Panel I: Special Focus 2014 Diabetes, Depression, & Distress. February 25, :15 am 2:10 pm

Transcription

1 Panel I: Special Focus 2014 Diabetes, Depression, & Distress February 25, :15 am 2:10 pm

2 COMRADE: Collaborative Care Management for Distress and Depression in Rural Diabetes Doyle M. Cummings, Pharm.D. for the COMRADE Care Team East Carolina University, Greenville, NC

3 East Carolina University, Brody School of Medicine & Health Sciences Division University Partners Health Psychology Social Work Family Medicine Nutrition Sciences Endocrinology Community Partners Healthy Lives, Healthy Choices Lucille Gorham Intergenerational Center Rural primary care practices Community Health Centers Health Departments

4 Project Goals & Description 1. Evaluate a collaborative and stepped care intervention that is tailored to the severity of distress/depression and initial response. 2. To evaluate mediators of the relationship between improvement in psychological measures (distress/depression) and improvement in HbA1c. 3. To evaluate the business sustainability of the intervention in primary care settings with local community support. Medical Care Behavioral Care IMPROVED OUTCOMES

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6 Nurse Care Manager (RN-CM) + CHW Integrated Care Model Behavioral Medical/Pharmacologic 1 Self-management Lifestyle, SMALL changes RN-CM RN-CM 1 Maintain current pharmacologic regimen 2 Self-management Problem-solving Therapy for Primary Care RN-CM PCP 2 Oral /injectable glucose-lowering Rx 3 Cognitive behavioral therapy RN-CM, Psych PCP, PharmD 3 Advancing doses Add on additional Rx Anti-depressant Rx 4 Refer to Psychiatry RN-CM, Psych, Psychiatry PCP, Pharm D, specialist 4 Pursue consultation with Psychiatry or Endocrinology

7 Evaluation & Sustainability Indicators/Target Body Mass Index (BMI) Glucose and HbA1c Blood pressure Depression 43 Diabetes Distress 44 Source/measurement method Equation with weight and height TelCare monitor and DCA Vantage Measured twice in sitting position PHQ-2 (screener); PHQ-9 DDS-2 (screener); DDS-17 Self-care activities 45 Diabetes Self-care Activities (SDSCA) Self-efficacy 46 Diabetes Empowerment Scale Subjective wellbeing 47 Satisfaction With Life Scale (SWLS) Functional Capacity 48 Duke Activity Status Index (DASI) Social Support Med adherence 49 Health Literacy Costs: QALYs Modified Dunst Support Scale Morisky Modified Med Adherence (MMAS) New Vital Sign Direct/indirect costs/hrqol/euroqol-5d Sustainability Improved reimbursement under bundled payment systems Cost-based reimbursement in rural FQHC sites Incident to billing for services provided by nonphysician providers Contractual reimbursement for reduced ER/hospital utilization Sharing costs across multiple providers and sites Leveraging communitybased support and funding.

8 Current Status Project Coordinator hired; CHW identified; care manager being recruited IRB submitted Equipment quote procured Final protocol being developed Orientation with staff, practice, and community members planned

9 Enhancing Patient, Practice, and Community Capacity for Collaborative Diabetes, Depression, and Diabetes Distress Management Bethany M. Kwan, PhD, MSPH, Russell E. Glasgow, PhD, Bonnie T. Jortberg, PhD, RD, CDE, Donald E. Nease, Jr., MD, Alicyn Kaiser, PA-C, MMSc, Perry Dickinson, MD University of Colorado School of Medicine Metro Community Provider Network

10 Partnering Organizations University of Colorado School of Medicine (B. Kwan, R. Glasgow, B. Jortberg, D. Nease, P. Dickinson) Anschutz Medical Campus, Aurora, Colorado Department of Family Medicine and Colorado Health Outcomes Practice-Based Research Networks (PBRNs) Metro Community Provider Network (A. Kaiser) Metropolitan Denver area network of Federally Qualified Health Centers (FQHCs) Colorado Foundation for Public Health & Environment (S. Miller, I. Kane)

11 Project Goals & Description Improve self-management, mental and physical health, and the experience of health care for patients with diabetes and depression and/or diabetes distress by: Providing patient-centered, tailored 5As action planning Linking patients to appropriate practice and/or community-based resources Implement the program in a feasible, scalable, and sustainable manner and build upon existing capacity by engaging stakeholders in Boot Camp Translation

12 Integrated Care Model Depression Health Behavior Distress Assess, Advise + Agree Connection to Health automated assessment and counseling to help patients with setting goals and action plans CR BHP DE PCP Assist + Arrange Practice-tailored mechanism to identify and link patients with appropriate practice and/or community resources (e.g., warm hand-off, referral) BHP: behavioral health provider; PCP: primary care provider; DE: diabetes educator; CR: community resource Resource Use and Experience Tracking + Feedback System for tracking patient use and experience with selected resources

13 Evaluation & Sustainability Design and Evaluation Clustered randomized trial (pilot, feasibility) Staggered implementation in random selection of 4 of 8 MCPN practices, > patients/practice RE-AIM Multiple data sources: Database of administrative, clinical, claims and patient-reported outcomes data; patient surveys &interviews; practice surveys &interviews Sustainability Strategy & Tactics Boot Camp Translation: Longitudinal Relationships Leverage existing assets, aligning innovative workforce & payment models Demonstrating value and utility for multiple stakeholders

14 Boot Camp Translation (BCT) Community engagement methodology Build productive, sustainable relationships with the community to inform the design of the intervention Initial day-long intensive kick-off meeting Patients, providers, community resource representatives, medical/behavioral health experts and project team as facilitators Presentation of the evidence by experts in diabetes, depression, and self-management (level setting) Brainstorming and discussion by the group (consensus and planning) Series of 30-minute conference calls +1-2 in-person meetings Initial Kick-Off Event (4/11): Identifying the right resource for the right patient

15 Ongoing Diabetes Self-Management Support in Church-Based Settings Gretchen A. Piatt, MPH, PhD, Martha M. Funnell, MS, RN, CDE, Robin Nwankwo, RD, MPH, CDE, Mary Janevic, PhD, Kathy Balint, PhD University of Michigan Detroit Parish Nurse Network of Southeast Detroit, Inc

16 Background DSME is effective in the short-term Long term diabetes self-management support (DSMS) is needed Who, where, when, and how to provide effective, sustained DSMS? Limited access and availability of DSMS programs, especially for low-income African Americans

17 Partnering Organizations University of Michigan (UM) Department of Medical Education Recognized for work in psychosocial aspects of diabetes behavior change in African American communities Other UM Partners: UM School of Public Health Michigan Center for Diabetes Translational Research UM Institute for Clinical and Health Research (MICHR) Detroit Parish Nurse Network of Southeast Michigan, Inc (DPNN) Non-profit that serves the needs of the poor, elderly, uninsured and underinsured through advocacy and support of parish nurse ministries

18 Project Goals & Description Examine the relative effectiveness of parish nurse-led diabetes self-management support (DSMS) and peer leader-led DSMS compared to enhanced usual care within the context of the church-based setting. Implement DSMS in a feasible, scalable, and sustainable manner

19 Project Goals & Description Cont d T 0 T 1 T 2 T 3 9 African American Churches R A N D O M I Z A T I O N Parish Nurse Support (n=3 churches) Peer Leader Support (n=3 churches) Enhanced Usual Care (n=3 churches) Diabetes Self- Management Educa on Diabetes Self Management Educa on Diabetes Self Management Educa on Diabetes Self- Management Support Groups Diabetes Self- Management Support Groups Ongoing Support T 0 T 1 T 2 T 3 T 0 T 1 T 2 Ongoing Support T 3 Legend Figure 1. Study Diagram T 0 : Baseline T 1 : 3 Month Assessment T 2 : 9 Month Assessment T 3 : 15 Month Assessment

20 Partners Parish Churches Nurses Patients Peer Communities Leaders Outcomes/Effectiveness Short Term A1c Distress Depression Intermediate Short term + Medication adherence, dietary intake, physical activity Long Term Public Health Impact Population level sustained improvements in A1c and distress Equitable distribution of improvements across churches and participants Key Elements of Support Assist in Self- Management Provide Social and Emotional Support Link to Clinical Care Provide Ongoing Support Integrated Care Model for Diabetes Self-Management Support

21 Process Indicators Evaluation Effectively recruit, retain, and support parish nurses and peer leaders? Effectively reach African Americans with diabetes in metro- Detroit? Was the study implemented as planned? Outcome Indicators Sustained improvements in glycemic control and diabetesrelated distress and other clinical and patient-centered outcomes, including weight, blood pressure, quality of life, and diabetes social support compared to enhanced usual care at 3, 9, and 15 month follow-up?

22 Key Elements for Effective Sustainability Dissemination of findings and tools Organizational Infrastructure Integration into healthcare systems Program recognition and billing potential

23 Sustainability Strategies Dissemination of findings and tools Participants, African American churches, community organizations, policy makers, the national Church Health Center, the American Nursing Association, and academic and public audiences Tool kit includes (1) curriculum and manuals, (2) data collection instruments to allow for program eval, and (3) information on the functions staff members need to sustain improved outcomes Organizational Infrastructure identify, procure, and facilitate communication with community partner organizations, including churches.

24 Sustainability Strategies Cont d Integration into Health Care Systems Currently DPNN is integrated into 4 large health systems Peer leaders as members of the healthcare team through the Chronic Health Home Program Recognition and Billing Potential ADA or AADE program recognition Each congregation would fall under a health system that has recognition; thus offering DSMS as a stand alone service and the possibility of future billing

25 Thank you Gretchen A. Piatt, MPH, PhD

26 Integrated Behavioral Health Project Shelia McCann, MEd, SM, GPC Health Choice Network of Florida Diabetes, Depression & Distress

27 A Health Center-Controlled Network 26 Primary, mental, and behavioral community health centers in Florida serving 503,236 patients Mission: Strengthen our members and partners: High quality service, support, and expertise a vehicle for strategic efforts Services: Health Information Technology, Finance, Managed Care, Clinical Services Target Population: Under and Uninsured residents Partner: University of Miami, Miller School of Medicine

28 Project Goals & Description Federally Qualified Health Center - Integration of behavioral health services into enhanced diabetes care Eligibility: No primary care/behavioral health appointments kept in past 12 months Strategy: Community Patient Navigators engaging, linking, and motivating to care; Embedded specialists Goal: 250 patients completing 3 primary care and 4 behavioral health visits in a 12-month period

29 Integrated Care Model COMMUNITY PATIENT NAVIGATOR Re-engagement Linkage Navigation Facilitation Peer Support CARE MANAGEMENT MEDICAL HOME CENTER Motivational appointment reminders Coordination with FQHC FQHC-PLANNED CARE VISITS Embedded specialists Consultation screening Treatment planning Diabetes selfmanagement education

30 Evaluation & Sustainability Evaluation Measures: Appointment experience Diabetes health outcomes Self-management behaviors PHQ-9 measures, before & after Sustainability: Reimbursement Managed care Network-wide implementation

31 Where Are We? Analyzing patient lists and reaching out Planning patient focus groups March 2014 Developing informatics Modifying integrated primary and behavioral care communication flows