ENVIRONMENTAL SCAN CHANGES IN HEALTH CARE DELIVERY AND THE ROLE OF DIABETES EDUCATORS PRESENTER DISCLOSURE INFORMATION

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1 CHANGES IN HEALTH CARE DELIVERY AND THE ROLE OF DIABETES EDUCATORS Where are we and where do we go from here? Sandra Drozdz Burke, PhD, APRN, CDE, FAADE Clinical Associate Professor & Director UIC College of Nursing at Urbana Urbana, Illinois PRESENTER DISCLOSURE INFORMATION In compliance with the accrediting board policies, the American Diabetes Association requires the following disclosure to the participants: University of Illinois at Chicago College of Nursing Employer American Association of Diabetes Educators Immediate Past President and Board Member Janssen Pharmaceuticals Consultant Genentech Consultant ENVIRONMENTAL SCAN What we know 3

2 DIABETES PANDEMIC Worldw ide DIABETES CASES AND COSTS * People with diabetes 23.7 million 44.1 million Annual diabetes spending $113 billion $336 billion People with diabetes over age 65 years Annual diabetes spending among Medicare population 8.2 million 14.6 million $45 billion $171 billion * Projected costs Huang, ES et al. (2009). Diabetes Care, 32, US HEALTHCARE SPENDING 2011 spending is at $2.7 Trillion = 17.9% of GDP Personal Health Care spending rose Growth In US Health Spending Remained Slow in 2010; Health Share of Gross Domestic Product Was Unchanged from 2009, Health Affairs, 2012; 2013.

3 2007 COST OF DIABETES CARE Direct Costs = $116 Billion Indirect Costs = $58 Billion $174 Billion American Diabetes Association, 2009 WE VE COME A LONG WAY. Or Have we? 8 WHO S TEACHING THE DIABETIC? E T Z WILE R, Evaluated the knowledge base of healthcare providers Nursing students (seniors) 44% did not know they could not withhold insulin from T1 patients during periods of illness 55% did not consider a diabetic diet a healthy, well-balanced diet for the whole family Dietitians 42% did not understand the need to continue to take insulin during illness 43% did not think of the diabetic diet as an option for the entire family Primary Care Physicians Inconsistent practice patterns Diabetes teaching done in hospitals by poorly prepared HCP Education follow-up rarely done Recommendations Better provider preparation Importance of on-going patient education for self-care Etzwiler, D. (1967). Who s teaching the diabetic? Diabetes, 16;

4 ENTER THE SPECIALTY Healthcare professionals who focus on helping people with and at risk for diabetes and related conditions achieve behavior change goals which, in turn, leads to better clinical outcomes and improved health status. Diabetes educators apply in-depth knowledge and skills in the biological and social sciences, communication, counseling, and education to provide self-management education/self-management training THE CERTIFIED DIABETES EDUCATOR 73% Nurses and Dietitians 90% Female 86% Caucasian 82% BS or higher degree 50 years Average Age Outpatient *Hospital *Non-Hospital *Physician Office Practice Setting Zribiec, TDE NATIONAL DIABETES EDUCATION PRACTICE SURVEY: RN RD NP/CNS Pharmacist Other Program Coord. AADE (unpublished data, 2012); Martin et al, 2012; Martin et al, 2008; Peeples & Austin, 2007

5 AADE WORKFORCE DATA ( 2 011) ,000 Educators 54,000 Educators Number of Diabetes Educators Needed WORKFORCE STUDY PROJECTION 100,000 80,000 60,000 40,000 20,000 Supply Demand and Beyond SHORT SIDEBAR Framing the dialogue

6 County-Level Estimates of Diagnosed Diabetes Among Adults Aged 20 years Trends County-Level Estimates of Diagnosed Diabetes Among Adults Aged 20 Years United States 2004 Percentage > County-Level Estimates of Diagnosed Diabetes Among Adults Aged 20 years United States 2005 Percentage >

7 County-Level Estimates of Diagnosed Diabetes Among Adults Aged 20 years United States 2006 Percentage > County-Level Estimates of Diagnosed Diabetes Among Adults Aged 20 Years United States 2007 Percentage > County-Level Estimates of Diagnosed Diabetes Among Adults Aged 20 Years United States 2008 Percentage >

8 County-Level Estimates of Diagnosed Diabetes Among Adults Aged 20 Years United States 2009 Percentage > WHERE IS THE EDUCATOR? Geographic Locations California Texas New York Pennsylvania Ohio Practice Settings Outpatient/Managed Care (39%) Clinical Inpatient (16%) Community Based (13%) Private or Physician Practice (11%) Other (12%) Martin, Lumber, Compton et al., TDE, POINTS OF CONCERN Profession % increase Dietitians 60,300 65,800 9% Pharmacists 269, ,800 17% Physicians 661, ,500 22% RNs 2,600,000 3,200,200 22% 24

9 CURRENT PRACTICE PATTERNS AND IDENTIFIED EDUCATIONAL NEEDS OF HCP. Aim: to gain a better understanding of practice patterns and educational gaps among (a select group of) providers Stratified National Sample Relatively high response rate(n = 974) * ADA (AACE) Guidelines WILLIA MSON E T A L, Provider Type MD: Internal Medicine MD: Family Practice Practice Guidelines* 34% (30%) 33% (19%) MD: Endocrinology 70% (65%) Nurse Practitioner 38% (26%) Physician Assistant 34% (23%) Pharmacist: Retail 8% (7%) Pharmacist: In-Pt. 8% (7%) CDE 71% (65%) Williamson, JC, Glauser, TA, Holder-Nevins, P, Schneider, D, Kruger, DF, Urquhart, BS, Whitfield, SF, & Dubois, AM. (2013). Clinical Diabetes, 31: 3 9. COMFORT LEVELS WITH TREATMENT REGIMENS Primary Care Providers Retail Pharmacists CDEs Basal Bolus 64% 40% 97% NPH alone 48% 43% 73% Long Acting Insulin 75% 55% 97% Fixed Mix Insulin 54% 39% 67% Analog Insulin 53% 40% 68% 50% of PCP reported they would refer to CDE for following conditions: 1. Complexity with diet associated with related conditions (most likely). 2. At diagnosis 3. When carbohydrate counting is needed 4. Difficulty with weight loss 5. Initiation of an injectable therapy (least likely) Williamson, JC, Glauser, TA, Holder-Nevins, P, Schneider, D, Kruger, DF, Urquhart, BS, Whitfield, SF, & Dubois, AM. (2013). Clinical Diabetes, 31: HEDIS INDICATORS 1. BMI assessment ranged from % 2. Influenza vaccination is ~52% (50 64 year olds) and ~68% in older adults 3. Smoking cessation strategy ~50% (counseling or medication 4. Comprehensive Diabetes Care 1. BP < 130/80: 38 48% 2. Eye Exams: 48 68% 3. A1c screening: 82 90% 1. A1c < 7%: 35 42% 2. A1c < 8%: 48 65% 3. A1C > 9%: 26 43% 4. LDL Screening: 75 88% 1. LDL < 100: 35 52% 5. Nephropathy monitoring: 78 90%

10 ADDITIONAL MEASURES PERTINENT TO DIABETES PATIENTS 1. Antidepressant Medication Management 2. Annual Monitoring for patients on long-term medications 3. Monitoring for patients using diuretics 4. Weight Assessment and counseling for children and adolescents 5. Older Adults 1. Physical Activity 2. Pneumococcal vaccination 3. Glaucoma Screening 4. Fall Risk Management 6. Preventing hospital readmission DIABETES EDUCATION Defining Quality PREMISES 1. Most patients with diabetes do not see endocrinologists 2. Patients with diabetes are responsible for 99% of their own care 3. Prevailing care models don t address chronic care needs 4. Information exchange Education 5. Knowledge Behavior Change 30

11 THE 8 12 MINUTE ENCOUNTER History and Physical Exam Medication Reconciliation Review of Blood Glucose Records Discussion of lab results Symptom management Self-management education????? Healthy Eating, Being Active, Taking Medications, Monitoring, Problem Solving, Reducing Risks, Healthy Coping 31 DIABETES EDUCATION The formal process through which persons with or at risk for diabetes develop and use the knowledge and skill required to reach their self-defined diabetes goals AADE, (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators. 32 THE PATHWAY OF DIABETES EDUCATION

12 DE IS EFFECTIVE IN HELPING CONTROL ILLNESS AND MAXIMIZE HEALTH Self care behaviors that impact Diabetes Hypertension Hyperlipidemia Obesity Multiple other chronic conditions 34 THE DIABETES EDUCATOR Definition Level 1 Non-professional healthcare provider; no clinical background per se; works with persons with diabetes in supportive and/or supervised environments. Level 2 Level 3 Level 4 Level 5 Healthcare professionals who care for those with diabetes; No specialized training in diabetes disease management Healthcare professionals with core knowledge and skills in diabetes education or management who are not credentialed in diabetes education or management. Meets academic, experiential and professional requirements established by NCBDE; The CDE demonstrates competency through written examination. Those with significant experience and advanced skills in delivery of diabetes education/management, e.g., BC-ADM AADE guidelines and competencies available at 35 HEALTHCARE REFORM WHERE ARE WE GOING? 36

13 In response to increasing growth in health care spending, public and private health care purchasers are introducing new payment models to promote higher-value care in the U.S. health care system. Traditional fee-for-service payment methodologies pay providers for each health care service delivered, regardless of efficiency. The fee-forservice system encourages higher-acuity specialty utilization to the exclusion of other critical health system activities such as care coordination or care collaboration. Thus, the fee-for-service payment model contributes to a fragmented health care delivery system resulting in duplicative care, preventable utilization, escalation of care to higher-acuity settings, and ultimately, poorer patient outcomes. (Chas Roades, Health A f fairs B log, 2/15/13) ACCOUNTABLE CARE ORGANIZATIONS Copyright at DGA Partners PATIENT CENTERED MEDICAL HOME Patient Centered, Coordinated, Accessible, Comprehensive care

14 CLOSING THE GAP 2012 HEDIS REPORT Unfortunately, we understand very little about how to motivate patients to adopt positive health behaviors. Many people do not understand basic health care language and are mystified by insurance benefit design. Faced with a daunting to do list, they have no idea where to begin. Nor do we effectively communicate the benefits and harms of treatments, or encourage consumers and their families to be active partners in treatment decisions. (p. 25) DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT Traditional settings Hospital clinics Clinician offices Community settings Community centers Faith-based institutions Libraries Daily activity settings Employee workplaces School sites 42

15 SELECTED HEALTHY PEOPLE 2020 GOALS 1. Improve glycemic control among persons with diabetes 2. Increase the proportion of the diabetes population with an A1C value <7% 3. Improve lipid control in persons with diabetes 4. Improve BP control in persons with diabetes 5. Ensure that persons with diabetes receive annual foot exam 6. Increase frequency of A1C testing 7. Increase number of persons with diabetes who receive of formal diabetes education Dietitians Primary care Physicians Physician Specialists Nurses COORDINATED CARE Mental Health Providers Home Care Providers Pharmacists Person with Diabetes Community Health Workers Diabetes Education Specialists Nurse Practitioners Physician Assistants Clinical Nurse Specialists Successful Self- Management Medication reconciliation Preventable hospital readmissions Preventable emergency depar tment visits If you re going to dream, Dream BIG

16 ALTGELD HALL, UNIVERSIT Y OF ILLINOIS Knowing is not enough; we must apply. Willing is not enough; we must do. - Goethe Photo by Larry Kanfer 46