Telligen s Diabetes Self-Management Programs LeadingAge Illinois Fall Conference September 27, 2016

Transcription

1 Telligen s Diabetes Self-Management Programs LeadingAge Illinois Fall Conference September 27, 2016 This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-IL-B2-8/ Presenter Merle Shapera, MS, RD, CDE, LDN Diabetes Program Specialist merle.shapera@hcqis.org 2 1

2 Presentation Objectives Describe our Mission with Everyone with Diabetes Counts Diabetes Self-Management Education (DSME) Train the Trainer Diabetes Peer Educator Training Identify ways we partner with Assisted and Supportive Living Facilities, Home Health Agencies and Our Other Partners 3 Telligen Quality Innovation Network Quality Improvement Organization Program Contracts with Centers for Medicare and Medicaid Services (CMS) Telligen represents Illinois, Iowa and Colorado QIO s exist in every state and work throughout each state Currently in 11 th Scope of Work 5 Year Contract 8/1/14-7/31/19 4 2

3 Centers for Medicare & Medicaid Quality Focus: QIN-QIO Goals Make care safer Strengthen person and family engagement Promote effective communication and coordination of care Promote effective prevention and treatment Promote best practices for healthy living Make care more affordable 5 Telligen QIN QIO 6 3

4 Telligen QIN s Strategic Initiatives 7 Healthcare Associated Infections Care Coordination Medication Safety Nursing Home Care Health Information Technology Quality Reporting and Incentive Programs Cardiac Health Diabetes Care Immunizations Goals of Everyone with Diabetes Counts Improve health equity for Medicare and Medicare- Medicaid persons with pre-diabetes and diabetes in minority and rural populations Engage physicians to refer patients for DSME and monitor/improve clinical measures Build sustainable diabetes education by training peer educators in DSME facilitation 8 Goal: 2136 DSME graduates by 7/31/19 4

5 Diabetes Statistics 10% of all Americans have diabetes 27% Seniors in Illinois (Medicare) have diabetes (1) 38% Senior African Americans and Latinos in Illinois have diabetes (2) 9 (1) CMS Chronic Conditions Warehouse, 2012 (2) CMS Gov Research Stat Data & Systems, Statistics Trends and Reports, Chronic Conditions DSME Education Utilization 57.4% adults with diabetes attended DSME classes in US This number decreases to ~12% in the zip codes in which we teach 10 preventative/fy_class.htm 5

6 Demographics of Our Area Cook County: South and West sides We teach in zip codes that are among the highest in: Gun violence and gun deaths Poverty and low income housing Food and Pharma Deserts Amputation rates Diabetes Dialysis Centers (ESRD) 11 Impact of DSME Physical health: 62% increase Emotional well-being: 46% increase Relationships with family and friends: 21% increase 12 Nicolucci A, et al. Diabet Med 2013;30:

7 Personal Benefits Associated with DSME Improved A1c levels Reduced onset or advancement of complications from diabetes, especially heart attacks, strokes and ESRD Improved quality of life Enhanced self-empowerment Increased coping skills Improvements in activity and eating 13 MA Powers et al, DSME Position Statement: Diabetes Care June 2015 Barriers to DSME in Senior Populations Lack of access to transportation Not connected to PCP/health providers: Lack of Understanding about Impact of DM Not knowing where DSME is available Frequent trips to PCPs, ER, urgent care, or specialists Family care responsibilities Health issues Fatigue Infections S/S of High BG High stress Safety Violence Finances Family well-being Lack of available money 14 7

8 Our DSME Curriculum Diabetes Empowerment Education Program (DEEP) From the University of Illinois (1) Evidence-based Utilized by many Quality Improvement Organizations (QIOs) throughout the country Culturally sensitive Engaging group format 15 (1) Midwest Latino Health Research,Training, and Policy Center Our DSME Classes 6 consecutive weeks 90 minute classes MUST attend 5/6 to graduate Target Population: Must have Medicare, Must have Diabetes or Pre-Diabetes African Americans, Latinos, Asians,Native Americans Caucasians who are dual eligible or living in known areas of low socioeconomic status 16 8

9 Identifying Areas of Diabetes Disparities Performed environmental scans to find zip codes with the highest disparities CMS Maps (2016) CMS Claim Data DSME Education Data Google Maps Websites 17 Identifying Potential Partners and Host Sites Local government officials Police and law enforcement agencies Directors of senior residence corporations Directors of public housing organizations Senior centers Administrators of community hospitals Church pastors and health ministry leaders Community health workers (CHW s) 18 9

10 Our Favorite Host Sites Participants more apt to attend classes where they live and frequent than at health centers: Senior centers and township centers Senior independent and supportive living facilities Senior meal programs Churches Libraries 19 Building Commitment Describe what they gain from DSME Share teaching tools and handouts Share successes PAS results (Pre and Post Tests) Participant stories Completion data Ongoing communication is KEY 20 10

11 Building Commitment Assess host site s prior experience/ success with program recruitment and implementation Ask: How can we help make you successful? Flyers Confirmation Calls Member Presentations Identify class champions Encourage site hosts to celebrate graduation 21 Knowledge, Coping Skills and Behavior Improvements 22 11

12 Engaging the Class To Maximize Attendance Socratic Method: Improved Retention and Understanding through Questions Encourage participant story telling Set behavior goals w/action plans at EVERY class Give reinforcement education tools at graduation 23 Education Materials Cultural Sensitivity: Appropriate images Reading Level: No higher than 6 th grade Language: Keep it simple Graphics: Appealing and colorful 24 12

13 Examples of Education Materials 25 Where Are We Now? Graduates as of 9/15/16: 485 Seniors (13% Pre DM) Attrition Rate Below 10% Conducted DSME in 56 sites Many groups forming buddy groups 41 peer educators trained 26 13

14 Participants Testimonials I wish I had this class 20 years ago when I was first diagnosed. Hattie E., DSME graduate 27 Partner s Testimonials "So often the community is forgotten. We get the short end of the deal when it comes to services. At the Kroc Center, our community members can come and get the information about diabetes they need. And it's free. Darlene Humphrey, Senior Center Supervisor 28 14

15 Support Long-Term Activation Reinforce goal setting Family members, caregivers invited Site host staff to attend DSME Buddy group formation BIGGEST CHALLENGE: Get those people to come to class who think they need DSME the least but have the poorest BG control! 29 Peer Educator Training Builds sustainable diabetes education Increases knowledge about diabetes based on facts and not myths Increases more open dialog about diabetes throughout communities in which peer educators live and work 30 15

16 PEER EDUCATOR TRAINING What s in it for our trainees? Two Day DEEP Curriculum Training Program Offered by an RD, CDE 3 year Certification as DEEP Peer Educator Hours of DSME experience to count for CDE or elevate a professional resume Will train anyone who is interested in learning and teaching DSME as a peer educator 31 PEER EDUCATOR TRAINING What s in it for Telligen? A commitment from the trainee to facilitate DSME classes in their communities or worksite: Graduating 20 seniors with diabetes or Pre DM within the 2 years following training per trainee 32 16

17 Contact Information Interested in More Information on Hosting a DSME Class or Being Trained as a Peer Educator? Merle Shapera, MS, RD, CDE, LDN Diabetes Program Specialist merle.shapera@hcqis.org 33 17