diabetes care for high risk populations: lessons from a community based program
Post on 20-Jan-2016
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Diabetes Care for High Risk Populations:
Lessons from a Community Based
Program
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Software Screen
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Today’s Speakers
Marie Laboissonniere RN Med CDOE CVDOEand
Susanne Campbell RN MS
St Joseph Center for Health and Human Services
Providence, RI
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Learning Objectives Participants will be able to:
•Describe resources available that enable uninsured/vulnerable patients to obtain medications, supplies and material support needed to work toward positive treatment options.
•Identify strategies to maximize internal/external resources to provide patients with nutritional, mental health and additional chronic care services.
•Identify educational and peer support opportunities to engage patients in taking a significant role in managing their own care.
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The Diabetes Resource Center (DRC)
Established in 1991 to meet the needs of people with diabetes who:
• Have limited or no resources• Are under – or uninsured
Have diabetes-related needs for :• Medications• Accessing primary care, specialty care, mental
health and case management services• Diabetes education
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Primary Goals
Patients will be able to manage their condition and improve clinical outcomes through access to :
• Primary Care • Podiatry, Ophthalmology • Medications• Diabetes Supplies • Mental health and case management • Nutritional services • Individual and group education
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Main Partners
• Rhode Island Dept of Health Chronic Care Collaborative (Diabetes and CVD)
• Colleges and Universities (student interns for pharmacy, nutrition, nursing, medical assistants);
• Funders (Blue Cross/Blue Shield, Rhode Island Foundation, Churches . Private Charities)
• Systemetrics (Pharmacy Assistance Software) • Drug companies • CMS-contracted QI Organization (Quality Partners• Private physicians that donate time • Volunteers (registry data entry, patient follow up)• Peer Navigator (Rhode Island Parent Information
Network)
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Challenges
• Growing number of uninsured patients • Employing professional staff that speak Spanish
(RD, Social Worker, RN) • Less grant funding opportunity with downturn in
economy • Place to come for “free care”• Free standing registry • Patient engagement and follow through
• Reimbursement for services
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Changes : Reduce Expenses, Improve Efficiency
• Integrated the DRC into the Adult Primary Care Program
• Implemented group diabetes classes (including mental health )
• Implemented peer support group • Implemented small group education • Automated the Pharmacy Assistance Program
(PAP) • Coordinated purchased supplies with PAP• Added Primary Care model requirement to
access other support services
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Changes: Team Expansion/Integration
• Co-located and integrated mental health • Expanded team to include RD, social worker,
Clinical Nurse Specialist, and peer navigator • Expanded relationship with Universities • Expanded community partnerships (exercise,
tobacco cessation, nutrition)• Expanded program to other chronic care
conditions • Collaboration with acute care: Diabetes Center
for Excellence
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Changes: Reimbursement
• Became ADA certified site and State recognized CDOE site
• Hiring RD who is can be reimbursed under Medicare and Medicaid
• Becoming a Patient Center Medical Home: Insurances paying more per member/month and pay for performance
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What Patients Need
Medications/strips: • Pharmacy Assistance Program : seeing 200
patients per month; • Increasing need for grant funded insulin and
supplies
• Increased need for Pharmacy samples
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What Patients Need
Mental Health • Resources for Basic Living Needs • Treatment for anxiety and depression • Peer support, particularly for Latino population
• Navigating the health care system
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What Patients Need
Access to Care • When becoming uninsured• When discharged from Hospital/ER • Earlier identification of pre-diabetes and
diabetes • Life Style Change Education, especially for
nutrition and managing conditions
• For management of chronic mental health conditions and co-morbid conditions
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Strategies
Medications/strips • Obtained grant through Rhode Island
Foundation to pilot bilingual Chronic Care Support position
• Implemented Pharmacy Assistance Program• Implemented Systemetics software• Improved clinical outcomes (total cholesterol,
LDL levels and HbA1c) • Reduced expenses for grant purchased
medication and supplies
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Strategies/Patient Resource Information
• For information on Pharmacy Assistance software (Systemetics) contact 888-593-1085 or info@rxassistplus.com
• For patients with insurance and high co pays, call Patient Advocate Foundation Co-Pay Release at 1-866-512-3861 (prompt “2” case management).
• Abbott and Roche offer glucose test strips, and meters for people who qualify for their program.
• For Abbott products: Call 1-800-222-6885 or visit www.abbottpatientassistancefoundation.org ;
• For Roche products: visit www.accuchek.com; and go to patient assistance program
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Strategies: Mental Health
• Obtained funding from Blue Cross/Blue Shield of RI for Project Access
• Blue Angel: Mission to integrate mental health and medical services
• Hired a bi lingual LICSW and CNS• Contracted with Psychologist for team support
and patient grand rounds• 320 patients screened by staff at Point of Care • Physician/patient discussion and referral for
case management, individual clinical intervention, support group
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Strategies: Mental Health
• Integrated social worker into Diabetes Education classes
• Implemented follow up peer support group • 452 patients with diabetes screened at point of
care; • 39% referred (60% Latino; 49% uninsured)• 72% improvement in HbA1C after interventions
• 59% established self management goal
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Strategies : Nutrition
• University Partnerships: URI Nutrition Science Program-student interns to obtain experience counseling patients with diabetes at no cost to patients
• Students providing educational resource packets • Reduced RN CDOE staff and replacing with RD• RI Neighborhood Pilot Project: referrals to St
Joe’s for medical, nutrition, education and pharmacy assistance; referral to Neighborhood partners for exercise, nutrition, social services and support groups
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Eye/Podiatry
• Hospital Collaboration: MD volunteer as part of staff privileges
• Once a month podiatry clinic• Once a month eye clinic (including specialty
referral and treatment)
• Increased referrals at earlier identification at “point of care” …take off socks, monofilament testing
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Strategies/Education
• Obtained a grant from Rhode Island Foundation to start diabetes education classes (on site and off site)
• Followed at ADA application guidelines when setting up program
• Obtained ADA recognition status for long term sustainability
• Partnered with hospital staff to provide Community Health Fair with over 200 people attending
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Strategies/Education
• Small patient group instruction for common skills-insulin injection and blood glucose monitoring
• Large group instruction for comprehensive diabetes education
• Telephone follow up to assess blood glucose patterns and titrate insulin to achieve blood glucose goals
• Follow up patient engagement to check on coping skills
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Strategies/Staff Education
• Staff nurses to obtain CDOE certification, and Tobacco Cessation Certification
• Nurses obtained CVD certification to expand from Diabetic Resource Center to Chronic Care Resource Center
• Partnered with Quality Partners for Chronic Kidney Disease resource education
• Integrated standards of care into the clinical note
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Strategies/Limited Resources
• Drug companies: Education for staff, patients and medication samples and strips; helped to underwrite costs of health fair
• Workforce Volunteer Program (AHEC): Placement of students and volunteer for career exploration and work experience (registry support, pharmacist student, medical assistant, nutrition
• Peer Navigator Program: Provides staff who can offer individual assistance for basic needs
• Churches and small foundations: medication/strips
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Future Plans
• Obtain Level 1 Patient Medical Home Status to position ourselves for better reimbursement
• Electronic Medical Record
• Expand to Pre-Diabetes
• Shared Medical Visit Pilot
• Shared Nutrition Visits
• Group follow up after CDOE classes
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Future Plans
• Through a Block grant, working with community groups to work on access to fresh fruits and vegetables in community markets and policy changes to address social determinants of health
• Working with SNAP program to offer on site Food Stamp application assistance
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Questions / Discussion
?
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Have additional questions?
Please contact us at info@rxassist.org
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