop People Completing PATH Workshops # of People Completing PATH Workshop*

28 Secondary Prevention: Enhance Fitness EF is an evidence-based physical activity program specifically designed for older adults (60 and older) but has been shown to work for all adults. NKFM has 3 EF trained fitness instructors and is in process of training more. NKFM goal is to bring this program to Southeastern MI Focus will be on individuals who have diabetes, hypertension and members of minority communities

29 Secondary Prevention: Diabetes Self-Management Education Programs NKFM and MDCH both provide support and technical assistance to 89 statewide certified diabetes self-management education programs These programs teach self-management to patients with diabetes and prediabetes: How to manage blood glucose How to make informed choices about nutrition and exercise How to treat complications of diabetes Patients with diabetes provide about 98% of their own care These programs in Michigan reached more than 28,000 people in 2008.

30 Increase in diabetes education reduces the incidence of CKD * People with DSME in Michigan

31 Tertiary Prevention egfr Identification Law passed in 2006 to identify CKD early. All Medicaid patients must have an egfr. Continuous Quality Improvement Working with managed care to identify CKD early (stage 3 and 4), educate primary care physicians on CKD, encourage referral to nephrologist for consult and focus on improving treatment (slow progression to kidney failure).

32 CKD: Classification by MDRD GFR Rationale for use GFR direct measurement of kidney function GFR best index of kidney function in health and disease GFR correlates with pathologic severity of disease GFR correlates functional level with risks of CKD progression and development of CV disease * G Manjunath, et al. Postgrad Med. 2001;110(6):55 62.

33 NKF CKD Stages 1 5 Stage 1 Description Chronic kidney damage with normal or GFR > 90 GFR Mild GFR Moderate GFR Severe GFR Kidney failure 60 89* <15 or dialysis * Kidney/Dialysis Outcomes Initiative. Am J Kidney Dis. 2002;39:S1 S266.

34 egfr Outcomes in Michigan

35 CKD Testing is increasing in Michigan * CKD Test Increasing

36 MCO Review of CKD Cost Data

37 MCO Results * Improved Lab Results

38 RESULTS: Michigan s Strategic Plan Primary, Secondary and Tertiary Interventions in Michigan Increase in kidney failure decreased by over half ESRD prevalence rates dropped significantly Incidence rates for ESRD for people with diabetes dropped significantly

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40 Percent % ESRD PREVALENCE RATES Year Michigan Florida Ohio New York National -12.0% -9.3% -8.7% -8.2% -5.4% 20.2%

41 Incidence of ESRD for Patients with Diabetes Percent % Year 14.8% Michigan Florida New York Arkansas National -30.2% -18.4% -20.0% -16.3% -23.9%

42 2005 HEDIS* Measures in Commercial Health Plans Show Michigan Providing Superior Diabetes Care HB A1C testing Hb A1C Control (lower is better) Eye Exam Lipid Control (LDL<130) Kidney Testing Source: National Committee for Quality Assurance (NCQA) *HEDIS - Health Plan Employer Data Information Set Michigan Region National

43 Brief History of Our Partnership DCPC provided funding in 1993 for a State Kidney Plan which was developed in concert with the Kidney Community DCPC created an RFP for $25,000 to focus on kidney disease prevention in 1994 The Michigan Legislature provided funding for the State Kidney Plan for $300,000 in These dollars were increased to $500,000 in 1997 due to positive results. (Created Diabetes/Kidney Disease state budget line!)

44 History (Continued) The Kidney Foundation received a Robert Wood Johnson Foundation grant with the help of the DPCP to provide primary prevention community-based initiative (an African American Salon program) in 2000 Over the next several years, additional funding came from the DPCP, the Cardiovascular Section, private foundations and federal sources for this prevention program and others (Barbershop Initiative and Head Start Initiative) A New State Kidney Plan was released in Focused also the Healthcare System through egfr/managed Care and Innovative Community Programs The Kidney Foundation was given the contracts for the Diabetes Outreach Networks in three regions.

45 Keys to Partnership Disease relationship overlap of diabetes with kidney disease Mutual funding Healthy Michigan Funds Diabetes/Kidney Disease state budget line Legislative advocacy by NKFM

46 Keys to Partnership Shared staff (Dialysis Nurse) Shared data, surveillance, materials, programs (e.g., Diabetes Outreach Networks (DONs), CQI, Renal Plan, Strategic Plans) Shared culture (e.g., Champions of Hope, Legislative Day, Diabetes Statewide Coalition) Shared contracts (e.g., MDCH funding & NKFM matching funds, mutual objectives, evaluation

47 Keys to Partnership Consistent communication (including non-crisis, face-to-face) Mutual trouble-shooting Stable leadership Mutual partners Cultivating trust

48 Future Plans Healthy Families -Statewide spread -Add pol/environmental change -Establish evidence base Spread of evidence-based programs -PATH -Enhanced Fitness -DPP-based programs

49 Future Plans Add key community partners - Y s -Arab Chaldean group -Managed care health plans -Aging networks CQI -MDRTC/UM -Key health plans

50 Future Plans Maintain 2 DONs (Grand Rapids, Det.) Michigan s budget crisis