PATIENT SELF-MANAGEMENT & PLANNED CARENOVEMBER 2014 – JUNE 2015 PILOT

Maine Chronic Disease Improvement Collaborative (CDIC)

Learning Session #2

Welcome & Introductions

DON’T WORRY…

We won’t have you share your favorite Valentine’s Day song BUT….

Chronic Disease is at the of our aim!

National Front Local Front

Chronic disease is the number one cause of

death.

32% of mortalities in Maine in 2010

Diabetes rates have risen from 6% to 8.7% in 10 years

92,000 adult residents living with diabetes

Why we are here…

Funder: Maine Centered for Disease Control (CDC) 1305: State Public Health Actions to Prevent & Control Diabetes, Heart Disease &

Obesity Project Partners:

Maine Quality Counts: project leadership, practice coaching, PCMH expertise Maine CDC: grantee and partner Partnership for Health: evaluation partner Stakeholder Advisory Group including

MMC Diabetes Collaborative Maine Cardiovascular Health Council Medical Care Development/Public Health HealthCentric Advisors Quality Improvement Organization QIO) Spectrum Generations (AAA) Maine Nurse Practitioner Association

About the Project

Our Goals

Expand knowledge on evidence based, safe, cost effective care

Implement/spread best practices and algorithms across the state

Improve quality, cost and safety

Teach and spread science of quality improvement

Drivers for Improving Chronic Care

Drivers for Improving Chronic Care

Supporting Patient Self-Management Pat Watson, MS,RD,LD,CDENathan Morse, CHES, TTS-C2/26/15

Goals of our Discussion

• Practices will identify barriers to engaging their patients in behavior change to help prevent the onset of T2DM and manage their existing T2DM

• Practices will increase awareness of programs and resources available to support patient self-management in areas of diabetes prevention and T2DM.

Opportunities: Prevention

Helping to prevent onset of Type 2 DM

http://www.cdc.gov/obesity/data/prevalence-maps.html

Barriers to Change/ Success: Your Narrative

• What has your practice identified as challenges to engaging your patients to help prevent T2DM?

• What are your successes?

Close to Home: Moving Forward

Questions for your team:

• How do you share your patient’s risk for developing T2DM with them?

• How do your patients set their goals related to preventing the onset of T2DM?

• Do your patients have the tools necessary to turn the tide and reduce their risk?

Your office:

• How does your office identify patients ready for change?

• What referrals do you make?• What are your patient barriers?• Who is following these patients?

Opportunities: Evidence- Based (and fun)

Prevention: National Diabetes Prevention Program

http://www.cdc.gov/diabetes/prevention/newsroom.htm

http://www.cdc.gov/diabetes/prevention/features.htm

Community Resources: NDPP

Exciting/ Evidence-based/ Proven:

http://rethinkdiabetes.org/resources-and-tools/Maine’s National Diabetes Prevention Program (NDPP) Information Portal

• Locating a local program/finding a partner• Advertising strategies for your practice • Lowering participation barriers• Sharing success• Resources

T2DM: Supporting Patient Self-Management

In your office, who:• Talks with patients about DSMT?• Encourages patient participation in DSMT?• Asks patients about barriers to attending DSMT?

Your local diabetes educator:• Partnering with local programs to reduce patient education

barriershttp://www.maine.gov/dhhs/mecdc/population-health/dcp/educationprogram.htm

Thank You

Optimizing Collaboration between the Primary Care Provider and the Specialist for Co-Managing

High Risk Patients

John Devlin, MD Endocrinologist

Collaborative Care

Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 2014

A team with a shared mission

using improved clinical systems todeliver improved care to a patient population

supported by operational and financial systems.Such care is continuously evaluated through

improvement processes and effectiveness measurement.

Population Management

Population ManagementCommunity Hospital, Grand Junction, CO

Comprehensive Primary Care Initiative (CMS): IHI Triple Aim

• Decrease unnecessary ED visits and hospitalizations

• Improve transitions of care

At Risk clients

1. Stratification (Low, Medium, High) based on stages of current (chronic) diseases

2. Implementation of a care management program to manage condition(s)

Murray D. American Diabetes Association Annual Conference, San Francisco, 2014

Level A Level B Level C Level D

• HbA1c ≥ 9• DM plus 1 or more

uncontr comorbid*

• In NON-SELF Management

• HbA1c 7-8.9• DM plus 1-3 co-

morbidities*

• Independent SELF Management State

• HbA1c < 7• DM plus 1-3 stable

co-morbidities*

• Hospice or SNF• Receives services

elsewhere• Patient Opted Out

• Requires BOTH physician and RN assessment

• RN Care Coordinator

• Health Coach Assessment

• Health Coach Assessment

N/A

Requires DSMT DSMT applicable with Primary Educational Activities + DSM Plan

DSMT applicable with Primary Educational Activities + DSM Plan

N/A

Tipping Point ≥ 4 out of 7

Tipping Point > 3 out of 7

Tipping Point ≤ 2 out of 7

Population Management:Risk Stratification Behavior Change

* May include: CHF, CAD, HTN, open wounds, neuropathy, nephropathy, retinopathy, gastroparesis

Population Management

Assessment

Care Coordination

Support

Wiegert K. ADA Annual Conference, San Francisco 2014

• Conduct Needs Assessment

• Assess Safety• Create Plan of Care

• Coordinate Services• Navigate Transitions

of Care• Prevent Unnecessary

Care

• Provide Education and Guidance

• Goal Setting• Encourage DSM

techniques

Population Management

“The focus of the population management process is to proactively manage the health of each patient through a coordinated team effort”

Diabetes management:

• Improve quality outcomes• Identify gaps in delivery of care• Advance clinical processes using efficient utilization of resources • Decrease avoidable episodic events with chronic conditions• Improve access to health care services by providing PCMH and

collaborative medical visits• Standardize care processes for disease specific conditions

Murray D. ADA Annual Conference, San Francisco 2014

Standardize Care Processes

Antihyperglycemic therapy in type 2 diabetes: general recommendations.

Inzucchi S E et al. Dia Care 2015;38:140-149

©2015 by American Diabetes Association

Victor Montori, Shared Decision-Making

Considerations in Medication Choice

• Efficacy• β cell function

• Hypoglycemia Risk

• Weight

• Side effects• Cardiovascular

• Cost

Glucose(mg/dL)

50 –

100 –

150 –

200 –

250 –

300 –

350 –

0 –

50 –

100 –

150 –

200 –

250 –

-10 -5 0 5 10 15 20 25 30

Years of Diabetes*IFG=impaired fasting glucose.Burger HG, Loriaux DL, Marshall JC, Melmed S, Odell WD, Potts JT, Jr., Rubenstein AH. 2001. Diabetes Mellitus, Carbohydrate Metabolism, and Lipid Disorders. Chap. in Endocrinology. 4th ed. Edited by Leslie J. DeGroot and J. Larry Jameson. Vol. 1. Philadelphia: W.B. Saunders Co. Originally published in Type 2 Diabetes BASICS. (Minneapolis, International Diabetes Center, 2000).

RelativeFunction

(%)

Fasting Glucose

Postmeal Glucose

Obesity IFG* Diabetes UncontrolledHyperglycemia

Insulin Resistance

-cell Failure

Can the Course of Type 2 Diabetes Be Altered?

Beta

-cel

l Fun

ction

(%)*

PostprandialHyperglycemia

IGT† Type 2DiabetesPhase I

Type 2DiabetesPhase II

Type 2DiabetesPhase III

Years from Diagnosis

Patients Treated with Metformin and/or Sulfonylureas (SUs)‡

Can The Decline Be Altered?UKPDS: Beta-cell Decline Over Time

25 –

100 –

75 –

0 –

50 –

l-12

l-10

l-6

l-2

l0

l2

l6

l10

l14

ADOPT: Treatment effect on primary outcome

Kahn SE et al. N Engl J Med. 2006;355:2427-43.

40

30

20

10

0

Glyburide

Metformin

Rosiglitazone

0 1 2 3 4 5

Years

Cumulative incidence of

mono-therapy failure*

(%)

Hazard ratio (95% CI) Rosiglitazone vs metformin, 0.68 (0.55–0.85), P < 0.001 Rosiglitazone vs glyburide, 0.37 (0.30–0.45), P < 0.001

N = 4351

*Time to FPG >180mg/dL

ADOPT: Treatment effect on insulin sensitivity and β-cell function

Kahn SE et al. N Engl J Med. 2006;355:2427-43.*At 4 years†Homeostasis model assessment (HOMA 2)

Insulinsensitivity†

(%)

50

60

40

30

0

Years

70

-Cell function†

(%)

80

90

70

60

0

Years

100

543210

GlyburideMetforminRosiglitazone

Treatment difference* (95% CI)

Rosiglitazone vs metformin12.6 (8.1 to 17.3), P < 0.001

Rosiglitazone vs glyburide41.2 (35.2 to 47.4), P < 0.001

Treatment difference* (95% CI)

Rosiglitazone vs metformin5.8 (1.9 to 9.8), P = 0.003

Rosiglitazone vs glyburide-0.8 (-4.7 to 3.1), P = 0.67

543210

UKPDS• Newly diagnosed type 2

diabetes; intensive versus conventional policy; primary report published September 1998

• Follow-up observation published October 2008

Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.

Post-Trial Changes in A1C

UKPDS resultspresented

Mean (95%CI)

Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.

MI Hazard RatioFatal or Non-Fatal MI or Sudden Death)

Intensive (Sulfonylurea/Insulin) Versus Conventional Glucose Control

HR (95%CI)

Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.

Glycemia Reduction Approaches in Diabetes:A Comparative Effectiveness Study (GRADE)

• Metformin 1000-2000 mg daily• HbA1c 6.5-8.5%• Duration < 10 years• Randomize:

• Glimepiride (SU) N = 1500• Sitagliptin (DPP-4 inhibitor) N = 1500• Liraglutide GLP-1 agonist N = 1500• Glargine insulin N = 1500

• Follow-up over 7 years

http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf+html

Figure 3

Getting to insulin

• Overcoming “psychological insulin resistance”• Patient• Provider

• Overcoming therapeutic inertia• Insulin initiation• Insulin titration

Basal Insulin

• Glargine vs. NPH

• Starting dose

• Combination with oral hypoglycemic drugs

• Titration

The Treat-to-Target TrialRiddle MC, et al. Diabetes Care 2003;26:3080-86

Randomized addition of glargine or human NPH insulin to oral therapy of

type 2 diabetic patients

Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 2003; 26: 3080-6

Riddle MC, et al. The Treat-to-Target TrialDiabetes Care 2003; 26: 3080-6

Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 2003; 26: 3080-6

Riddle MC, et al. The Treat-to-Target TrialDiabetes Care 2003

Hypoglycemia: Events per patient per year

All Symptomatic

Events

Confirmed ≤ 72 mg/dL

Confirmed ≤ 56 mg/dL

Glargine 13.9 9.2 3.0

NPH 17.7 12.9 5.1

http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf+html

Initiating insulin

• Typically begin at low dose 0.1-0.2 units/kg/day

• In more severely hyperglycemic 0.3-0.4 units/kg/day

Clinical Case

89 y.o. gentleman has had acceptable glycemic control until recently, on metformin 1000 mg BID and glipizide ER 5 mg daily.

• S. creatinine 1.12 (eGFR 58 ml/min/1.73m2)

Lately, he has had higher glucose readings overnight, with bedtime BGs in 200-260 mg/dl range. He admits to having desserts at night.

• Nocturia every 2 hours• S. creatinine increased to 1.3 (eGFR 48 ml/min/1.73m2)• His nephrologist tells him this is due to dehydration, and

advises him to drink more water

Your advice?• Stop eating dessert• Drink more fluids• Stop metformin• Start insulin

Multiple Chronic Medical Conditions

Health Services Models

Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 2014

Team approaches have been shown to improve quality of care and outcomes of patients with:

• Depression

• Diabetes

• Asthma

• Hypertension

• CHF

Medicare Patients

Ciechanowski PS. ADA Annual Conference, San Francisco 2014

Multiple morbidity is the norm:

• 80% of those with CHF

• 71% of those with Depression

• 56% of the with Diabetes

have 4+ Chronic Conditions

Health Services Modes for Natural Clusters of Illness

Ciechanowski PS. ADA Annual Conference, San Francisco 2014

Diabetes

HTN CAD

Depression

AHRQ Multiple Chronic Conditions (MCC) project

American Diabetes Assn. Annual Scientific Sessions, Chicago, June 22, 2013

48.9% of Cohort has a Behavioral Health Disorder

MCC Behavioral Health Group

Number Distinct Members

No BH 32,272

SA Only 1,610

MH Only SMI 5163

MH Only non-SMI 12,002

Dual (MH and SA) 7,861

MR/DD/TBI 4,233

OVERALL TOTAL 63,141

AHRQ MCC project, presented at Am Diabetes Assn, June 2013

118%

91%

80% 80% 77%

52%48%

-8%

-35%

Factors predicting developing complications: Persons with uncomplicated diabetes at baseline

Percent more likely…

Improved Continuity of Care

Improved Mental Health

AHRQ MCC project, presented at American Diabetes Association, June 2013

Selected statistically significant independent variables in regression

Clinical Vignettes

1.) Schizophrenic patient hearing voices that were telling him that starting insulin would cause cancer. CDE had to also provide education to the voices to correct misinformation so patient would feel comfortable starting insulin.

2.) Another patient with type 1 and thought disorder felt Novolog and Humalog caused his hair to smell like broccoli; CDE able to patiently work with him to restart analog insulin based on discussion that doing so would improve running/biking times (no ketones=faster times)—creativity at it’s best. Meet people where they are.

3.) When new patient referrals are triaged and it is determined that they will likely need to start insulin or transition to MDI, they are scheduled with CDE immediately following MD appointment to reduce barriers for doing so (strike while the iron is hot). Provider updates CDE on plan and off we go. F/U with CDE can be more frequent to ease transition, answer questions, make insulin adjustments prn.

4.) Otherwise, we accommodate pts as best we can at time of appointment when insulin or other injectable is unexpectedly needed rather than having them return (or cancel/no show) on a different day to do so.

To address lack of treatment intensification

Schmittdiel et al. J Gen Intern Med 2008;23(5):588-594

Study: 161,697 patients (Kaiser Permanente)

• HbA1c > 7%• Systolic BP > 130• LDL > 100

Adequate ad-herence

Poor adherenceClinical Inertia30-47% lacked treatment

intensification by healthcare team

20-23%

Literature Review

Ciechanowski PS. ADA, San Francisco 2014

Problems with patients:

• Poor collaboration• Non-adherence • Missed appointments• Dissatisfaction with care• Do-it-alone approach• Poor self-care• Stress, anxiety and depression

providers

Collaborative Care

Ciechanowski PS. ADA Annual Conference, San Francisco 2014

PatientPCP

Psychiatric and Medical Case Review

CareManager

Multi-Condition Collaborative Care

Ciechanowski PS. Am Diabetes Assn Annual Conference, San Francisco 2014

Program goals:• Improve depression care

• Behavioral activation• Antidepressants

• Improve medical disease control• A (A1c)• B (Blood Pressure)• C (LDL-Cholesterol)• D (Depression)

• Improve self-care• Diet, exercise• Smoking cessation• Glucose monitoring

Multi-Condition Collaborative Care

Ciechanowski PS. ADA Annual Conference, San Francisco 2014

Identify Goals

SupportSelf-care

Monitor Progress

Treat-to-Target

Systematic

Case Review

CareCoordina

tion

Core Components

Multi-Condition Collaborative Care

Ciechanowski PS. ADA Annual Conference, San Francisco 2014

Nurse training:• Motivational interviewing/enhancement

• Problem solving

• Behavioral activation

• Antidepressants

• Treat-to-Target• HbA1c• Blood Pressure• LDL

Multi-Condition Collaborative Care

Ciechanowski PS. ADA Annual Conference, San Francisco 2014

Treat-to-Target:• Treatment titration

• Frequent and consistent• Relentless, incremental increases/changes

• Always• Increase/change to next step• If not, document why not!

• Treat-to-Target Algorithm• Simplified and uniform approaches across

conditions to achieve targets• Riddle, Diabetes Care 2003• Kaiser Permanente, Care Management Institute

Approach to starting and adjusting insulin in type 2 diabetes.

Inzucchi S E et al. Dia Care 2015;38:140-149

©2015 by American Diabetes Association

Pre-mixed insulins

Target: FPG 100 mg/dLSubjects (n = 364) were randomized to:

Insulin glargine once daily + continued OADs

Pre-mixed insulin 70/30 BID

Baseline Endpoint

Time (wk)0 24

Treatment Regimen

*Sulfonylurea +metforminOAD=oral anti-diabetic drugJanka HU et al. Presented at: American Diabetes Association 64th Scientific Sessions; June 4-8, 2004; Orlando, FL; Abstract 548-P; Study 4027

Insulin Glargine Plus OADs vs Twice-Daily Pre-Mixed Insulin

OADs*

Change in A1C From Baseline to Study Endpoint

Janka HU, et al. Diabetes Care. 2005;28:254-259

8.85 8.83

7.157.49

5

6

7

8

9

Insulin Glargine + OAD Pre-mixed

P<0.0005

A1c

Superior HbA1c Reduction With Glargine Plus OADs vs Twice-Daily Pre-Mixed Insulin

Baseline

24 week

Documented Hypoglycemic Episodes Per Patient-Year

Less Hypoglycemia With Glargine Plus OADs vs Twice-daily Premixed Insulin

Average dose = 28.2 IU with G + OAD vs 64.5 IU with premixed insulinWeight Gain: 1.4 ± 3.4 kg with G + OAD vs 2.1 ± 4.2 kg with pre mixed insulin

Janka HU, et al. Diabetes Care. 2005;28:254-259.

4.1

9.9

0

2

4

6

8

10

# of Episodes

Per

Patient-Year

P<0.0001

Insulin Glargine + OAD Premixed

Three-year efficacy of complex insulin regimens in Type 2 Diabetes

Holman RR, et al. N Engl J Med 2009;361:1736-47

Treating to Target in Type 2 Diabetes (“4-T”)

• Suboptimal HbA1c while taking metformin and sulfonylurea

• Randomly assigned to receive biphasic insulin b.i.d., prandial aspart t.i.d., or basal detemir once daily (or b.i.d. as needed)

• Target BG: ac 72-99 mg/dl, and 2-h pc 90-126 mg/dl

Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med 2009; 361: 1736-47

Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med 2009; 361: 1736-47

Basal insulin: titration

• Glargine dose can be increased every 5-7 days based on SMBG

• At doses above ~ 50 units daily, it may be more effective to split the dose into twice daily injections

• Doses above 1 unit/kg/day are unlikely to offer additional benefit, and addition of prandial insulin should be considered

Basal to “Basal Plus 1”

A strategy of adding bolus insulin to an existing basal insulin regimen in a stepwise manner

• Add a single daily bolus injection with the largest meal of the day

• Add further bolus injections at additional meal(s) if necessary

Rosenstock J et al. The CADRE Handbook of Diabetes Management. New York, NY: Medical Information Press; 2004:145-168.

Starting Basal/Bolus Therapy

• Starting insulin dose is based on weight–0.2 x wgt. in lbs. or 0.5 x wgt. in kg

• Bolus dose (aspart/lispro) = 20% of starting dose at each meal

• Basal dose (glargine/NPH) = 40% of starting dose at bedtime