CHI Franciscan Matt Levi Director Virtual Health Services March 31, 2015
Reflection / 2
Agenda Introduction and background Matt Levi Director of Franciscan Health System Virtual Health Katie Farrell Manager of Franciscan Medical Group Diabetes Services Dr. Louis Lim Medical Director of Quality, Franciscan Medical Group Virtual Diabetes Management Pilot Service overview Results Conclusions and implications / 3
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Development timeline Diabetes identified and key stakeholders brought on board Second iteration of pilot launches All patients completed 6 month milestone 2012 2013 2014 2015 Virtual chronic disease management first conceived and proposed Initial pilot vendor pulls out just before launch First patients begin / 5
Why Diabetes? Expensive Prevalent Chronic Progressive / 6
Katie Farrell, RD, CDE Registered Dietitian, Certified Diabetes Educator Diabetes Services Manger
What is Diabetes Self-Management Training (DSMT)? It is an intervention in which patients learn about diabetes and how to implement the self-management that is imperative to control the disease. Topics covered in Diabetes Education Sessions: Healthy eating Being active Monitoring Taking medication Problem solving Healthy coping Reducing risks DSMT helps patients to improve glycemic control, which could reduce the risk for diabetes complications, hospitalizations, and health care costs. Fewer than 7% of persons received DSMT within 1 year after diagnosis with diabetes. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6346a2.htm?s_cid=mm6346a2_e / 8
Diabetes Self-Management Training is a Smart Investment Cost Savings Medicare average cost savings of $135 per month among beneficiaries who completed a DSME program Diabetes Self-Management Education/Training Reimbursement toolkit October 2013 / 9
VDMP: Virtual Diabetes Management Program We have been effectively delivering diabetes education for a long time, this is the same information delivered in a new way / 10
Home Monitoring Equipment / 11
Remote Home Monitoring Challenges: Significant technology challenges Cellular not a reliable approach for all patients 9/24 (37%) patients had to be converted to THEIR broadband 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 Recommendations: Continue with current strategies Re-examine how patient BPs are monitored and managed / 12
VDMP: Virtual Diabetes Management Program 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 patient 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 / 13
VDMP: Virtual Diabetes Management Program Delivering diabetes education in a new way Outreach by mail Identify Eligible Patients: A1c 8% Outreach by phone call Ideally they call us upon receiving letter Patients Respond After letter received, we call patient Sign up for Meet and Greet Send Enrolment Packet Schedule first Virtual Visit (VV) / 14
VDMP: Virtual Diabetes Management Program First VV once enrolled : Intake phone call from NCM (Nurse Care Manager) First VV (Virtual Visit) with CDE (Certified Diabetes Educator) Engagement assessment & multidisciplinary team development of individualized care plan 24/7 RN monitoring by Avery Health systolic BP >160 or <90 and diastolic alert thresholds >100 or <50 and BG alert thresholds set at <60 X 2 in 30 minutes or >300 / 15
Participant Population Gender 14 10 Male Female Age Range (years) Average Age (years) 37 to 80 58 / 16
Final Schedule Care began: March 31, 2014 Last patient to enroll equipment install: July 8, 2014 Care ended: December, 31, 2014 Final enrollment: 25 o 22 patients completed program o 3 disenrolled o One at patient request o Two for non-participation / 17
VDMP: Virtual Diabetes Management Program 25 high risk patients with diabetes Have an HbA1c of 8% or greater Type 2 Diabetes taking an oral hypoglycemic medication or insulin daily AND meet any two of the following clinical criteria: Have had 1 ED, urgent care or inpatient visit in the past 6 months with either a primary diagnosis of diabetes or their presenting concern is related to their diabetes Have an LDL over 100 mg/dl or on lipid lowering medication Have blood pressure greater than or equal to 140/90 or be on antihypertensive therapy We did not have obesity as a criteria / 18
Patient Interactions by Type / 19
VDMP: Virtual Diabetes Management Program 150 100 Alerts 110 alerts Alerts 50 9 alerts 0 Total BG Alerts Hypo BG Alerts Hyper BG Alerts / 20
VDMP: Virtual Diabetes Management Program 10 8 6 4 2 0 9.51% HgbA1c Pre HgbA1c Average 7.18% HgbA1c Post HgbA1c / 21
VDMP: Virtual Diabetes Management Program Standard Deviation HgbA1c Intake: Average 9.51% Std Deviation 2.06 Discharge: Average 7.17% Std Deviation.89 / 22
VDMP: Virtual Diabetes Management Program HgbAIC Goal: in last 3 months M1 Result M4 1/30/2014 5/29/2014 9/18/2014 16.5 6.9 6.5 HgbAIC Goal: in last 3 months M1 M4 M6 11/12/2013 5/30/2014 9/16/2014 9.4 8.8 6.7 HgbAIC Goal: in last 3 months M1 M4 M6 1/17/2014 4/11/2014 7/7/2014 12 8.4 6.8 HgbAIC Goal: in last 3 months M1 M4 M6 2/24/2014 6/3/2014 10/6/2014 9.3 7.5 7.6 HgbAIC Goal: in last 3 months M1 M4 M6 10/8/2013 5/2/2014 9/9/2014 10.3 10.7 9.6 HgbAIC Goal: in last 3 months M1 M4 M6 4/7/2014 5/28/2014 10/2/2014 8 6.6 6 HgbAIC Goal: in last 3 months M1 M4 M6 3/13/2014 6/12/2014 9/12/2014 / 7.5 7.1 7.9 23
Improving Blood Glucose Trends / 24
VDMP: Virtual Diabetes Management Program 10000 8000 6000 4000 2000 0 Self Monitoring of Blood Glucose BG Measurements Expected BG measurements actual Monitoring / 25
VDMP: Virtual Diabetes Management Program 4000 Self Monitoring of Blood Pressure 3000 2000 1000 Measuring Blood Pressure 0 Blood pressure measurement expected Blood pressure measurement actual / 26
VDMP: Virtual Diabetes Management Program 1500 1226 Health Checks 1000 782 500 Health Checks 0 Wellness questions texted Wellness questions resonded / 27
VDMP: Virtual Diabetes Management Program 500 400 300 200 100 0 Weight reports expected Body Weight Weigh reports actual Body Weight / 28
VDMP: Virtual Diabetes Management Program Diabetes Pathway Compliance Rate Follow up with PCP Smoking status Depression screening Foot exams Eye exams Dental exams Labs Kidney function Medication reconciliation Compliance rate improved from 52% to 85% (20 measures) / 29
Results: Most patients made significant improvements in diabetes selfmanagement, lifestyle behaviors, and adherence to their care plans: o Diet o Activity o Medications o Glucose monitoring I drive past McDonald s now instead of thru McDonald s HbA1c impacts: o Some patients made significant reductions as much as a 10 points o Most patients made improvements o Median reduction in this population = 2.33% decrease (Pval=0.0004) o Some showed no improvement / 30
Results: Diabetes Pathway Compliance Rate (DPCR): o 20 measures that constitute best practice for DM type 2 patients o Patient compliance with these twenty measures went from 52.5% on intake to 85.0% on discharge (Pval=0) There were ZERO unplanned hospitalizations, ER or Urgent Care visits related to diabetes Four previously unknown cases of HTN identified #1 Value: created accountability for their actions; encouraged them to change; reassuring them that someone cares Enrollees rated program 9.0 out of 10.0 / 31
Patient Interview Positives: Patients rated program highly overall: avg. 9.0/10 #1 Value: Creating accountability for their actions; encouraging them to change; reassuring them that someone cares CDE VV, developing a personalized relationship with CDE Increased monitoring of BG/BP creates readiness to learn Like glucometer mobility / 32
Patient Interview Negatives Technology not reliable o Video rarely works o Connectivity challenges o Tablet o Screen size, volume, battery life, limited range from hub Tied to Zilant hub, would prefer more options to complete virtual visits and health checks Not practical for most to do health checks daily Especially when limited to doing at home, on tablet / 33
Patient Interview Desired Changes: OK to do just telephone virtual visits Do health checks and virtual visits from PC or smart phone Batch health checks to allow completing a week in one sitting More interactions via smart phones / text messaging o including daily wellness question Group support opportunities Regular support group meetings Online community Group education opportunities Exercise measuring device More links to external content / 34
CHI Franciscan Dr. Louis Lim Medical Director of Quality
Why Did We Choose Diabetes? NATIONALLY: 21 million individuals diagnosed with diabetes in the United States.* 11 million Emergency Department visits associated with diabetes.# 48 thousand new kidney dialysis patients in 2008 associated with diabetes.# 7.6 million patients with diabetes reported heart disease or a stroke. * HEALTH SYSTEM: Diabetes care needs significant improvement. Diabetes measures such as performance of foot exams and eye exams are below recommended NCQA benchmarks. Target higher risk patients who are not responding to routine diabetic care. Explore innovative ways to improve patient engagement. * 2011 CDC data. # 2008 CDC data. / 36
Intended Goals and Outcomes Improve chronic disease management through use of cost-effective tools and processes including telehealth Expand FMG/FHS exposure to CDM and virtual health service models Collect and track longitudinal healthcare costs (e.g., ER visits, admissions and readmissions) for enrolled patient s Measure the impact of pilot interventions on high risk diabetes type II patients in terms of their HgA1c s Improve patient education and self-efficacy in diabetes management, including increasing medication, diet, & exercise compliance Improve patient compliance and support the continuity of the relationship between patients and their primary care providers Increase patient and provider satisfaction / 37
Conclusions and Next Steps Program very effective in improving diabetes control. Improved engagement by patients. Program is time and resource intensive. Partnership between clinical staff, telehealth professionals and administrative support is crucial. Reimbursement source still needs to be determined. Exploring opportunity to partner with care management to address high risk patients. Continue to follow patients to monitor longer term outcomes. VDM3 (management, maintenance & monitoring) / 38
Questions / 39