HEALTHY LIVING WITH CHRONIC CONDITIONS PHYSICIAN TOOLKIT

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1 HEALTHY LIVING WITH CHRONIC CONDITIONS PHYSICIAN TOOLKIT

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3 HEALTHY LIVING WITH CHRONIC CONDITIONS SHARED DECISION MAKING HELPING MY PATIENTS BECOME INVOLVED Shared Decision Making (SDM) has been shown to improve patient knowledge and clarity about medical preferences, and to reduce conflict in the decision making process. It also has the potential to: 1.) Increase patient trust in their physicians 2.) Increase patient compliance 3.) Increase satisfaction with decisions and the decision process 4.) Improve utilization of evidence-based preventive services 5.) Reduce utilization of emergency room visits The goals of SDM are consistent with and supportive of the triple aim. In addition, SDM has intrinsic value. Patient preferences matter, especially when making preference-sensitive decisions, where the best choice for the patient depends on their values and preferences and the medical evidence is clear. Physicians generally do not know their patients preferences unless they ask about them. Therefore, in many situations, a shared rather than delegated model for decision making is desirable. -Minnesota Shared Decision Making Collaborative 40 # king n a r s e t k Sta r o Y w tes e a t N S d e t ni in the U ercentage of np o es. d t e e s b a a i b d n with o i t a l u p po SOU w.ame RC E: ww ricashea lthrankin gs.org

4 HEALTHY LIVING WITH CHRONIC CONDITIONS WHAT IS PREDIABETES? UNDERSTANDING PREDIABETES A person with prediabetes has a blood sugar level higher than normal, but not high enough for a diagnosis of diabetes. According to Ann Albright, Ph.D., RD,. director of the Center for Disease Control & Prevention s Division of Diabetes Translation, The CDC estimates that more than 79 million Americans ages 20 years and older have prediabetes. Without intervention, 15 to 30 percent of those men and women will develop type 2 diabetes within 5 years. You can make a difference in that future for your patients. -ALMOST- 4.5 MILLION NEW YORKERS ARE ESTIMATED -TO HAVE- PREDIABETES The Diabetes Prevention Program brings physicians an effective lifestyle change program proven to prevent or delay the onset of type 2 diabetes in patients by 58 percent, and in patients age 60 or older by 71 percent. SOURCE: Center for Disease Control and Prevention The Diabetes Prevention Program is mirrored after the National Diabetes Prevention Program and supports participants in making lifestyle changes to reduce their risk for type 2 diabetes including weight loss, increased physical activity and healthy eating. The primary focus of this initiative is diabetes prevention. However, many of your patients already have chronic condition such as diabetes or high blood pressure. This toolkit will provide the information you need to help your patients living with these chronic conditions % PERCENTAGE OF PEOPLE WITH DIABETES IN NYS SOURCE: Center for Disease Control and Prevention

5 HEALTHY LIVING WITH CHRONIC CONDITIONS LOCAL PROGRAMS EMPOWERING PATIENTS TO BECOME PARTNERS IN THEIR HEALTH CARE There are several programs that can help you engage your patients to be active partners in their care. Two programs that are effective are the Diabetes Prevention Program and Living Healthy management programs. The Diabetes Prevention Program is a structured lifestyle change program. The program helps participants make lifestyle changes to reduce their risk for type 2 diabetes. The Lifestyle Coach works with groups of participants to: Lose weight through healthy eating Be more physically active Learn to recognize and overcome barriers to healthy eating and physical activity 16 1 HOUR SESSIONS Plus the option of 4 extra sessions for additional support Living Healthy is a chronic disease self-management program. The program aims to increase the knowledge of people living with chronic conditions and teach them the skills to better manage those conditions. The program encourages people knowledgeable about their health to take that extra step to fully engage in their health care. There are specific Living Healthy programs for Diabetes and Chronic Pain. Subjects covered in the workshops include: Treatment decision-making and problem solving Communication with family, friends and physicians Making healthy eating decisions Using your mind to manage pain, stress and other negative emotions Living Healthy will not conflict with existing programs or treatment. It is designed to enhance regular treatment and disease-specific education such as Better Breathers, cardiac rehabilitation or diabetes education HOUR SESSIONS

6 HEALTHY LIVING WITH CHRONIC CONDITIONS SATISFYING CRITERIA FOR PCMH A THESE EVIDENCE BASED PROGRAMS CAN HELP YOU REACH PCMH AND MEANINGFUL USE In connection with your EMR and other resources, these programs can assist you in reaching Patient Centered Medical Home (PCMH) and Meaningful Use. Provide educational resources or assist in self management Use EMR to identify patient-specific education resources and provide to more than 10% of patients Develop and document self-management goals in collaboration with patients Document self-management abilities for patients/families Provide self-management tools (for patient to record self-care results) to patients/families Counsel patients/families to adopt healthy behaviors Maintain current resource list on five topics or key community services areas of importance to practice s population Track referrals provided to patients Offer opportunities for health education and peer support

7 D MEANINGFUL USE PREVENTION MAINTENANCE DIABETES PREVENTION PROGRAM LIVING HEALTHY LIVING HEALTHY WITH DIABETES LIVING HEALTHY WITH CHRONIC PAIN

8 HEALTHY LIVING WITH CHRONIC CONDITIONS REFERRALS AND RESOURCES HOW DO I ENROLL MY PATIENTS? WNY WNY is a personal and confidential source for locating a variety of free and low-cost services that are available to people who live in Western New York is designated as a phone number for people to call that provides one point of access to the community s full range of social, health and government services. By calling s professionally trained staff, your patients receive referrals to services which NY CONNECTS Finding the right long term services and support to help your patients can be very confusing. NY Connects is your trusted place for information and assistance about long term services and support, whether they are paying for services themselves, through insurance, or are eligible for a government program. NY Connects can also help you enroll in a local Diabetes Prevention Program or Living Healthy. provide solutions to a variety of problems such as: Local NY Connects Information and Assistance How do I enroll in the Diabetes Prevention Program Specialists provide personalized counseling to or Living Healthy? help your patients make informed decisions and I am out of heart medication, can someone help? can assist you in accessing available long term My mother s snowed in and has no food. services and support to meet existing or future What if my daughter can t pay her medical bills? long term needs. They can contact NY Connects I can t afford a lawyer, where can I get legal advice? even if they already use long term services and support. TO REGISTER CALL 211 OR REGISTER ONLINE AT OR

9 New York State Diabetes Prevention Program (NYS DPP) Prediabetes Identification and Intervention Algorithm Screen or test patient if age 45 OR Patient is overweight or obese (BMI 24 kg/m 2 or BMI 22 kg/m 2 if Asian) AND positive for at least one of the following: 1 (See back page for risk information collection options.) Physical inactivity Family history of diabetes in parent, brother or sister History of gestational diabetes mellitus (GDM) or baby over nine pounds Member of a high-risk ethnic population (African American, Latino, Native American, Asian American, or Pacific Islander) Hypertension ( 140/90 mmhg or on therapy for hypertension) HDL cholesterol <35 mg/dl and/or triglyceride level >250 mg/dl History of cardiovascular disease (CVD) A1C 5.7%, IGT or IFG on previous testing Polycystic ovarian syndrome (PCOS) Medications that predispose to diabetes 2 Acanthosis nigricans YES NO Review patient medical records to determine if a FPG, OGTT, 3 or A1C has been performed in the past 24 months, or if the patient has history of GDM. YES NO Utilize one of the following diagnostic tests to determine prediabetes or diabetes status: 4 Fasting Plasma Glucose (FPG) Oral Glucose Tolerance Test (OGTT) 3 A1C Patient doesn t meet the screening criteria at this time: If indicated, provide National Diabetes Education Program (NDEP) diabetes risk reduction materials. Reassess for prediabetes and diabetes risk annually. RESULTS Diagnostic Test Normal Range Prediabetes Range Diabetes Range FPG 99 mg/dl 100 mg/dl 125 mg/dl 126 mg/dl OGTT 139 mg/dl 140 mg/dl 199 mg/dl 200 mg/dl A1C 5.6% 5.7% 6.4% 6.5% Normal Range Provide patient with National Diabetes Education Program (NDEP) diabetes risk reduction materials. They are available at Repeat testing should occur within three years of the previous negative test or annually if patient has multiple risk factors. Prediabetes Range Provide patient counseling on diagnosis or risk status and answer questions. Educate about diabetes prevention using therapeutic lifestyle changes (5-7% weight loss, 150 minutes of physical activity per week). Refer to NYS DPP if available. Explain the NYS DPP and provide patient with program brochure. Complete NYS DPP Patient Recommendation and encourage patient to register for program. Send NYS DPP Patient Recommendation directly to your local program provider if consent is provided by patient. Provide National Diabetes Education Program (NDEP) diabetes risk reduction materials. They are available at Schedule follow-up appointment with patient as needed. Give positive feedback around lifestyle changes. Reevaluate for progression to diabetes annually. Diabetes Range Conduct second test to confirm diagnosis. Counsel patient on diabetes diagnosis and answer questions. Initiate therapy. Provide National Diabetes Education Program (NDEP) materials for controlling diabetes. Refer patient to Certified Diabetes Educator (CDE) and/or Diabetes Self-Management Education (DSME). 5

10 Diabetes Prevention: Proven, Possible and Powerful! The NYS DPP is an evidence-based program for adults with diagnosed prediabetes or who are at high risk for developing type 2 diabetes. The program is led by a trained Lifestyle Coach and meets one hour per week for 16 weeks, followed by at least six monthly follow-up sessions. The program is delivered in community or health care settings, in groups of people, where personal lifestyle goals are set by each participant. The sessions cover healthy eating, physical activity, and lifestyle changes to help participants achieve the goals that lead to the prevention or delay of a diabetes diagnosis, including a 5-7% weight loss and maintenance, and a gradual increase in physical activity to 150 minutes per week. The NYS DPP is based on clinical research trial led by the National Institutes of Health, which showed that people with prediabetes can prevent or delay type 2 diabetes by 58% overall, and 71% in people 60 years of age and older. Common ICD-9 Codes for Diabetes Screening V77.1 Diabetes Screening Abnormal Glucose Impaired Fasting Glucose Impaired Glucose Tolerance Other Abnormal Glucose Obesity Overweight CPT Codes for Diabetes Screening CPT Fasting Plasma Glucose Test CPT Post-meal Glucose CPT Oral Glucose Tolerance Test CPT Hemoglobin A1C Medicare may cover up to two fasting blood glucose tests each year, based on individual risk factors. 1 Potential methods to collect patient risk factor information: Conduct chart review for patients with upcoming appointments Nurse or physician assistant may collect the information at the time of office visit Review/pull information from electronic health records 2 Common medications that predispose diabetes include nicotinic acid, glucocorticoids, thyroid hormone, diazoxide, ß-adrenergic agonists, thiazides, Dilantin, -Interferon and others. 3 2-h plasma glucose using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. 4 Clinicians should determine the most appropriate test based on the following considerations: Fasting status of the patient General office protocol and capacity of office staff and equipment Ability to provide follow-up and encourage action from the patient if testing occurs outside of office visit. 5 Visit the following websites to find a Certified Diabetes Educator or Diabetes Self-Management Education program in your area: American Diabetes Association Recognized Programs: American Association of Diabetes Educators (AADE) Recognized Programs: York AADE Find a Diabetes Educator: References American Diabetes Association. Standards of Medical Care in Diabetes Diabetes Care. January 2012; 35(1):S13-S14. Ackerman RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the Community: The DEPLOY Pilot Study. Am J Prev Med. 2008; 35(4): Diabetes Prevention Program Research Group. 10-year Follow-up of Diabetes Incidence and Weight Loss in the Diabetes Prevention Program Outcomes Study. Published online October 29, Abstract available at International Expert Committee. International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes. Diabetes Care. July 2009; 32(7):1-8. Promotional support for the NYS DPP is provided by the New York State Department of Health Diabetes Prevention and Control Program. The NYS DPP is part of the National Diabetes Prevention Program, led by the Centers for Disease Control and Prevention NEW YORK STATE DEPARTMENT OF HEALTH 11/12

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