Beyond the Doctor-Patient Visit: Diabetes Group Appointments and Other Strategies at

HealthCare Partners

Cozzette Lyons, M.D.

Internist, Physician Champion-DGAs

June 27, 2014

Learning Objectives

Discuss goals, benefits and challenges encountered in designing interventions aimed at diabetic patients outside of the traditional medical appointment.

Explore current and planned clinical interventions aimed at patients with diabetes.

Describe specifics of the implementation, operational experience and clinical impact of diabetic group appointments (DGAs).

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Diabetes Burden at Our Organization

1 2 Solo 5 6 ACO - ACO- Total w/o Total Senior Comm ACO

Program Purpose

To provide a population health intervention for high-risk diabetic patients to improve clinical outcomes through a shared group health enhancement model that operates beyond the traditional doctor-patient office visit.

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Diabetic Group Appointment (DGA) Goals

Increase patients’ understanding of diabetes and help create sustainable behavior change through:

An active, team approach -- including caregivers—family, friends, & providers in a supportive, group environment.

Engage patients in their care and set wellness goals.

Improve clinical outcomes-metrics.

DGA Benefits

Structured medical supervision by licensed health professionals

Andralogic approach to patient learners (dynamic; interactive)

RN & RD CDE consultations for individualized care plans

Telephone outreach by RN CDE between visits

Maximize capacity & resources

Cost-effective in long-term

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What are “Usual Treatment” Strategies Pre-DGA?”

After diabetes diagnosis:

Health Enhancement Classes

Diabetes Survival Skills,

Diabetes Management Series,

Diabetes Nutrition

Diabetes Support- Individual counseling with RN/CDE or RD/CDE

Exercise Series- Sit & Fit; Walking Group

How Do We Select Patients for DGA Inclusion?

Determined for each participating site from the organization’s Diabetes Registry

Focus on high-risk diabetic patients with an emphasis on their last A1c measurement

Patient Profile: Age; gender; primary language; education; Group vs. IPA; insurance type

Exclusions:

Type 1 Diabetes

Gestational Diabetes

Dementia/Organic Brain Disorder

Length and Personnel

2.5 hour gratis group appointment with ~10 patients

Once a month, at same time, each month

Groups in English and Spanish, depending on clinical site

Personnel:

Health Educator/Promotora

Registered Dietitian, Certified Diabetes Educator

Registered Nurse, Certified Diabetes Educator

Endocrinologist, Internist, or Nurse Practitioner

Medical Assistant

Operational Components

Pre-DGA Session:

Chart Review-

If on ASA, ACEI, LP Rx; if BP controlled; adjust medication

Patients in need of close medical assessment

Lab work & referrals

Screen for graduates

Prepare user-friendly support materials-

food models; organ/disease models; handouts; graduate baskets; etc.

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Operational ComponentsPatient Arrives

Takes Vitals

Draws necessary labs if needed

Review/demonstrate/serve items used for healthy breakfast

One-on-one with RD/CDE or RN/CDE; case review with Physician Champion for medication adjustments prn

Group education session/conversation map/topic for the month

Low-carb snack demonstration

Group exercise

Action Plan

Satisfaction Survey

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Conversation Map Curriculum

• On the Road to Better Managing Diabetes

• Diabetes and Healthy Eating

• Diabetes Nutrition with a Registered Dietitian

• Carbohydrate Counting

• Action of Diabetes Medication with a Registered Nurse

• Monitoring your Blood Glucose

• Complications of Uncontrolled Diabetes

• Continuing your Journey with Diabetes

• Exercise

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Clinical Values Examined

Blood drawn for baseline HbA1c and LDL values

Ensures eligibility for DGA and that values have not changed

Values assessed q3mo

Diabetic foot examination--every six months following

Weight, blood pressure, and fasting blood glucose

Evaluated at each appointment

PHQ-9 survey for depression

Other– ACR; vitamin D; CMP

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Report Center

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Report Center

18

Report Center

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When Do The Patients Reach Goal?

Goal:

HbA1c <7.0% for patients <65 years

HbA1c <8.0% for patients ≥65 years

Graduation:

Certificate and acknowledgment during DGA

Gift basket with diabetes book, cookbook, measuring cups and spoons, brown rice, and diabetic seasonings.

Graduation survey

730

430

332

246

169

130

81 6837

725

295

417

367

313

234

179148

102

0

100

200

300

400

500

600

700

800

0 3 6 9 12 15 18 21 24

Active Patients Patients with ResultsValues

Months in Program

Active Patients Patients with Results

Location IncomingControlled Classes AgeGroup

8.20

8.40

8.60

8.80

9.00

9.20

9.40

9.60

9.80

10.00

0 3 6 9 12 15 18 21 24

Average HbA1c

Months in Program

Average HbA1c

Location IncomingControlled Classes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 3 6 9 12 15 18 21 24

Percent Controlled

Months in Program

Percent Controlled

Location IncomingControlled Classes Graduated

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Implementation Costs-Each Appointment

Implementation CostsItem Price

Conversation map $900 (gratis to organization)

Breakfast $25-35

Medical and Invitation Supplies $385

Kitchen Supplies $167

Food and Visual Models + Handouts $680

Doctor Chart Review (2 Hours) $193

Health Educator (11 Hours) $282

RD/CDE (5-6 Hours) $165-272

Medical Assistant (3 Hours) $50

Doctor in DGA (3 Hours) $290

California salary estimates from : http://www.bls.gov/oes/current/oes_nat.htm#29-0000

Learning Lessons

DGAs appears to help lower HbA1c and LDL values.

C-suite buy-in, WFM (what’s in it for me?).

Standardizing education—given different implementation sites-new workflows, greater collaboration, compliance/privacy concerns.

Socio-economic status and health literacy differences.

Response rate--appointment times, attendance, and attrition.

Future Considerations

Use of specific knowledge, problem-solving ability, & QoL assessment tools with dedicated staff to check internal consistency & validity of information gathered.

Incorporation of standardized treatment algorithms across all sites (OHAs; insulin; ASA; ACEI; statins)

Culturally Sensitive Care Beyond the Doctor-Patient Visit

How do we enhance our outreach to particularly vulnerable (Latino/Hispanic) patients beyond the doctor-patient visit?