Diabetes Healthcare DeliveryA National Tragedy

Angelo Sinopoli, MDChief Medical Officer

Chair, MedicineUniversity Medical Group

Total Health

Percent of Diabetic Medicare Enrollees Receiving Appropriate Management

Diabetes Care in South Carolina

• Two Inpatient Diabetes Educators• Insulin order sets

– IV insulin– SQ insulin– Pregnancy

• Insulin pump protocols and standardized order sets

• Multidisciplinary Diabetes team• Hypoglycemia initiative

Inpatient Diabetes Management

Glucotec

8

The Care Continuum andthe Accountable Care Organization

Accountable Care Organization Value Proposition: The programs, people, protocols, and payment that define care delivery and patient movement along the care continuum

Graphic: Sg2

• Focus on the Medicaid Population in the Medicine Clinic

• A focus on the big six: Diabetes, CHF, Asthma, COPD, HTN, CAD

• Initial focus on Diabetes as a pilot• Focus on quality measures and utilization

Duke Innovation Grant

• Developed a process for stratifying patients by ER and Hospital utilization

• Developed an intake process for initiating patients into the “enhanced care” program for buy-in.

• Working with e-CW to develop CDSS and standard outcomes reporting

Duke Innovation Grant

• Added a Nurse practitioner to the clinic for monitoring and increased access for this patient population

• Added a Care Manager for coordination of care and Care Coordination

• Developed an Emergency Room Care Management role

• Worked to change the culture of the clinic

Duke Innovation Grant

• Restructured the Outpatient Diabetes Self Management Program and connected it to the clinic population– Changed the hours of education to make it more

patient friendly– Streamlined the referral process– Implemented central scheduling– Refined the billing processes– Reorienting around primary care practitioners

Duke Innovation Grant

• Developed Clinical Advisory Teams (CAT) to develop and agree upon standard quality measures by which we would be measured

• PQRI measures were used as baseline measures but allowed for a higher standard of performance– Also supports “meaningful use” across the system

• These were developed for Diabetes, CHF, HTN, COPD, and Asthma

Duke Innovation Grant

Physician Quality Reporting System (PQRS – was formerly PQRI)

GHS Diabetes Quality Measuresapproved by Clinical Advisory Team

in 09

Diabetes Quality Measures

• HgbA1C Measurement and Control• LDL Measurement and Control• BP Measurement and Control• BMI Measurement and Plan• Annual Urine (protein) exam• Annual Foot Exam• Annual Dilated eye exam/Retinopathy Severity

Diabetes Quality Measures

• Antithrombotic Therapy• Use of ACE/ARB Therapy• Tobacco Use• While influenza and pneumococcal

immunizations are expected to be addressed for this patient population, GHS will handle them as individual quality measures for all patients according to protocols

No such thing as a simple diabetic– All have one or more significant co-morbidities such

as CHF, CAD, COPD or HTN

Duke Innovation GrantChallenges

• No telephone• Poor living conditions• Ongoing Medicaid eligibility changes• Transportation

– No car– Have to get a ride to the clinic or even to the bus stop– Long bus ride with multiple stops– Easier to call an ambulance or wait until someone is

off from work to take them to the ER

Duke Innovation GrantChallenges

• Defined utilization as being for ALL diagnoses, related and non-related to study conditions

• Did not exclude outliers

Duke Innovation GrantResults

• Emergency Room visits down 26%• Hospital days down 55%• Initial PQRI compliance increased by 70% • A significant improvement of HgA1c was noted

Duke Innovation GrantResults

• Add additional eligible Medicaid patients• Add unfunded population• Connect to AccessHealth SC Grant

Duke Innovation GrantPhase Two

• Use the infrastructure and knowledge developed around the Duke Grant to expand to other populations

• Develop a Diabetes Toolkit• Further engage Primary Care around Diabetes• Develop IT systems around identifying and

tracking patients with particular diseases• Obtain front-end disease registry

Diabetes Care

Questions?