The New Complex Patient. of Diabetes Clinical Programming

Transcription

1 The New Complex Patient as Seen Through the Lens of Diabetes Clinical Programming 1 Valerie Garrett, M.D. Medical Director, Diabetes Center at Mission Health System Nov 6, 2014

2 Diabetes Health Burden High Morbidity Macrovascular complications (ischemic heart disease, stroke) Microvascular complications (retinopathy, nephropathy, neuropathy) Leading cause non traumatic amputation, blindness High prevalence depression Frequent hospitalization 7 th leading cause of death National Surveillance Data, Centers for Disease Control and Prevention

3 Diabetes Prevalence by Age National Surveillance Data, Centers for Disease Control and Prevention

4 Diabetes Economic Burden Update Indirect costs: $69 billion Lost productive capacity, absenteeism, early mortality 88% incurred by population under 65 years age Direct medical cost: $176 billion 13% of health care dollars spent directly attributable to diabetes Medical expenditures 2.3 times higher than if no diabetes 59% spent on population 65 years and older Economic costs of Diabetes in the U.S. in 2012, American Diabetes Association

5 Direct Medical Cost 8% Residential facility 9% Physician office visits 12% Diabetes medications and supplies 18% Medications for complications 43% Hospital inpatient care Economic costs of Diabetes in the U.S. in 2012, American Diabetes Association

6 Changing the Focus, Changing the Locus Diabetes Complications: Risk Reduction Comprehensive disease treatment reduces complications and mortality Multicomponent, team based chronic care model effective strategy for long term benefit Diabetes: Disease Prevention Early medical therapy, intensive lifestyle change yields sustained reduction in risk progression Emerging awareness need for balance between burden of disease with burden of treatment Shared decision making foundation for patient engagement Management of Hyperglycemia in Type 2 Diabetes, A Patient Centered Approach American Diabetes Association & European Association for Study of Diabetes, 2012

7 Mission Health System 730 bed regional referral center in Asheville NC 5 community hospitals in rural western NC counties Population 1 million Highest proportion government payer mix among NC peers Accountable Care Organization application for Jan 2015 launch

8 Regional Population 19% aged 65 years and older 24% uninsured 63% obese or overweight 13% diabetes 2012 Regional Assessment, WNC Healthy Impact

9 Inpatient Diabetes at Mission Hospital 27% prevalence 20% longer length of stay 15 25% higher cost of care

10 Health Care Delivery Network Inpatient Emergent Inpatient Skilled Facility Home Home Health Clinic Hospice Acute Care Centric Management Population Centric Management

11 Mission Health System: Infrastructure for Integrated Diabetes Care Delivery Enterprise data warehouse under development Electronic medical record early stages integration Care management in few ambulatory care settings Diabetes care unstandardized and fragmented Community based organization (CBO) diabetes initiatives not well aligned with health system goals

12 Diabetes Clinical Programming Evidence based best practice care pathways Provider professional development Clinical decision support Patient engagement models Process and outcome measures Care Process Model Ambulatory Care Acute Care Post Acute Care

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14 Ambulatory Care Redesign: Diabetes Center Talented team of certified diabetes educators and disease management health coaches Increasing diabetes incidence Declining referrals/attendance Re establish value of formal self management skill training 3,000 2,500 2,000 1,500 1, Diabetes Education Attendance Diabetes Initial Visit 1/2 hrs Diabetes Group Class 1/2 hrs Ambulatory Care Acute Care Post Acute Care

15 Diabetes Education: Customized Programming with Health Coaching Emphasis Initial Health Coach Visit High Intensity Track Comprehensive Diabetes Education Medium Intensity Track Nutrition Focus For Healthy Living Low Intensity Track Nutrition Refresher With Distance Coaching 5 Group Classes 1 Nutritionist Visit 2 Nutritionist Visits 1 Nutritionist Visit 1 Phone Coaching Session Ambulatory Care Acute Care Post Acute Care

16 Diabetes Education: Customized Programming with Health Coaching Emphasis Outcomes Medium and high intensity tracks most popular 71% increase in group class attendance Average A1C reduction 1.7% No significant weight loss < 50% completion rate Future Work Test impact site expansion and care management Examine self selection Explore barriers participation Ambulatory Care Acute Care Post Acute Care Diabetes Education Attendance FY 2014 Launch Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Initial Health Coaching 1/2 hrs Diabetes Group Class 1/2 hrs

17 Acute Care: Advanced Practitioner Diabetes Team Background Endocrinologists unable to meet inpatient specialty service diabetes care needs, long waits for new outpatient referrals RCT funded by Department of Defense Compared centralized diabetes management by advanced practitioners supervised by hospitalists to usual care Showed improved glucose control in surgical and medical subspecialty groups Goals Improve inpatient glucose control Reduce endocrinologist time away from practice Provide safe transition of care with enhanced discharge management plan Consult mechanism Automated per protocol for cardiovascular surgery patients Practice alert through clinical decision support in EMR for surgical patients Provider initiative Ambulatory Care Acute Care Post Acute Care

18 Acute Care: Advanced Practitioner Diabetes Team Cardiovascular surgery: Equivalent glucose control Reduced time to discharge last hospital day by median 1.8 hours Reduced endocrinologist inpatient service volume by 40 50% Surgery service line: Reduced patient 2 day weighted mean CBG from 172 to 156 mg/dl Coincident 40% reduction spinal surgery surgical site infections Future work: Expand team role in surgical pre admission and post discharge care Measure intermediate glucose control outcomes after discharge Explore endocrinology practice priorities for expedited referral Ambulatory Care Acute Care Post Acute Care

19 Diabetes Clinical Programming Priorities Implement care process models for comprehensive diabetes care throughout health system Test patient engagement models that incorporate activation and behavioral health assessments Develop provider education platform for diabetes medical therapy Engage CBOs to align to enhance healthy behaviors and supportive social network Ambulatory Care Acute Care Post Acute Care

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