May 9, FaithAnn Amond, RN Navigator Care Central Ellis Medicine

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1 A Systems Approach to Diabetes Care Hospital to Home. Improving Care Transitions and Outcomes Helen Hayes Hospital West Haverstraw, NY James Desemone, MD Director of Medical Staff Quality Diabetes and Endocrinology Ellis Medicine FaithAnn Amond, RN Navigator Care Central Ellis Medicine May 9, 2013 Dr. Desemone and Ms. Amond have no financial disclosures nor conflicts of interest 41 yo man Ketosis-Prone Type 1 Diabetes for 9 years cc: unable to move left side of his body arrival by EMS (girlfriend called 911) Meds: detemir 70 units at hs aspart 30 units with meals pioglitazone 30 mg daily Diabetes HPI: No eye, kidney or foot complications Never had a severe hypoglycemic reaction Smoking: age 13, 1 PPD 1

2 41 yo man Ketosis-Prone Type 1 Diabetes for 9 years PMH MVA 1993 w/ traumatic brain injury, knee damage and lumbar spine injury Physical Exam 196#, BMI 27.12, P-64, BP 102/66, R-16 Moving all 4 extremities Lab HbA1c 10.1% Admitting Dx: TIA 41 yo man Ketosis-Prone Type 1 Diabetes for 9 years Discharged HD #3. detemir 24 units HS aspart 7 units with meals Dx Left hemiparesis due to conversion disorder 41 yo man Ketosis-Prone Type 1 Diabetes for 9 years 3 days after discharge: ED visit cc: left leg pain MRI: DJD of spine, moderate spinal stenosis Discharged home 2

3 A System Approach to Diabetes Care By attending this conference, the participant should be able to: 1. Name three components of a community health system. 2. Explain how diabetes education reduces the cost of care 3. Name the percentage of patients with diabetes that physicians refer to diabetes education Hospital Readmissions CHF COPD Pneumonia AMI Hospital Readmissions What about Diabetes? Keeps a low profile Frequently a secondary diagnosis 3

4 NYS 30d Readmission Rates, 2008 Healthcare Association of New York State, July 2010 Estimated Adult Diabetes Prevalence in NYS, Healthcare Association of New York State, December 2011 Percentage of NYS Admissions with Diabetes as 1 o or 2 o Dx Healthcare Association of New York State, July

5 Community Health Alliance Patients Hospital Pi Primary Care AND Medical Homes safetynethospital.blogspot.com Community Health Alliance Patients Hospital Health Home Pi Primary Care AND Medical Homes 5

6 Community Health Alliance Patients Hospital Care Coordinator/Navigator Acute Care Interventional Team Community Health Workers Case Management Chronic Care Intervention Team Health Home Pi Primary Care AND Medical Homes Social and Community Services Coordination across the Continuum through Communication Where Does Diabetes Fit In? 6

7 What We Want Safe, High Quality Clinical Care Cost Savings Hospital Costs Account for Majority of Total Costs of Diabetes Per Capita Health Care Expenditures (2002) rs Dollar Inpatient Nursing Home Physician s Office Outpatient Prescription Insulin and Supplies Diabetes Without Diabetes Hogan P, et al. Diabetes Care. 2003;26: Reducing Readmissions Improved Diabetes Treatment by the Provider? Referral to a Diabetes Self- Management Training and Education (DSMT/E) Program? 7

8 Assessing the Value of Diabetes Education 2005, 2006, 2007 Insurance Commercial or Medicare Purpose: Evaluate the impact of Diabetes Self- Management Training and Education (DSMT/E) on the cost of care Number of Patients with Diabetes Who Received Education 8

9 Preliminary Conclusion The CARE with DSMT/E is better. 9

10 Assessing the Value of Diabetes Education, 2008 Cost Commercially Insured Group Per Member Per Month (PMPM) $940 $920 $ $880 $ $ $820 $800 0 Visits 1 Visit >2 Visits Tucker ME. Hospitalist News Digital Network, $100 $80 $60 Assessing the Value of Diabetes Education, 2008 Medication Cost Commercially Insured Group Per Member Per Month (PMPM) $40 $20 $0 0 Visits 1 Visit >2 Visits Tucker ME. Hospitalist News Digital Network, Assessing the Value of Diabetes Education, 2008 Hospital Admissions Commercially Insured Group Admissions per 1000 members Visits 1 Visit >2 Visits Tucker ME. Hospitalist News Digital Network,

11 The Impact of Diabetes Education Conclusions 1. Reduction in cost of care was driven by reducing admissions Two or more DSMT/E sessions per year is better than 0 or 1 sessions per year 2. DSMT/E Physicians refer to DSMT/E infrequently Patients of physicians who refer to DSMT/E receive better care Reducing (Re)Admissions for People with Diabetes Certified Diabetes Educators Community Health Alliance Patients Hospital Care Coordinator/Navigator Acute Care Interventional Team Community Health Workers Case Management Chronic Care Intervention Team Health Home Pi Primary Care AND Medical Homes Social and Community Services 11

12 41 yo man Ketosis-Prone Type 1 Diabetes for 9 years Discharged HD #3. detemir 24 units HS aspart 7 units with meals Dx Left hemiparesis due to conversion disorder Coordination across the Continuum through Communication 12

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