Managing Complex Diabetic Patients in the Primary Care Setting. Tyree Morrison, CRNP, CDE Laura Previte, RN, BSN

Transcription

1 Managing Complex Diabetic Patients in the Primary Care Setting Tyree Morrison, CRNP, CDE Laura Previte, RN, BSN

2 OBJECTIVES Discuss epidemiology of diabetes Present overview of current treatment guidelines Discuss challenges of caring for diabetics in primary care setting Using medical home model of care Understand what we created at FPCA Case studies from FPCA

3 DIABETES FACTS CDC Data, million people have diabetes 1 out of 4 do not know they have diabetes 86 million have prediabetes more than 1 out of 3 adults $245 billion a year in medical costs and lost work wages Medical costs twice as high Continued

4 DIABETES FACTS 9 out of 10 do not know they have prediabetes Without weight loss and moderate physical activity, 15-30% of people with prediabetes will develop type 2 diabetes within 5 years Risk of death for adults with diabetes is 50% higher than for those without diabetes 7 th leading cause of death in U.S. Medical costs are twice as high for those with diabetes

5 DIAGNOSTIC CRITERIA Diagnostic criteria for pre-diabetes and type 2 diabetes mellitus 2 fasting glucose readings of > 126 mg/dl OR 2 hour plasma glucose > 200 mg/dl during oral glucose tolerance test OR Random plasma glucose > 200 mg/dl with classic symptoms of hyperglycemia

6 THE COMPLEX DIABETIC PATIENT What constitutes a complex diabetic patient -Hyperglycemia plus Multiple Co-Morbid Conditions and Complications which include: Dyslipidemia Hypertension Obesity/Weight Management Issues Renal Disease Peripheral and Autonomic Neuropathy Diabetic Eye Disease Gastrointestinal Peripheral Vascular Disease Dental disease Heart failure

7 CURRENT TREATMENT GUIDELINES ADA AND JOSLIN Cornerstones of Treatment: Lifestyle modification #1 intervention Individual approach to medication and glycemic control targets Team approach Medical specialists Diabetes educators Patient-centered self-management Individualized treatment plan

8 CHALLENGES IN PRIMARY CARE SETTING Cost of specialists Availability of endocrinologists Wait time for appointments Acuity and age of patient Losing patient connection To refer or not refer Decision Tree

9 FPCA STATS At Frederick Primary Care Associates (FPCA) 9 practice sites 45 providers ~73,000 active patients Office hours 7 days a week, including evenings and walk-ins 1 out of 10 adult patients have diabetes (~6,000 patients) 1 out of 3 adult patients with BMI >30 (~23,000 patients)

10 EDUCATION THE MISSING PIECE History of FPCA s clinical education program Comprehensive Wellness Program with focus on diabetes 6-week diabetes education class One-on-one 30-minute consultations Continuous glucose monitor Insulin pumps Weight management/nutritional counseling Seasonal food seminars Newsletter Support groups And more.

11 WHAT FPCA OFFERS DIABETICS One-on-one diabetes education consultations Insulin and oral medication management Continuous glucose monitoring Insulin pump training and management Registered Nurse who provides care coordination

12 DISADVANTAGES FOR PATIENTS Stigma of not seeing specialist Limited scope of practice No hospital rounding

13 ADVANTAGES FOR PATIENTS Continuity of care Facilitated communication between providers Comprehensive patient data available through EMR Familiarity with practice Non-diabetes needs addressed Lower cost of co-pay More 1-on-1 attention

14 THEIR STORIES

15 IDENTIFYING PATIENTS Patient must be: Appropriate for outpatient management Engaged in self-management Identified by: PCP referrals Outside referrals Health IT reports i.e., diagnostic studies, hospitalizations, CRISP, PCMH program, etc. Patient/Self referrals

16 PATIENT-CENTERED MEDICAL HOME (PCMH) According to National Committee for Quality Assurance (NCQA) A way of organizing primary care Emphasizes care coordination Emphasizes communication Higher quality Lower costs Improve experience of care for patients and providers Care coordination (goal-oriented) Population health

17 WHAT IS CARE COORDINATION? NCQA definition: ensure that beneficiaries health care needs, preferences for health services and information sharing across health care staff and facilities are met over time. Care coordination maximizes the use of effective, efficient, safe, and high-quality patient services that ultimately lead to improved health care outcomes. National Quality Forum definition: Conscious effort by two or more health care professionals to facilitate and coordinate the appropriate delivery of health care services for a patient.

18 PCMH AND DIABETES CARE Team/holistic care and facilitate coordination with appropriate resources i.e., PCP, specialist, medical resources, community programs, prescription assistance plans, etc. Closer monitoring Avoid unnecessary hospital or emergency room encounters Provide education about health condition Encourage patient to actively participate in health care decisions and self-management Discuss concerns or questions with nurse Support to patient and family Solicit input regarding goals and management plan

19 COSTS AND BENEFITS COSTS Nurse care coordinator salary Health information technology support Ramp up to become a qualified PCMH through NCQA Patient support resources BENEFITS Quality time spent with patients Early intervention Support Liaison Engage patients in their care

20 BENEFITS OF THE PROGRAM

21 LET S MEET BETSY Betsy 59-year-old, married, white female No children Self-employed writer No smoking/alcohol/substance use 8-year history of diabetes

22 CARE PLAN GOALS PCP S GOALS Diabetes education Diabetes control Lower cholesterol Weight loss Medication management PATIENT S GOALS Weight loss Diabetes control

23 PATIENT HISTORY Past Medical History: Ovarian cyst, bronchitis, asthma, anemia, allergies, congenital duplicate kidney, osteoarthritis hips and knees Past Surgical History: Right nephrectomy, bilateral total knee replacements, tubal ligation, breast reduction Family History: Heart disease, mental health issues

24 BARRIERS TO OPTIMAL HEALTH Transportation Financial Non-adherence (medication) Knowledge deficit/lack of understanding Mobility Caregiver duties

25 UNCONTROLLED CONDITIONS DIABETES OBESITY HYPERLIPIDEMIA DEPRESSION

26 DIABETES Onset 2005 In denial for years Medications Metformin 500 mg b.i.d. Victoza 1.8 mg q.d. Levemir 100 units b.i.d. Novolog sliding scale a.c. meals Lisinopril 10 mg q.d. Abnormal hemoglobin A1c - 9.6% Abnormal lipids LDL 126, Triglycerides 213 Extreme daytime fatigue Normal kidney function Normal vitamin B12

27 DIABETES Problems identified: Poor self-management Metformin timing Sliding scale Non-compliance with low-carb diet Non-adherence to medication regimen Knowledge deficit of disease process

28 OBESITY 20+ year history Weight fluctuations over past 10 years Never exercised Bilateral TKRs Extreme fatigue

29 HYPERLIPIDEMIA Onset 15 years ago Non-compliant with low-fat diet Strong family history of heart disease Abnormal lipid panel: Total cholesterol 230 mg/dl Triglycerides 213 mg/dl HDL 61 mg/dl LDL 126 mg/dl Pravastatin 80 mg daily

30 DEPRESSION PHQ2 positive Medications Abilify 20 mg daily Wellbutrin 300 mg daily Zoloft 100 mg daily

31 FALL 2013 CARE PLAN INITIATED Focused on diabetes Diabetes education Sliding scale insulin regimen Metformin timing Diabetes education class Pill organizer Excedrin Migraine changed to caffeine tablets Started baby aspirin Hemoglobin A1c 8.5% (down from 9.6%) Started hepatitis B series Foot exam Diabetes education class (transportation issue) Started exercising 15 minutes 3x/week Continuous glucose monitoring performed

32 CGM PRIOR TO INSULIN PUMP Average blood sugar highest blood sugar lowest blood sugar 73 + ~280 units of insulin daily + extended postprandial excursions = GOOD CANDIDATE FOR INSULIN PUMP

33 A1Cs PRIOR TO INSULIN PUMP 14 HEMOGLOBIN A1Cs

34 WINTER 2013 A1c 7.1% (down from 8.5%) Insulin pump process started Indecision Fear Financial concerns Support from PCP, CDE, and Medtronic Insulin pump started January Oral diabetic meds stopped Total daily insulin use ~130u/day Attending insulin pump support group Weight gain Tradjenta vs. Victoza Hypoglycemia unawareness discovered Education performed by care coordinator and CDE Continues exercising 15 minutes 3-5x/week

35 SPRING 2014 I feel so much better. I m not fatigued anymore. Stopped caffeine! Hemoglobin A1c 6.5% (down from 7.1%)!! Blood sugars in range a.c. Final hep B and shingles vaccinations Regular exercise 30 minutes 3x/week bike/treadmill Daily insulin usage 100 units/day max no meal boluses Monthly insulin pump downloads interim phone contact DRE scheduled WWE by PCP Agrees to Outcomes medication review Interested in decreasing antidepressant usage tapering schedule for Abilify provided by PCP Switched to Victoza

36 INSULIN PUMP DOWNLOAD MAY DOWNLOAD Average blood glucose = Average total daily insulin = units

37 SUMMER 2014 Hemoglobin A1c 5.8%!! Monthly insulin pump downloads Mentoring/supporting other pumpers Weight loss Exercise treadmill, bike, Zumba! Weaning off Abilify Recent labs WNL diabetes, renal, lipids

38 INSULIN PUMP DOWNLOAD SEPTEMBER DOWNLOAD Average blood glucose = Average total daily insulin =

39 A1Cs POST INSULIN PUMP 10 HEMOGLOBIN A1Cs

40 BENEFITS OF PUMP

41 CARE PLAN GOALS PCP S GOALS Diabetes education Diabetes control Lower cholesterol Weight loss Medication management PATIENT S GOALS Weight loss Diabetes control

42 CARE PLAN GOALS PCP S GOALS Diabetes education Diabetes control Lower cholesterol Weight loss Medication management PATIENT S GOALS Weight loss Diabetes control

43 SUMMARY How did Care Coordination benefit patient? Optimal diabetes control accomplished through support, education, resources, communication. Medication management/compliance Improved depression weaning off high-volatility medications Improved energy and overall sense of well being Exercising regularly

44 LESSONS LEARNED Have a 5-year plan Support of Board of Directors Budget Adequate staffing Marketing plan Referral base Funding Clinic space Ongoing training/education Develop relationships with community groups and pharmaceutical/medical equipment companies

45 REFERENCES