exploring comprehensive diabetes prevention and care in oregon · exploring comprehensive diabetes...
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Exploring Comprehensive
Diabetes Prevention and Care in Oregon
March 16, 2016
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Patient-Centered Primary Care Institute
Online Modules Webinars Website Learning Collaboratives Trainings TA Network
Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures • Access to Care “Health care team, be there when we need you” • Accountability “Take responsibility for making sure we receive the best
possible health care” • Comprehensive Whole Person Care “Provide or help us get the health care,
information and services we need” • Continuity “Be our partner over time in caring for us” • Coordination and Integration “Help us navigate the health care system to get
the care we need in a safe and timely way” • Person and Family Centered Care “Recognize that we are the most important
part of the care team - and that we are ultimately responsible for our overall health and wellness”
Learn more: http://primarycarehome.oregon.gov
PCPCH Model of Care
Presented by:
Don Kain, M.A., R.D., C.D.E Registered Dietitian and Certified
Diabetes Educator Harold Schnitzer Diabetes Center
Oregon Health and Science University
Sarah Worthington, MPH, RD Healthy Communities Coordinator Deschutes County Health Services
Tracy Carver, MPA State Lead
Everyone with Diabetes Counts Acumentra Health
After this webinar participants will be able to:
• List the components and goals of the National Diabetes Prevention Program
• State the rationale for screening patients for prediabetes
• Differentiate between the DPP, Diabetes Self-Management Education (DSME) and the Stanford Diabetes Self-Management Program (DSMP)
• Describe the critical role that patient centered primary care homes can play in referring high risk patients in Oregon to the National DPP, DSME and DSMP
Objectives
On the Horizon…
Diabetes = 29 million Prediabetes = 86 million
(Estimated 1 million in OR) • 37% of US adults • 51% of US adults 65 years
old and older • 15-30% develop DM within 5
years if no action is taken CDC: A Snapshot of Diabetes in the
United States, 2014. 7
What about Oregon?
Oregon Diabetes Report, January 2015. 8
Diabetes by the Numbers
9
Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults
2013
2013
Obesity (BMI ≥30 kg/m2)
Diabetes
1994
1994
2000
2000
No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%
No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%
10
Diabetes Prevention & Self-Management Programs
National Diabetes Prevention Program • CDC sponsored year-long program designed for individuals with
prediabetes
Diabetes Self-Management Education (DSME) • Comprehensive self-management program designed for individuals
with a diagnosis of diabetes • Blood glucose monitoring, healthy eating, physical activity,
medications, healthy coping
Stanford Diabetes Self-Management Program (DSMP) • An evidence-based peer-supported self-management program for
people with Type 2 diabetes designed to help participants gain confidence in controlling symptoms and in day-to-day self-management
11
Diabetes Prevention & Self-Management Programs Blood Sugar
Level Program Program Goals Program
Leader Prediabetes Diabetes Prevention
Program 7% weight loss 150 minutes of physical activity
Lay person or healthcare professional
Diabetes- New onset, poorly controlled, or in need of refresher
Diabetes Self-Management Education (DSME)
Healthy Eating Being active Monitoring Taking medication Healthy Coping
Healthcare professional
Diabetes- Needing support with implementing self-management behaviors
Stanford Diabetes Self-Management Program (DSMP)
Teach skills for daily self-management Increase patient activation/self-efficacy Promote effective communication with care team
Certified Leader: peer educator or healthcare professional
12
• People ≥ 45 years of age, especially if BMI ≥ 25 – Repeat in 3 years if normal
• Screen earlier and more often if BMI ≥ 25 plus – Physically inactive – 1st degree relative with type 2 diabetes – High risk ethnic group – Hypertensive (≥ 140/90 or on treatment) – HDL < 35 and/ or TG > 250 – History of cardiovascular disease – History of polycystic ovarian syndrome – History of gestational diabetes or baby ≥ 9 lb – Previous diagnosis of pre-diabetes
ADA Clinical Practice Recommendations. Diabetes Care 2013;35(Suppl 1):S11
Who Should be Screened for Diabetes?
13
Diabetes Risk Factors
Contributing Factors • Family history • Aging • Ethnicity • Obesity • Inactivity
Associated Risk • Low HDL, high triglycerides • Hypertension • Coronary Artery Disease • Peripheral Vascular
Disease • Gestational Diabetes
– Or having a baby ≥ 9 lbs
• Polycystic ovary syndrome • Prediabetes
14
National Diabetes Prevention Program
15
National Diabetes Prevention Program Original Research
Multicenter NIH Clinical Trial • 3,234 participants with prediabetes • 27 clinical centers in U.S.
Lifestyle • Reduced calories, low-fat diet • 150 minutes of exercise per week (30
minutes of walking 5 days per week) • Weight loss goal = 7% of body weight
Metformin • 850 milligrams BID
Placebo
DPP Research Group. New England Journal of Medicine. 346: 393-403, 2002.
Study Results Lifestyle • Risk for developing
diabetes decreased by 58%
Metformin • Risk for developing
diabetes decreased by 31%
16
What Did the DPP Research Study Show?
• Weight loss was the most important factor in lowering the risk for type 2 diabetes
• The effect of weight loss on the risk for type 2 diabetes was the same across the board – regardless of sex, socioeconomic status, race, or ethnicity
• Millions of people at risk for diabetes in the U.S. can prevent or delay type 2 diabetes through modest weight loss as part of a structured lifestyle program 17
Group Delivery of DPP
The same outcomes can be achieved if the Lifestyle Change
Program is: – Offered in community-
based settings – Delivered in a group – Facilitated by a trained
Lifestyle Coach without a health care background
– Offered without incentives
• DEPLOY Study • Special Diabetes Program
for Indians Diabetes Prevention Demonstration Project
• Montana Diabetes Prevention Program
• Minnesota I CAN Prevent Diabetes Program
18
Eligible National DPP Participants
Overweight Adults: • Adult aged 18 years and older with a BMI of 24 or greater
(Asian Americans: 22 or greater)
Prediabetes: • Prediabetes diagnosed through blood test (Fasting blood
sugar, A1C, oral glucose tolerance test)
• OR history of gestational diabetes
• OR increased risk based on prediabetes risk quiz
https://doihaveprediabetes.org/pdf/Prediabetes_RiskTest_12.11.pdf 19
National DPP Goals and Structure
• Weight Loss: 5-7% of starting body weight
• Increasing physical activity to 150 minutes
• 16 weekly sessions delivered once a week during months 1-6
• Monthly or bi monthly sessions during months 7-12
Program Goals Program Structure
20
National Diabetes Prevention Program How it Works…
Relies on self-monitoring, goal setting, group process
• One hour sessions
• Self-monitoring of weight, food intake, minutes of physical activity
• Goal/action plan set at each session
• Lifestyle Coach leverages group process to allow group to problem-solve and support change
21
National Diabetes Prevention Program
1. Welcome 2. Be a Fat and Calorie Detective 3. Three Ways to Eat Less Fat and Fewer Calories 4. Healthy Eating 5. Move Those Muscles 6. Being Active: A Way of Life 7. Tip the Calorie Balance
8. Take Charge of What’s Around You 9. Problem Solving 10. Four Keys to Healthy Eating Out
11. Talk Back to Negative Thoughts 12. The Slippery Slope of Lifestyle Change 13. Jump Start Your Activity Plan 14. Make Social Cues Work for You 15. You Can Manage Stress 16. Ways to Stay Motivated
Skills
Controlling the external environment
Psychological and emotional
Content- 1st 16 weeks of program
22
https://public.health.oregon.gov/PreventionWellness/SelfManagement/Documents/oregon_dpp_contacts.pdf
Diabetes Prevention in Oregon Find a Program
Clatsop Multnomah
Tillamook
Jackson
Klamath
Lake
Harney Malheur
Deschutes
Morrow
Umatilla Wallowa
Union
Baker Jefferson
Wasco
Wheeler
Grant
Sherman Gilliam
Coos
Curry
Josephine
Douglas
Crook
Clackamas
Hood River
Marion
Linn
Lane
Lincoln
Polk
Benton
Diabetes Prevention Program
No program
23
Prediabetes Awareness PSA Campaign
www.doihaveprediabetes.org
24
Helping Patients at Increased Risk
Begin screening patients for prediabetes • Fasting blood sugar • A1C (no fasting required) If patient tests positive for prediabetes (FBS: 100-125; A1C: 5.7-6.4) refer that patient to a DPP in your community Don’t have a DPP in your community? • Consider having one of your staff trained as a DPP Lifestyle Coach
• Coordinate with local community organization to have one their staff
trained as a DPP Lifestyle Coach
25
Next Steps- Resources for Screening & Referral
Prevent Diabetes STAT (Screen/Test/Act Today) Initiative http://www.cdc.gov/diabetes/prevention/lifestyle-program/deliverers/screening-referral.html • Resources for Screening, Testing & Referral
• Materials to Engage Patients
• Materials to Share with Colleagues & Healthcare Team
26
DPP IN CENTRAL OREGON 2016 PILOT PROGRAM
S A R A H W O R T H I N G T O N M P H , R D D E S C H U T E S C O U N T Y H E A L T H S E R V I C E S
27
ABOUT DESCHUTES COUNTY HEALTH SERVICES
• Living Well Central Oregon: Crook, Deschutes, Jefferson • CDSMP (Chronic Disease Self-Management Program) • DSMP(Diabetes Self-Management Program) • Tomando Control • Spanish DSMP (Diabetes Self-Management Program) • Living Well with Chronic Pain (coming soon)
• Electronic Health Record Referrals with FQHC • May 2014
• New Director Jane Smilie
28
SELF-MANAGEMENT IN CENTRAL OREGON
Tri County Map of Central Oregon Living Well 29
LAYING THE GROUNDWORK
• Capacity Building at Deschutes County Health Services • Lifestyle Coach Training • Knowledge building • Drafted proposals for 1 to 3 year pilot programs
• SRCH (Sustainable Relationships for Community Health) • Key Partners and Champion Supporters
30
REFERRAL PROCESSES
• Developed Resources provided to both clinics • St. Charles Family Care
• Presented DPP at physician’s monthly meeting • Providers sent fax referrals to DCHS
• Mosaic Medical • Ran a query to identify patients with prediabetes • Identified patients during office visits • Referrals Center faxed patient information to DCHS
31
PARTICIPANT ENROLLMENT
• Initial Contact Call • Intake Interview
• Demographic-medical • Diabetes Risk Test • Participant Contract
• Program Documentation • Montana software program • OR Compass Portal (soon to be
released) 32
CURRENT STATE OF DPP CENTRAL OREGON
• 16 people registered • First Workshop held
January 27, 2016 • 5 people have not
continued for various reasons
• 11 are going strong!
33
FUTURE OF DPP IN CENTRAL OREGON
• Deschutes County • DCHS: continues to pursue funding opportunities
• Focus: Redmond, Bend • La Pine Community Health Center
• Crook and Jefferson County • Mini-grants for training lifestyle coaches
34
QUESTIONS?
35
Diabetes Self Management Education (DSME)
36
Diabetes Self Management Education (DSME)
Diabetes is a complex burdensome chronic disease that requires making numerous daily decisions regarding food, physical activity, medications, and more
• A person with diabetes is in charge of his/her own diabetes care 99.9% of the time
• To many patients having diabetes feels like having a second job
37
DSME Defined
• The process of facilitating the knowledge, skill & ability necessary for diabetes care
• It is the position of the American Diabetes Association (ADA) that all individuals with diabetes receive DSME at diagnosis and as needed thereafter
38
Concrete Examples of DSME
39
Who Delivers DSME?
Primary instructor responsible for designing and planning DSME must be a nurse, dietitian, pharmacist or other trained or credentialed healthcare professional (Certified Diabetes Educator)
• Other DSME contributors may include: practice-
based care managers, social workers and mental health counselors, trained community health workers, peers and family members
40
Is DSME Reimbursable?
Centers for Medicare & Medicaid Services (CMS) and many private payers reimburse for delivery of DSME
• CMS reimburses for 10 hours of initial DSME within 12 months of first DSME visit and for 2 hours of DSME each subsequent year
• For reimbursement, entity delivering DSME must be accredited by either the ADA, American Association of Diabetes Educators (AADE), or the Indian Health Service (IHS)
41
Other DSME Reimbursable Services
CMS also reimburses for the delivery of the following discipline-specific counseling:
• Medical Nutrition Therapy (MNT) provided by a registered dietitian
• Medication therapy management delivered by pharmacists
• Psychosocial counseling offered by mental health professionals
42
Is DSME Effective?
• Improves A1C by as much as 1%
• Reduces onset and/or advancement of diabetes complications
• Improves quality of life
• Improves lifestyle behaviors such as – Healthy eating – Engaging in physical activity
Powers, M. A., et al. Diabetes Care. Published online before print June 5, 2015, doi: 10.2337/dc15-0730
43
Is DSME Effective?
• Enhances self efficacy & empowerment
• ↑ healthy coping
• ↓ presence of diabetes-related distress & depression
44
Is DSME Well Utilized?
The number of people who receive DSME is low:
– Only 6.8% of those newly diagnosed, who have private health insurance receive DSME
– Only 4% of eligible Medicare participants access DSME
Powers, M. A., et al. Diabetes Care. Published online before print June 5, 2015, doi: 10.2337/dc15-0730 45
Improving DSME Access in Oregon
Referrals for DSME must be made by a health care provider
– To locate a DSME provider near you please visit:
• http://professional2.diabetes.org/erp_zip_search.aspx
• http://www.diabeteseducator.org/ProfessionalResources/accred/Programs.html
46
Supporting Self-Managers
• Diabetes is a complex and burdensome disease
• In order for people to be effective self-managers, DSME lays the foundation, but requires ongoing support to maintain gains made during education
47
Stanford University Diabetes Self-Management Program
48
Quality Innovation Network-Quality Improvement Program: Everyone with Diabetes Counts Initiative
• Centers for Medicare & Medicaid Services (CMS) national initiative to improve access to diabetes self-management education in underserved communities
• Objectives:
– Increase access and improve referral pathways to diabetes self-management education programs and services.
– Work with clinics to improve diabetes care and monitoring and optimize billing Medicare for DSMT and MNT.
49
Stanford’s Diabetes Self-Management Program
(DSMP)
• Evidence-based intervention • Peer-supported model • 2.5 hours per week; 6 weeks • 10–15 participants • Trained peer leaders • Part of Stanford suite of programs
50
7 Tenets of Self-Care Behavior
AADE7® Self-Care Behaviors Diagram by Nevada Wellness For more information, visit: https://www.diabeteseducator.org/patient-resources/aade7-self-care-behaviors
51
DSMP Topics and Tools
Physical Activity
Medications
Decision-Making
Action Planning
Breathing Techniques
Understanding Emotions
Problem-Solving
Using Your Mind
Sleep
Communication
Healthy Eating
Weight Management Working with Health Professionals
Self-Management Tool Box
2012 Stanford Chronic Disease Self-Management Program Workshop Leader Manual 52
Oregon DSMP: Early results
Oregon “Everyone with Diabetes Counts” DSMP Communities 2015 data:
• Pre-post surveys collected from participants
in 11 workshops: – 73 graduates – 33 non-graduates
53
Self-reported health conditions
2015 Data Report on Oregon “Everyone with Diabetes Counts” DSMP Communities 54
Patient confidence in setting self-management goals
2015 Data Report on Oregon “Everyone with Diabetes Counts” DSMP Communities
Pre N=52 P-value: Yes: 0.001* Maybe: 0.003* Post N=41 *statistically significant
55
Managing stress related to diabetes
2015 Data Report on Oregon “Everyone with Diabetes Counts” DSMP Communities
Pre N=52 P-value: Yes: 0.000* Maybe: 0.008* Post N=41 *statistically significant
56
Communication with provider
2015 Data Report on Oregon “Everyone with Diabetes Counts” DSMP Communities
Pre N=52 P-value: Yes: 0.036* Post N=41 *statistically significant
57
DSMP in Oregon
More information on DSMP programs in Oregon: • Upcoming workshops by county:
http://www.acumentra.org/resources/diabetes-self-management-program-calendar/
• Stanford Self-Management Program contacts by county:
http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/LivingWell/Documents/Programs/countynmbrs.pdf
National and International Licensed Organizations: • http://patienteducation.stanford.edu/organ/dsmpsites.html
58
DSMP Programs in Oregon
59
Medical Nutrition Therapy (MNT)
Referral to Diabetes Self-Management Education
Pre-diabetes
Diabetes Prevention
Program (DPP)
Diabetes Self-Management Training (DSMT)
Diabetes
Stanford Diabetes Self-Management Program (DSMP)
Newly diagnosed
This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-B2-16-10-OR 3/1/16 60
DSMP and DSME Partnership
Benefits of partnering with DSME and DSMP Nevada Wellness DSME Toolkit
61
Contact us!
Tracy Carver, MPA [email protected]
(503) 382-3931
Don Kain, MA, RD, CDE [email protected] (503) 494-5249
Sarah Worthington MPH, RD [email protected]
(541) 322-7446
What Questions Do You Have?
Type questions into the Questions Pane at any time
Thank You! Please complete post-webinar survey
Resources • Centers for Disease Control and Prevention (CDC), A Snapshot of Diabetes in the United
States, 2014 • Oregon Health Authority, Oregon Diabetes Report, 2015 • American Diabetes Association (ADA), Clinical Practice Recommendations: Diabetes Care,
2013 • Ad Council, So…Do I have Prediabetes? • American Association of Diabetes Educators, AAED7 Self-Care Behaviors, 2010 • Stanford Diabetes Self-Management Program • State of Nevada, Nevada Wellness DSME Toolkit, 2016 • Center for Medicare & Medicaid Services Everyone with Diabetes Counts Initiative Schedules & Contacts • National Diabetes Prevention Program, Oregon Contacts, 2016 • Acumentra Health, Upcoming DSMP workshops by county • OHA Public Health, Stanford Self-Management Program contacts by county, 2015
Journals
• Lefevre, M. on behalf of the U.S. Preventive Services Task Force. (2014). Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Factors: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 161:587-593.
• Lorig K, Ritter PL, Villa FJ, Armas J, Community-based peer-led diabetes self-management: a randomized trial. Diabetes Educator, 35(4):641-651, 2009.
• Lorig, Kate R. DrPH*; Ritter, Philip PhD*; Stewart, Anita L. PhD†; Sobel, David S. MD‡; William Brown, Byron Jr., PhD*; Bandura, Albert PhD§; Gonzalez, Virginia M. MPH*; Laurent, Diana D. MPH*; Holman, Halsted R. MD* Chronic Disease Self-Management Program: 2-Year Health Status and Health Care Utilization Outcomes. Medical Care, November 2001 - Volume 39 - Issue 11 - pp 1217-1223
• Powers, M. A.; Bardsley, J.; Cypress, M.; Duker, P.; Funnell, M.M.; Fischl, A.H.; Maryniuk, M.D.; Siminerio, L.; and Vivian, E. (2015). Diabetes Self-Management Education and support in Type 2 Diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care. Diabetes Care 38.doi: 10.2337/dc15-0730
• Terris King, DD, MS; Susan B. Fleck, RN, MMHS; Elisa Estrella, BA; S. Maggie Reitz, PhD, OTR/L, FAOTA The Centers for Medicare & Medicaid Services Diabetes Health Disparities Reduction Program Fam Community Health Vol. 36, No. 2, pp. 119–124, 2013.
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