Transcript What is Diabetes - Cardiovascular and Diabetes Coalition of Indiana

CMS QIN-QIO Cardiac Health & Everyone
With Diabetes Counts Overview
Don Gettinger
Sharon Barclay
Objective
Provide an overview of the goals of the Centers for Medicare & Medicaid Services
(CMS) Quality Innovation Network-Quality Improvement Organization (QIN-QIO)
11th Scope of Work (SoW) and Everyone With Diabetes Counts (EDC) initiative
including what diabetes educators need to know to become involved in improving
outcomes for those with or at risk for diabetes.
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Restructuring
Began exciting new, multi-state 5-year contract:
• August 1, 2014 - July 31, 2019
Beneficiary and Family Centered Care (BFCC)-QIOs
• #2 nationwide - Case Review and Monitoring
• www.keproqio.com
Quality Innovation Network (QIN)-QIOs
• #14 nationwide - Quality Improvement (QI) Activities
• www.atomAlliance.org
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atom Alliance
Multi-state alliance for powerful change composed of three nonprofit, healthcare QI
consulting companies.
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CMS 11th SoW Task Overview
Goals
• Improve Cardiac Health
• Reduce Disparities in Diabetic Care
• Improve Prevention Coordination through Meaningful Use (MU) of Health
Information Technology (HIT)
• Collaborate with Regional Extension Centers (RECs)
• Reduce Healthcare Associated Infections (HAIs)
• Improve Mobility and Decrease Healthcare Acquired Conditions in Nursing
Homes
• Continue and Create Coordination of Care Community Coalitions
• Provide assistance in Value-Based Payment, Quality Reporting and the Physician
Feedback Reporting Program
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Cardiac Health
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Cardiac Health: atom Alliance
Spread Million Hearts initiative
Churches, providers,
hospitals, communities, civic
groups
Physician Practices - Certified
Electronic Health Record
Technology (CEHRT)
Report and track:
Aspirin/Antithrombotic with
IVD
Controlled blood pressure
Cholesterol LDL-C
Tobacco cessation
Home Health Agencies
Join www.millionhearts.org
Your Church can participate!
100 Congregations for Million Hearts
If you know of any congregation from any faithorganization that would also be interested in
participating, please share this information with them.
Feel free to contact us with questions at
.
[email protected]
Patient Education
Key tools and resources
Health literature
Spanish translation version
Many tools or patient resources
Patient & Family Engagement
Have patient
representatives involved
Empower patients with
Medicare to understand
their care and be an active
participant in their care
Give patients with Medicare
the knowledge and
confidence to ask important
health-related questions
and get answers
Diabetes
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Medicare Diabetes Prevalence &
Expenditures
60% of Medicare beneficiaries have multiple chronic
conditions*
14% of Medicare beneficiaries have 6 or more chronic
conditions. Top 5 are: Hypertension, High Cholesterol,
Ischemic Heart Disease, Arthritis and Diabetes*
Dual Eligible beneficiaries (those with both Medicare and
Medicaid coverage) are 1.4 times more likely to have diabetes*
26.9% of Medicare beneficiaries age 65+ (10.9 million
Americans) have diabetes and account for about 32% of
Medicare spending**
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Information for this slide is from the AADE Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health Disparities Program, gave on 11/14/14
*Source: CMS Chronic Conditions Among Medicare Beneficiaries, Chartbook, 2012 Edition
**Source: 2013 testimony by the Congressional Diabetes Caucus in the US House of
Representatives and the American Diabetes Association)
Everyone With Diabetes Counts (EDC)
Initiative
Pilot launched in Florida seven years ago
Expanded to nine states/territories (NY,
GA, LA, WV, TX, MS, MD, DC, US VI)
Expanded nationally to all QIN-QIOs
with 11th SoW
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Information for this slide is from the AADE
Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health
Disparities Program, gave on 11/14/14
EDC Goals
Improve health equity by improving health
literacy
EDC is a disparity reduction program.
Engage both beneficiaries and health care
providers
Improve actual clinical outcomes in the six
measures
Facilitate sustainable diabetes education
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Information for this slide is from the AADE
Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health
Disparities Program, gave on 11/14/14
EDC Components
EDC’s five components:
• Recruitment and education of beneficiaries
• Recruitment and education of physician practices
and staff
• Recruitment of partners/stakeholders
• Data collection and analysis
• Sustainability planning/implementation
EDC is a continuous plan/do/study/act (PDSA) cycle;
“keep or tweak”
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Information for this slide is from the AADE
Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health
Disparities Program, gave on 11/14/14
Accomplishing EDC
Recruit, enroll, and teach beneficiaries utilizing a
CMS-approved evidence-based DSME program
• Provide free DSME classes
• 6 consecutive weeks
• 1 class a week
• 1 ½ to 2 hours each class
• Family members or care-givers encouraged to
attend
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Information for this slide is from the AADE
Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health
Disparities Program, gave on 11/14/14
Accomplishing EDC (Continued)
Increase the number of diabetes educators, certified diabetes
educators, community health workers (CHWs), and certified
diabetes education sites in Indiana
Recruit physicians
• Improve adherence to standards of care for people with
diabetes
•
•
•
•
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Improve provider data collection and data analysis skills
Improve use of electronic health records (EHRs)
Educate provider staff
Provide technical assistance to interested practitioners
Information for this slide is from the AADE
Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health
Disparities Program, gave on 11/14/14
Accomplishing EDC (Continued)
Recruit local and state partners and stakeholders
• Mutual disseminate of aligned tools, resources and program
information
• Collaborate on the train-the-trainer and sustainability plans
Utilize Data
• QIN‐QIO will obtain clinical results of diabetes measures for
10% of Medicare beneficiaries who complete DSME
• CMS will match the data to Medicare claims data
• Allows for following beneficiaries’ data longitudinally
over time
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Information for this slide is from the AADE
Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health
Disparities Program, gave on 11/14/14
DSME Program
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Diabetes Education and Empowerment
Program (DEEP)
University of Illinois at Chicago Midwest Latino Health Research Training and
Policy Center
Developed to provide community residents with the tools to better manage their
diabetes in order to reduce complications and lead healthier, longer lives. Based on
principles of empowerment and adult education
Two Components
• Train-the-Trainer
• Three day-workshop
• Training stresses development of skills and knowledge related to diabetes by
using interactive group activities
• Diabetes Patient Education
• DSME content divided into eight modules
Revised every two years (or as needed) to reflect the most current knowledge and
information.
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DEEP DSME Modules
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Understanding the Human Body
• Exercises to establish trust and
solidarity
• Systems and organs diabetes
affects
• Description of what diabetes does
to the Organs
Monitoring Your Body
• Teach signs, symptoms, and
monitoring of hypoglycemia
and hyperglycemia and ways to
monitor
• Teach diabetes management
using glucose meter
What is Diabetes
• Diabetes defined
• Risk factors
• Signs and symptoms of diabetes
Get Up and Move: Diabetes and
Exercise
• Teaching physical activity as a
method to control diabetes
• Making time for regular
physical activity
DEEP DSME Modules (Continued)
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Nutrition
• Basic nutritional concepts
• How to read food labels (calories)
carbohydrates, salt, and trans fats
• MyPlate method and food
portions
• Exercises on salt and fat hidden in
food
Introduction to Medications
• Medications for control of
diabetes, hypertension and
cholesterol
• Medications actions, cautions,
and side effects
• Self-management care guides
Preventing Diabetes Complications
• Smoking and circulatory
problems
• The importance of daily foot care
• Reporting abnormalities to
providers
• Visiting different specialists for
prevention and control
Coping with Diabetes
• Emotional aspects of diabetes
(e.g., stress, depression and
patients’ rights)
• Involving family and friends in
care management
DEEP Goals
Improve and maintain quality of life
Prevent complications and disabilities
Improve eating habits and maintain adequate nutrition
Increase physical activity
Develop self-care skills
Improve patient and health care team relations
Increase use of available resources
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DEEP - Methodology & Teaching
Methodology Based
• National medical care and selfcare education guidelines
• Participatory education
• Adult education principles
• Group work techniques
• Progress towards a healthy
lifestyle
• Role-playing
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Teaching Strategies
• Brainstorming
• Problem-solving
• Feed-back
• Demonstrations
• Modeling
• Role-playing
DEEP – Target Audiences
DEEP is directed towards:
• Persons with diabetes
• Their relatives and caregivers
DEEP is written to be implemented by:
• Professionals who care for persons with diabetes
• Community Health Workers
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DEEP – Participatory Education
Adults learn best when they are actively engaged and when they learn by doing
Participants learn through discussion and experience
Uses the facilitator concept
Responds to needs of the group
Group involvement for planning and action
• Facilitator and students set goals
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DEEP - Participatory Education
(Continued)
Learning:
WE REMEMBER:
of what we read
of what we hear
of what we see
of what we see and hear
of what we do
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Activity Example
Visual representation of the amount of sugar and fat in a typical diet.
Photo taken by Nancy Semrau, Quality Improvement Advisor
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DEEP – Flexibility
Modules can be covered in any order in 6 sessions without compromising the
program’s integrity
Two trainers for each workshop is recommended but not required
Designed to be adapted to the needs and abilities of the organization and group
• Missed sessions can be made up at the discretion of the trainer and participants
• Supplies & materials can be made or purchased
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Becoming a Part of EDC
Person with diabetes or pre-diabetes
• Attend diabetes education classes when available in the community
• Encourage others to attend diabetes education classes
• Ask community leaders to volunteer a site for education in the community
Partners and Stakeholders
• Contact the QIN-QIO to discuss potential collaborations related to increasing
diabetes educators and/or diabetes education sites and cross spreading aligned
tools, information and resources
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Becoming a Part of EDC (Continued)
Providers
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•
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•
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Volunteer to become an education site
Refer patients to the free Medicare diabetes education classes
Encourage diabetics and pre-diabetics to attend available classes
Contact us to learn more about free QIN-QIO assistance in becoming a certified
diabetes education site for Medicare billing and training appropriate staff to
facilitate the DEEP DSME classes
Becoming a Part of EDC (Continued)
CDE and Coordinating Body/Local Networking Group Collaborations
• Encourage health care providers to take the Certified Diabetes Educator (CDE)
exam
• Volunteer to be a “CDE Champion” and speak on QIN hosted webinars
• Volunteer to be a “CDE Champion” for QIN hosted CDE exam study groups
Collaboration ideas are always welcome!
31
Information for this slide is from the AADE
Webinar presentation Susan Fleck, RN, MMHS,
Government Task Leader, CMS Health
Disparities Program, gave on 11/14/14
Presentation Acronyms
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AADE
American Association of Diabetes Educators
ABCS
Aspirin, Blood Pressure, Cholesterol, and Smoking
ADA
American Diabetes Association
BFCC-QIO
Beneficiary and Family-Centered Care-Quality
Improvement Organization
CDE
Certified Diabetes Educator
CHW
Community Health Worker
CMS
The Centers for Medicare & Medicaid Services
DEEP
Diabetes Education and Empowerment Program
DSME
Diabetes Self-Management Education
EDC
Everyone With Diabetes Counts
EHR
Electronic Health Record
Presentation Acronyms (Continued)
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HAI
Healthcare Associated Infections
HHA
Home Health Agency
HHQI
Home Health Quality Improvement
HHS
Department for Health and Human Services
HIT
Health Information Technology
LAN
Learning and Action Network
PQRS
Physician Quality Reporting System
QI
Quality Improvement
QIN-QIO
Quality Innovation Network-Quality Improvement
Organization
QIO
Quality Improvement Organization
REC
Regional Extension Center
SoW
Scope of Work
For More Information
Visit new Website for details
www.atomAlliance.org
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Indiana atom Alliance Team
Don Gettinger
Quality Data Reporting Manager
812-243-0847
[email protected]
Angela Goode
Quality Improvement Advisor
317-670-6407
[email protected]
Jill Peterson, RN, CRRN
Quality Improvement Advisor
812-562-0006
[email protected]
Cathie Pritchard, LPN, RHIT
Quality Improvement Advisor
765-505-3529
[email protected]
Jean Brizzi, RHIA
HIT Specialist
219-302-1458
[email protected]
Deborah Garrison-Downey,
MSHE/MBA-SSGA
HIT Specialist
317-646-0201
[email protected]
Sharon Barclay, RN, MSN
Quality Improvement Advisor
317-646-0887
[email protected]
This material was prepared by the atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QINQIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
Content presented does not necessarily reflect CMS policy 14.A1.08.009