Transcript Workable Strategies for Implementing Best Practice

Diabetes Care for High Risk
Populations:
Lessons from a Community Based
Program
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Software Screen
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Today’s Speakers
Marie Laboissonniere RN Med CDOE CVDOE
and
Susanne Campbell RN MS
St Joseph Center for Health and Human
Services
Providence, RI
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Learning Objectives
Participants will be able to:
•Describe resources available that enable
uninsured/vulnerable patients to obtain medications,
supplies and material support needed to work toward
positive treatment options.
•Identify strategies to maximize internal/external
resources to provide patients with nutritional, mental
health and additional chronic care services.
•Identify educational and peer support opportunities
to engage patients in taking a significant role in
managing their own care.
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The Diabetes Resource Center (DRC)
Established in 1991 to meet the needs of people
with diabetes who:
• Have limited or no resources
• Are under – or uninsured
Have diabetes-related needs for :
• Medications
• Accessing primary care, specialty care, mental
health and case management services
• Diabetes education
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Primary Goals
Patients will be able to manage their condition and
improve clinical outcomes through access to :
• Primary Care
• Podiatry, Ophthalmology
• Medications
• Diabetes Supplies
• Mental health and case management
• Nutritional services
• Individual and group education
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Main Partners
• Rhode Island Dept of Health Chronic Care Collaborative
(Diabetes and CVD)
• Colleges and Universities (student interns for pharmacy,
nutrition, nursing, medical assistants);
• Funders (Blue Cross/Blue Shield, Rhode Island
Foundation, Churches . Private Charities)
• Systemetrics (Pharmacy Assistance Software)
• Drug companies
• CMS-contracted QI Organization (Quality Partners
• Private physicians that donate time
• Volunteers (registry data entry, patient follow up)
• Peer Navigator (Rhode Island Parent Information
Network)
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Challenges
• Growing number of uninsured patients
• Employing professional staff that speak Spanish
(RD, Social Worker, RN)
• Less grant funding opportunity with downturn in
economy
• Place to come for “free care”
• Free standing registry
• Patient engagement and follow through
• Reimbursement for services
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Changes : Reduce Expenses,
Improve Efficiency
• Integrated the DRC into the Adult Primary Care
Program
• Implemented group diabetes classes (including
mental health )
• Implemented peer support group
• Implemented small group education
• Automated the Pharmacy Assistance Program
(PAP)
• Coordinated purchased supplies with PAP
• Added Primary Care model requirement to
access other support services
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Changes: Team
Expansion/Integration
• Co-located and integrated mental health
• Expanded team to include RD, social worker,
Clinical Nurse Specialist, and peer navigator
• Expanded relationship with Universities
• Expanded community partnerships (exercise,
tobacco cessation, nutrition)
• Expanded program to other chronic care
conditions
• Collaboration with acute care: Diabetes Center
for Excellence
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Changes: Reimbursement
• Became ADA certified site and State recognized
CDOE site
• Hiring RD who is can be reimbursed under
Medicare and Medicaid
• Becoming a Patient Center Medical Home:
Insurances paying more per member/month and
pay for performance
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What Patients Need
Medications/strips:
• Pharmacy Assistance Program : seeing 200
patients per month;
• Increasing need for grant funded insulin and
supplies
• Increased need for Pharmacy samples
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What Patients Need
Mental Health
• Resources for Basic Living Needs
• Treatment for anxiety and depression
• Peer support, particularly for Latino population
• Navigating the health care system
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What Patients Need
Access to Care
• When becoming uninsured
• When discharged from Hospital/ER
• Earlier identification of pre-diabetes and
diabetes
• Life Style Change Education, especially for
nutrition and managing conditions
• For management of chronic mental health
conditions and co-morbid conditions
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Strategies
Medications/strips
• Obtained grant through Rhode Island
Foundation to pilot bilingual Chronic Care
Support position
• Implemented Pharmacy Assistance Program
• Implemented Systemetics software
• Improved clinical outcomes (total cholesterol,
LDL levels and HbA1c)
• Reduced expenses for grant purchased
medication and supplies
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Strategies/Patient Resource
Information
• For information on Pharmacy Assistance software
(Systemetics) contact 888-593-1085 or
[email protected]
• For patients with insurance and high co pays, call Patient
Advocate Foundation Co-Pay Release at 1-866-5123861 (prompt “2” case management).
• Abbott and Roche offer glucose test strips, and meters
for people who qualify for their program.
• For Abbott products: Call 1-800-222-6885 or visit
www.abbottpatientassistancefoundation.org ;
• For Roche products: visit www.accuchek.com; and go to
patient assistance program
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Strategies: Mental Health
• Obtained funding from Blue Cross/Blue Shield of
RI for Project Access
• Blue Angel: Mission to integrate mental health
and medical services
• Hired a bi lingual LICSW and CNS
• Contracted with Psychologist for team support
and patient grand rounds
• 320 patients screened by staff at Point of Care
• Physician/patient discussion and referral for
case management, individual clinical
intervention, support group
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Strategies: Mental Health
• Integrated social worker into Diabetes Education
classes
• Implemented follow up peer support group
• 452 patients with diabetes screened at point of
care;
• 39% referred (60% Latino; 49% uninsured)
• 72% improvement in HbA1C after interventions
• 59% established self management goal
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Strategies : Nutrition
• University Partnerships: URI Nutrition Science
Program-student interns to obtain experience
counseling patients with diabetes at no cost to
patients
• Students providing educational resource packets
• Reduced RN CDOE staff and replacing with RD
• RI Neighborhood Pilot Project: referrals to St
Joe’s for medical, nutrition, education and
pharmacy assistance; referral to Neighborhood
partners for exercise, nutrition, social services
and support groups
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Eye/Podiatry
• Hospital Collaboration: MD volunteer as part of
staff privileges
• Once a month podiatry clinic
• Once a month eye clinic (including specialty
referral and treatment)
• Increased referrals at earlier identification at
“point of care” …take off socks, monofilament
testing
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Strategies/Education
• Obtained a grant from Rhode Island Foundation
to start diabetes education classes (on site and
off site)
• Followed at ADA application guidelines when
setting up program
• Obtained ADA recognition status for long term
sustainability
• Partnered with hospital staff to provide
Community Health Fair with over 200 people
attending
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Strategies/Education
• Small patient group instruction for common
skills-insulin injection and blood glucose
monitoring
• Large group instruction for comprehensive
diabetes education
• Telephone follow up to assess blood glucose
patterns and titrate insulin to achieve blood
glucose goals
• Follow up patient engagement to check on
coping skills
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Strategies/Staff Education
• Staff nurses to obtain CDOE certification, and
Tobacco Cessation Certification
• Nurses obtained CVD certification to expand
from Diabetic Resource Center to Chronic Care
Resource Center
• Partnered with Quality Partners for Chronic
Kidney Disease resource education
• Integrated standards of care into the clinical note
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Strategies/Limited Resources
• Drug companies: Education for staff, patients
and medication samples and strips; helped to
underwrite costs of health fair
• Workforce Volunteer Program (AHEC):
Placement of students and volunteer for career
exploration and work experience (registry
support, pharmacist student, medical assistant,
nutrition
• Peer Navigator Program: Provides staff who
can offer individual assistance for basic needs
• Churches and small foundations:
medication/strips
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Future Plans
• Obtain Level 1 Patient Medical Home
Status to position ourselves for better
reimbursement
• Electronic Medical Record
• Expand to Pre-Diabetes
• Shared Medical Visit Pilot
• Shared Nutrition Visits
• Group follow up after CDOE classes
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Future Plans
• Through a Block grant, working with community
groups to work on access to fresh fruits and
vegetables in community markets and policy
changes to address social determinants of
health
• Working with SNAP program to offer on site
Food Stamp application assistance
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Questions / Discussion
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Have additional questions?
Please contact us at [email protected]
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