Diabetes Management Collaborative

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1 Diabetes Management Collaborative Benjamin Miller, PsyD University of Massachusetts Medical School Department of Family Medicine and Community Health

2 Diabetes and Consultation! The goals of this presentation:! Explain Type 2 Diabetes! Statistics! Role of consultant! Stepped care model! Needs and Wants! Interventions

3 What is Type 2 Diabetes?! A Chronic endocrinological disorder characterized by abnormalities in glucose metabolism due to abnormalities in the production and/or utilization of the hormone insulin (Gonder( Gonder-Frederick, Cox, & Ritterband,, 2002)

4 T2DM Statistics! Chronic illnesses such as diabetes account for approximately 80% of the deaths in Western countries (Maes( Maes, Leventhal, and DeRidder,, 1996)! Diabetes is the 7 th leading cause of death in the United States (Centers for Disease Control and Prevention, 2002)! Diabetes affects approximately 17 million Americans (American Diabetes Association, 2001)! Direct and indirect costs related to diabetes range from 57$ to 98$ billion dollars (American Diabetes Association, 1998)! T2DM is strongly related to obesity (80%), age, and over 2/3 have e a first or second cousin with the disease (Haffner( Haffner,, 1998)! Additionally, Haffner (1998) found that the risk for T2DM is higher in minority groups, but T1DM is higher in Caucasians

5 T2DM Statistics! If the US increased the overall regular or vigorous activity from 22% to 30%, the nation might avoid losing 326,895 years of potential life (Robbins & Fonseca, 2001)

6 Impact of Diabetes! Research has shown the connection between obesity and T2DM (American Diabetes Association, 2000)! Obesity has risen over 74% in the past decade (Mokdad et al., 2003)! In America, sugar and fat represent more than half of the dietary energy intake (American Institute for Cancer Research, 1997)

7 The Role of the Consultant! Due to the implications obesity has for individuals with T2DM, weight loss and nutritional improvement through behavioral intervention is a common treatment goal (Jeffery et al., 2000)! Fewer than 10% of patients are able to control T2DM through diet and exercise alone (Gonder( Gonder- Frederick, Cox, & Ritterband,, 2002)

8 The Role of the Consultant! Treatment regimens, diagnosis, and symptomatology can lead to psychological distress (Lustman( Lustman,, 1988; Wells, Golding,, & Burnam,, 1988; Wilkinson, 1991)! Approximately 10% to 15% of patients diagnosed with diabetes mellitus meet DSM-IV criteria for major depression (Anderson, Freedland,, Clouse, & Lustman,, 2001; Katon et al., 2004 )! These psychological symptoms can lead to interference with self-treatment (Christenson, Moran, & Wiebe,, 1999)

9 The Stepped Care Schema Tertiary Consult with MD Referral See 3-5 Sessions Newly Diagnosed Assess Intervention Follow up PRN Pre- Diabetic Psychoeducation Main role of the consultant

10 The Identified Problem Psychologist s s reported M.D. M.D. s must spend a significant amount of time treating the complications of diabetes, which result from poor self-management of the disease. Eye Problems ER Visits Renal Failure Limb Amputation Diabetes Hyperglycemia Neuropathy Hypoglycemia Cardiovascular Disease This results in patients termed frequent fliers or high utilizers of medical services

11 ! WANTS: Physician! # of patients presenting w/ diabetes complications resulting from poor self-management! Cost Offset (will become a NEED after year 1)! NEEDS:! To be more efficacious in treating Type 2 Diabetes! Show outcomes for Behavioral Health services implemented! Must be able to bill for services using CPT codes

12 Behavioral Health Consultant! WANTS:! Opportunity to Educate Staff! Offer Primary & Secondary Interventions (refer out for Tertiary Care)! Be able to offer a Group Appointment (diabetes education) the first of the month have space, time, and referrals! NEEDS:! Physician referrals names on referral card, next to the physicians; Behavioral Health tab in medical chart! Multi-disciplinary team approach (not interdisciplinary)! $10,000 Consulting Fee for 1-year 1 of services! Office space, overhead covered

13 ! 6-months: Presenting Outcomes! Assessment findings regarding Patient s s knowledge about diabetes following Group Appointments! Pre- & Post-intervention scores on Diabetes Empowerment Scale (DES), Problems Areas in Diabetes Scale (PAID), Appraisal of Diabetes Scale (ADS)! Glucose readings at medical visits before and after behavioral health intervention! Patient Satisfaction with Behavioral Health Services! 12-months: months: Same as 6-m 6 m with the addition of -! # of repeat visits for diabetes complications! Utilization of CPT codes! Potential Cost Offset

14 One Session Intervention! Step I: Explore the Problem Issue (Past)! Step II: Clarify Feelings and Meaning (Present)! Step III: Develop a Plan (Future)! Step IV: Commit to Action (Future)! Step V: Experience and Evaluate the Plan (Future) (Funnell & Anderson, 2004)

15 Three Session Intervention! Session I: Assess/Psychoeducation! Session II: Nutrition! Session III: Exercise

16 5 Session Group! Session One: Assess/Psychoeducation! Session Two: Managing Mood! Session Three: Nutrition! Session Four: Exercise! Session Five: Stress Management

17 References! American Diabetes Association (1998). Economic consequences of diabetes d mellitus in the U.S. in Diabetes Care, 21, ! American Diabetes Association (2000). Type 2 diabetes in children n and adolescents. Diabetes Care, 23, ! American Diabetes Association (2001). Facts and figures. Retrieved ed February 2, 2005, from =*.jspandevent=link(b1)! American Institute for Cancer Research (1997). Food, nutrition, and the prevention of cancer: a global perspective. Washington, DC: AICR.! Anderson, R., Freedland,, K., Clouse, R., & Lustman,, P. (2001). Prevalence of comorbid depression in adults with diabetes: a meta- analysis. Diabetes Care, 24, ! Anderson, B.J. & Rubin R.R. (1996). Practical psychology for diabetes clinicians. Alexandria, VA: American Diabetes Association. Anderson, R.M., Funnell,, M.M., Fitzgerald, J.J., & Marrero, D.G. (2000). The Diabetes Empowerment E Scale: A measure of psychosocial self-efficacy. efficacy. Diabetes Care, 23, ! Bradley, C. (1994). Measures and perceived control in diabetes. In C. Bradley (Ed.), Handbook of psychology and diabetes (pp ). Amsterdam: Harwood Academic Publishers.! Boule,, N. G., et al. (2002). Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: A meta-analysis analysis of controlled clinical trials. Scandinavian Journal of Medicine and Science in Sports, 12, ! Carey, M. P., Jorgensen, R. S., Weinstock,, R. S., Sprafkin,, R. P., Lantinga,, L. J., Carnrike,, C. L., Jr., Baker, M. T., & Meisler,, A. W. (1991). Reliability and validity of the Appraisal of Diabetes Scale. Journal of Behavioral Medicine, 14, Centers for Disease Control and Prevention. (n.d( n.d.)..). In 2002 Diabetes surveillance system: Number and percent of I.S. population pulation with diagnosed diabetes.. Retrieved February 2, 2005, from Christenson, A. J., Moran, P. J., & Wiebe,, J. S. (1999). Assessment of irrational health beliefs: Relation n to health practices and medical regimen adherence. Health Psychology, 18, ! Glasgow, R. E. (1994). Social-Environmental factors in diabetes: Barriers to diabetes self-care. In C. Bradley (Ed.), Handbook of psychology and diabetes research and practice (pp ). 349). Berkshire, England: Hardwood Academic.! Glasgow, R. E., Funnell,, M. M., Bonomi,, A. E., Beckham, V., & Wagner, E. H. (2002). Self-management aspects of improving chronic illness care Breakthrough Series: Implementation with diabetes and a heart failure teams. Annals of Behavior Medicine, 24, ! Glasgow, R. E., McCaul,, K. D., & Schafer, L. C. (1986). Barriers to regimen adherence among persons with insulin-dependent diabetes. Journal of Behavioral Medicine, 9, ! Gonder-Frederick, L. A., Cox, D. J., & Ritterband,, L. M. (2002). Diabetes and behavioral medicine: The second decade. Journal of Consulting and Clinical Psychology, 70, ! Haffner,, S. M. (1998). Epidemiology of type 2 diabetes: Risk factors. Diabetes Care, 21(Suppl. 3), C3-C6. C6.! Jeffery, R. W., Epstein, L. H., Wilson, G. T., Drewnowski,, A., Stunkard,, A. J., & Wing, R. R. (2000). Long-term maintenance of weight loss: Current status. Health Psychology, 19, 5-16.! Katon,, W. J., et al. (2004). The pathways study: A randomized trial of collaborative care in patients with diabetes and depression. Archives of General Psychiatry, 61,

18 References Cont.! Katon,, W., Von Korff,, M., Ciechanowski,, P., Russo, J., Lin, E., Simon, G., et al. (2004). Behavioral and a clinical factors associated with depression among individuals with diabetes. Diabetes Care, 27, ! Lustman,, P. J. (1988). Anxiety disorders in adults with diabetes mellitus. Psychiatric Clinics of North America, 11, ! Miller, N. H. (1997). Compliance with treatment regimens in chronic asymptomatic diseases. American Journal of Medicine, 102, ! Polonsky,, W. H., Anderson, B. J., Lohrer,, P. A., Welch, G., Jacobson, A. M., Aponte, J. E., & Schwartz, C. E. (1995). Assessment of diabetes-related distress. Diabetes Care, 18, ! Maes,, S., Leventhal,, H., & DeRidder,, D.T. D. (1993). Coping with Chronic Diseases. In M. Zeidner & N.S. Endler (Eds.), Handbook of Coping: Theory Research, and Applications (pp ). 251). New York: Wiley.! Mokdad,, A. H., Ford, E. S., Bowman, B. A., Dietz, W. H., Vinicor,, F., Bales, V. S., et al. (2003). Prevalence of obesity, diabetes, es, and obesity-related health risk factors. JAMA, 289, ! Snoeck,, F. J., & Skinner, T. C. (2000). Psychology in diabetes care (1st ed.). Chichester,, England: Wiley.! The Diabetes Control and Complications Trial Research Group (1993). 93). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329, ! Wagner, E. H. (2000). The role of patient care teams in chronic disease management. BMJ, 320, ! Wagner, E. H., Austin, B., & Von Korff,, M. (1996). Improving the outcomes in chronic illness. Managed Care Quarterly, 4, ! Wells, K. B., Golding,, J. M., & Burnam,, M. A. (1988). Psychiatric disorder in the population with and without chronic medical conditions. American Journal of Psychiatry, 145, ! Whitlock, E. P., Orleans, C. T., Pender, N., & Allan, J. (2002). Evaluating primary care behavioral counseling interventions: An evidenced- based approach. American Journal of Preventative Medicine, 22, ! Wilkinson, G. (1991). Psychological problems and psychiatric disorders in diabetes mellitus. In J. Pickup & G. Williams (Eds.), Textbook of diabetes (pp ). 791). London: Blackwell Scientific Publications.

19 Diabetes Management Collaborative What is Type 2 Diabetes? The Stepped Care Model Outcome Assessment: 6-months: Assessment findings regarding Patient s s knowledge about diabetes following Group Appointments Pre- & Post-intervention scores on Diabetes Empowerment Scale (DES), Problems Areas in Diabetes Scale (PAID), Appraisal of Diabetes Scale (ADS) Glucose readings at medical visits before and after behavioral health intervention Patient Satisfaction with Behavioral Health Services 12-months: Same as 6-m 6 m with the addition of - # of repeat visits for diabetes complications Utilization of CPT codes Potential Cost Offset Important Statistics: Chronic illnesses such as diabetes account for approximately 80% of the deaths in Western countries (Maes( Maes, Leventhal,, and DeRidder,, 1996) Diabetes is the 7th leading cause of death in the United States (Centers for Disease Control and Prevention, 2002) Diabetes affects approximately 17 million Americans (American Diabetes Association, 2001) Direct and indirect costs related to diabetes range from 57$ to 98$ billion dollars (American Diabetes Association, 1998) T2DM is strongly related to obesity (80%), age, and over 2/3 have a first or second cousin with the disease (Haffner( Haffner,, 1998) Tertiary Consult with MD Referral See 3-5 Sessions Newly Diagnosed Assess Intervention Follow up PRN Pre-Diabetic Psychoeducation

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