2/24/2015. Collaborative Care. Population Management. Population Management. Population Management

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1 Collaborative Care Optimizing Collaboration between the Primary Care Provider and the Specialist for Co-Managing High Risk Patients John Devlin, MD Endocrinologist A team with a shared mission using improved clinical systems to deliver improved care to a patient population supported by operational and financial systems. Such care is continuously evaluated through improvement processes and effectiveness measurement. Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 214 Population Management Community Hospital, Grand Junction, CO Comprehensive Primary Care Initiative (CMS): IHI Triple Aim Population Management Decrease unnecessary ED visits and hospitalizations Improve transitions of care At Risk clients 1. Stratification (Low, Medium, High) based on stages of current (chronic) diseases 2. Implementation of a care management program to manage condition(s) Murray D. American Diabetes Association Annual Conference, San Francisco, 214 Level A Level B Level C Level D HbA1c 9 DM plus 1 or more uncontr comorbid * In NON-SELF Management Requires BOTH physician and RN assessment Requires DSMT Tipping Point 4 out of 7 Population Management: Risk Stratification Behavior Change HbA1c DM plus 1-3 comorbidities * Independent SELF Management State RN Care Coordinator Health Coach Assessment DSMT applicable with Primary Educational Activities + DSM Plan Tipping Point > 3 out of 7 HbA1c < 7 DM plus 1-3 stable co-morbidities * Health Coach Assessment DSMT applicable with Primary Educational Activities + DSM Plan Tipping Point 2 out of 7 Hospice or SNF Receives services elsewhere Patient Opted Out * May include: CHF, CAD, HTN, open wounds, neuropathy, nephropathy, retinopathy, gastroparesis N/A N/A Assessment Conduct Needs Assessment Assess Safety Create Plan of Care Population Management Care Coordination Coordinate Services Navigate Transitions of Care Prevent Unnecessary Care Support Wiegert K. ADA Annual Conference, San Francisco 214 Provide Education and Guidance Goal Setting Encourage DSM techniques 1

2 Population Management The focus of the population management process is to proactively manage the health of each patient through a coordinated team effort Diabetes management: Improve quality outcomes Identify gaps in delivery of care Advance clinical processes using efficient utilization of resources Decrease avoidable episodic events with chronic conditions Improve access to health care services by providing PCMH and collaborative medical visits Standardize care processes for disease specific conditions Standardize Care Processes Murray D. ADA Annual Conference, San Francisco 214 Antihyperglycemic therapy in type 2 diabetes: general recommendations. Victor Montori, Shared Decision-Making 215 by American Diabetes Association Inzucchi S E et al. Dia Care 215;38: Video / Web Mullan et al Arch Intern Med 29 Considerations in Medication Choice Efficacy β cell function Hypoglycemia Risk Weight Side effects Cardiovascular Cost Can the Course of Type 2 Diabetes Be Altered? Glucose (mg/dl) Relative Function (%) Obesity IFG* Diabetes -cell Failure Postmeal Glucose Insulin Resistance Uncontrolled Hyperglycemia Fasting Glucose Years of Diabetes *IFG=impaired fasting glucose. Burger HG, Loriaux DL, Marshall JC, Melmed S, Odell WD, Potts JT, Jr., Rubenstein AH. 21. Diabetes Mellitus, Carbohydrate Metabolism, and Lipid Disorders. Chap. in Endocrinology. 4th ed. Edited by Leslie J. DeGroot and J. Larry Jameson. Vol. 1. Philadelphia: W.B. Saunders Co. Originally published in Type 2 Diabetes BASICS. (Minneapolis, International Diabetes Center, 2). 2

3 Beta-cell Function (%)* 2/24/215 1 Can The Decline Be Altered? UKPDS: Beta-cell Decline Over Time l l IGT Postprandial Type 2 Hyperglycemia Diabetes Phase I l -6 l l l -2 2 Years from Diagnosis Patients Treated with Metformin and/or Sulfonylureas (SUs) Type 2 Diabetes Phase II l 6 l 1 Type 2 Diabetes Phase III l 14 ADOPT: Treatment effect on primary outcome N = 4351 Cumulative incidence of monotherapy failure* (%) Hazard ratio (95% CI) Rosiglitazone vs metformin,.68 (.55.85), P <.1 Rosiglitazone vs glyburide,.37 (.3.45), P < Years Glyburide Metformin Rosiglitazone *Time to FPG >18mg/dL Kahn SE et al. N Engl J Med. 26;355: Insulin sensitivity (%) 4 ADOPT: Treatment effect on insulin sensitivity and β-cell function Treatment difference* (95% CI) Rosiglitazone vs metformin 12.6 (8.1 to 17.3), P <.1 Rosiglitazone vs glyburide 41.2 (35.2 to 47.4), P < Years *At 4 years Homeostasis model assessment (HOMA 2) 1 Rosiglitazone Cell function (%) 7 Metformin 6 Glyburide 1 2 Years Treatment difference* (95% CI) Rosiglitazone vs metformin 5.8 (1.9 to 9.8), P =.3 Rosiglitazone vs glyburide -.8 (-4.7 to 3.1), P =.67 Kahn SE et al. N Engl J Med. 26;355: UKPDS Newly diagnosed type 2 diabetes; intensive versus conventional policy; primary report published September 1998 Follow-up observation published October 28 Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 28;359: Post-Trial Changes in A1C MI Hazard Ratio Fatal or Non-Fatal MI or Sudden Death) Intensive (Sulfonylurea/Insulin) Versus Conventional Glucose Control UKPDS results presented Mean (95%CI) HR (95%CI) Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 28;359: Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 28;359:

4 Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE) Metformin 1-2 mg daily HbA1c % Duration < 1 years Randomize: Glimepiride (SU) N = 15 Sitagliptin (DPP-4 inhibitor) N = 15 Liraglutide GLP-1 agonist N = 15 Glargine insulin N = 15 Follow-up over 7 years Figure 3 Getting to insulin Overcoming psychological insulin resistance Patient Provider Overcoming therapeutic inertia Insulin initiation Insulin titration Basal Insulin Glargine vs. NPH Starting dose Combination with oral hypoglycemic drugs Titration The Treat-to-Target Trial Riddle MC, et al. Diabetes Care 23;26:38-86 Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 23; 26: 38-6 Randomized addition of or human insulin to oral therapy of type 2 diabetic patients 4

5 Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 23; 26: 38-6 Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 23; 26: 38-6 Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 23 Hypoglycemia: Events per patient per year All Symptomatic Events Confirmed 72 mg/dl Confirmed 56 mg/dl Glargine Initiating insulin Typically begin at low dose In more severely hyperglycemic.1-.2 units/kg/day.3-.4 units/kg/day NPH Clinical Case 89 y.o. gentleman has had acceptable glycemic control until recently, on metformin 1 mg BID and glipizide ER 5 mg daily. S. creatinine 1.12 (egfr 58 ml/min/1.73m 2 ) Lately, he has had higher glucose readings overnight, with bedtime BGs in 2-26 mg/dl range. He admits to having desserts at night. Nocturia every 2 hours S. creatinine increased to 1.3 (egfr 48 ml/min/1.73m 2 ) His nephrologist tells him this is due to dehydration, and advises him to drink more water Multiple Chronic Medical Conditions Your advice? Stop eating dessert Drink more fluids Stop metformin Start insulin 5

6 Health Services Models Team approaches have been shown to improve quality of care and outcomes of patients with: Depression Diabetes Asthma Hypertension CHF Medicare Patients Multiple morbidity is the norm: 8% of those with CHF 71% of those with Depression 56% of the with Diabetes have 4+ Chronic Conditions Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 214 Health Services Modes for Natural Clusters of Illness AHRQ Multiple Chronic Conditions (MCC) project Diabetes Depression HTN CAD American Diabetes Assn. Annual Scientific Sessions, Chicago, June 22, % of Cohort has a Behavioral Health Disorder MCC Behavioral Health Group Number Distinct Members No BH 32,272 SA Only 1,61 MH Only SMI 5163 MH Only non-smi 12,2 Dual (MH and SA) 7,861 MR/DD/TBI 4,233 OVERALL TOTAL 63,141 AHRQ MCC project, presented at Am Diabetes Assn, June % 4 or More Chronic Conditions Factors predicting developing complications: Persons with uncomplicated diabetes at baseline 91% Mental Illness and Substance Abuse 8% 8% Serious Mental Illness Percent more likely 77% Decline in Mental Increased Health Fragmented Care 52% Non-Serious Mental Illness Selected statistically significant independent variables in regression 48% 3 Chronic Conditions Improved Continuity of Care -8% Improved Mental Health AHRQ MCC project, presented at American Diabetes Association, June % 6

7 Clinical Vignettes 1.) Schizophrenic patient hearing voices that were telling him that starting insulin would cause cancer. CDE had to also provide education to the voices to correct misinformation so patient would feel comfortable starting insulin. 2.) Another patient with type 1 and thought disorder felt Novolog and Humalog caused his hair to smell like broccoli; CDE able to patiently work with him to restart analog insulin based on discussion that doing so would improve running/biking times (no ketones=faster times) creativity at it s best. Meet people where they are. To address lack of treatment intensification Study: 161,697 patients (Kaiser Permanente) HbA1c > 7% Systolic BP > 13 LDL > 1 3.) When new patient referrals are triaged and it is determined that they will likely need to start insulin or transition to MDI, they are scheduled with CDE immediately following MD appointment to reduce barriers for doing so (strike while the iron is hot). Provider updates CDE on plan and off we go. F/U with CDE can be more frequent to ease transition, answer questions, make insulin adjustments prn. 4.) Otherwise, we accommodate pts as best we can at time of appointment when insulin or other injectable is unexpectedly needed rather than having them return (or cancel/no show) on a different day to do so. Clinical Inertia 3-47% lacked treatment intensification by healthcare team 2-23% Adequate adherence Poor adherence Schmittdiel et al. J Gen Intern Med 28;23(5): Literature Review Collaborative Care Problems with patients: providers Poor collaboration Non-adherence Missed appointments Dissatisfaction with care Do-it-alone approach Poor self-care Stress, anxiety and depression PCP Patient Care Manager Psychiatric and Medical Case Review Ciechanowski PS. ADA, San Francisco 214 Multi-Condition Collaborative Care Program goals: Improve depression care Behavioral activation Antidepressants Improve medical disease control A (A1c) B (Blood Pressure) C (LDL-Cholesterol) D (Depression) Improve self-care Diet, exercise Smoking cessation Glucose monitoring Ciechanowski PS. Am Diabetes Assn Annual Conference, San Francisco 214 Identify Goals Multi-Condition Collaborative Care Core Components Support Self-care Monitor Progress Treat-to- Target Systematic Case Review Care Coordination 7

8 Multi-Condition Collaborative Care Nurse training: Motivational interviewing/enhancement Problem solving Behavioral activation Antidepressants Treat-to-Target HbA1c Blood Pressure LDL Multi-Condition Collaborative Care Treat-to-Target: Treatment titration Frequent and consistent Relentless, incremental increases/changes Always Increase/change to next step If not, document why not! Treat-to-Target Algorithm Simplified and uniform approaches across conditions to achieve targets Riddle, Diabetes Care 23 Kaiser Permanente, Care Management Institute Approach to starting and adjusting insulin in type 2 diabetes. Pre-mixed insulins Inzucchi S E et al. Dia Care 215;38: by American Diabetes Association Insulin Glargine Plus OADs vs Twice-Daily Pre-Mixed Insulin Treatment Regimen Target: FPG 1 mg/dl Subjects (n = 364) were randomized to: 9 8 Superior HbA1c Reduction With Glargine Plus OADs vs Twice-Daily Pre-Mixed Insulin Change in A1C From Baseline to Study Endpoint P< Baseline 24 week OADs* Insulin glargine once daily + continued OADs A1c Pre-mixed insulin 7/3 BID 6 Time (wk) 24 Baseline Endpoint *Sulfonylurea +metformin OAD=oral anti-diabetic drug Janka HU et al. Presented at: American Diabetes Association 64th Scientific Sessions; June 4-8, 24; Orlando, FL; Abstract 548-P; Study Insulin Glargine + OAD Pre-mixed Janka HU, et al. Diabetes Care. 25;28:

9 Less Hypoglycemia With Glargine Plus OADs vs Twice-daily Premixed Insulin Documented Hypoglycemic Episodes Per Patient-Year P<.1 Three-year efficacy of complex insulin regimens in Type 2 Diabetes Holman RR, et al. N Engl J Med 29;361: # of Episodes 6 Per Patient-Year Insulin Glargine + OAD 9.9 Premixed Treating to Target in Type 2 Diabetes ( 4-T ) Suboptimal HbA1c while taking metformin and sulfonylurea Randomly assigned to receive biphasic insulin b.i.d., prandial aspart t.i.d., or basal detemir once daily (or b.i.d. as needed) Target BG: ac mg/dl, and 2-h pc mg/dl Average dose = 28.2 IU with G + OAD vs 64.5 IU with premixed insulin Weight Gain: 1.4 ± 3.4 kg with G + OAD vs 2.1 ± 4.2 kg with pre mixed insulin Janka HU, et al. Diabetes Care. 25;28: Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med 29; 361: Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med 29; 361: Basal insulin: titration Glargine dose can be increased every 5-7 days based on SMBG At doses above ~ 5 units daily, it may be more effective to split the dose into twice daily injections Doses above 1 unit/kg/day are unlikely to offer additional benefit, and addition of prandial insulin should be considered Basal to Basal Plus 1 A strategy of adding bolus insulin to an existing basal insulin regimen in a stepwise manner Add a single daily bolus injection with the largest meal of the day Add further bolus injections at additional meal(s) if necessary Rosenstock J et al. The CADRE Handbook of Diabetes Management. New York, NY: Medical Information Press; 24:

10 Starting Basal/Bolus Therapy Starting insulin dose is based on weight.2 x wgt. in lbs. or.5 x wgt. in kg Bolus dose (aspart/lispro) = 2% of starting dose at each meal Basal dose (glargine/nph) = 4% of starting dose at bedtime 1