Michigan’s Diabetes Prevention and Control Program & National Kidney Foundation Michigan: A Successful Partnership

•Dan Diepenhorst, MI DPCPdiepenhorstd@michigan.gov•Linda Smith-Wheelock, NKFMlsmith-wheelock@mkfm.org

Kidney Disease in Michigan

More than 940,000 Michigan adults have CKD and most are unaware of their condition.

Approximately one in eight Michigan adults over the age of 20 has CKD.

The number of people with CKD continues to grow as the number of people with uncontrolled diabetes and high blood pressure grows.

70% of CKD cases caused by diabetes and high BP can be prevented or delayed.

An Epidemic of Kidney Disease

* Clinical Practice Guidelines for CKD Am J Kidney Dis. 2002;39(suppl 1):S17–S31.* GFR = glomerular filtration rate (mL/min/1.73 m2); *with kidney damage

Stage 1: GFR ≥90*

Stage 3: GFR 30–59

Stage 4: GFR 15–29

Stage 2: GFR 60–89*

Stage 5: GFR <15

n=5,900,000

n=5,300,000

n=7,600,000

n=400,000n=300,000

* United States Renal Data System (USRDS) 2000 Annual Data Report • WWW.USRDS.ORG.

ESRD: Risk by Ethnicity

reference

*

*

*

*P <0.0001

1.00

4.45

3.57

1.59

0

1

2

3

4

5

White Black Native Asian

Odd

s R

atio

Racial Differences in ESRD in US from 1990–1998

0

200

400

600

800

1000

New Cases per Million 1st QtrDetroit Wayne County Michigan

New Cases of Kidney Failure in Michigan

National Average355

934Per million

607Per Million

390Per million

* A Stack. Am J Kidney Dis. 2003;41:310–318.

CKD: Delayed Referral to Nephrologist

CKD: Reasons for Delayed Referral to Nephrologist CKD is under-recognized Failure to screen pts at-risk Fear of loss of control over pt PCPs unaware of incremental benefits of earlier

referral– Fewer ER visits (pulmonary edema)– Significant healthcare cost savings

Lack of education regarding CKD management

* R Sesso, AG Belasco. Nephron Dial Transplant. 1998;11:2417. DW Eadington. Nephron Dial Transplant. 1996;11:2124-2126. RJ Schmidt, et al. Am J Kidney Dis. 1996;32:278–283. P Jungers, et al. Kidney Int. 1993;41:S170–S173.

Michigan’s CKD Strategic Plan

A PartnershipBetween MDCHAnd NKFM thatestablished our Roadmap http://michigan.gov/diabetes

CKD: The Michigan Initiative1. Develop an early CKD identification process2. Screen and prevent CKD in patients who are at-

risk – encourage early referral for nephrology consult

3. Educate primary care physicians about diabetes, hypertension and CKD

4. Focus on Managed Care for Health Care System Change

5. Be in the community where people live, work and play with primary and secondary prevention programs.

CKD: Screening and Prevention Identify at-risk medical populations

– Hypertension– Diabetes– Metabolic syndrome– 1st degree relatives of ESRD pts

CKD history often neglected during Hx Identify at-risk ethnic groups

– Hispanics– African-Americans– American Indians (Native Americans)

* United States Renal Data System (USRDS) 2000 Annual Data Report • WWW.USRDS.ORG.

CKD Programs in MichiganSince early 1990’s, collaboration with two units of the MDCH:Diabetes Prevention and Control ProgramCardiovascular Disease, Nutrition and Physical Activity Section

Primary Prevention Healthy Hair Starts with Healthy Body™ Dodge the Punch Barber Shop Program™ Healthy Families Start with You

All programs use lay health educators and focus on healthy lifestyle changes such as exercise, healthy eating, smoking cessation and the importance of doctor visits.HH and DTP reach primarily African-Americans

School Education Programs such as Kids and Kidneys and Kids Interested in the Care of Their Kidneys

“We Care About More Than Your Hair”A Campaign of the National Kidney Foundation of Michigan

TM

Healthy Hair Program Goal: To prevent kidney disease by raising

awareness of its 2 primary causes: hypertension and diabetes and to encourage healthy lifestyle choices

Hair stylists in salons are trained as lay health educators

Two “health chats” are the centerpiece of the intervention– Risk assessment– Discussion of importance of healthy lifestyle– Encouragement to make positive changes

Outcomes from Primary Prevention Programs: Healthy Hair Healthy Hair has reached over 23,500

beauty salon clients with health education since 1999.

Surveys show that 64% of clients took a positive health step such as eating more nutritiously, increasing physical activity or stopping smoking.

In a review by the Agency for Healthcare Research and Quality in 2008, Healthy Hair was given an evidence rating of “moderate.”

Dodge the Punch Program• Developed as the male counterpart to the Healthy

Hair program• Barbers are trained to become lay health educators

in their barbershops Two “health chats” are the centerpiece of the

intervention (as with Healthy Hair)– Risk assessment– Discussion of importance of healthy lifestyle– Encouragement to make positive changes

Outcomes from Primary Prevention Programs: Dodge the Punch Has reached over 4,200 African-

American barbershop clients since 2005

58% of clients indicated that they had made at least one healthy lifestyle change.

Healthy Families Start with: YOU

A Promising Partnership

Healthy Families Program A multi-generational community-based

health education program Promotes the adoption of healthy nutrition

and physical activity habits Target population: preschool-aged children

and their low-income parents. Uses Head Start family service coordinators

to discuss the importance of nutrition and physical activity with Head Start parents.

Regie’s Rainbow Adventure Regie’s Rainbow Adventure is the

children’s intervention– Head Start teachers read these stories to

emphasize the importance of eating fruits and vegetables that “are the color of the rainbow”

– Children also create healthy snacks and play games related to the stories

– Stories are shared with parents so that good nutrition becomes a family goal

Testimonial from Healthy Families Program “Wanting to be a healthy role model to

my three young children, I joined the Healthy Families program. I was motivated to set healthy family goals and have lost over 20 pounds.”

Healthy Families Outcomes

Outcomes from Primary Prevention Programs: School Education Kids and Kidneys and Kids Interested

in the Care of their Kidneys– Have educated over 1 million elementary,

middle school and high school students since 1998

– Emphasize kidney disease prevention, nutrition and exercise

– Statewide evaluations have demonstrated a 20% knowledge gain with students

Secondary Prevention NKFM’s Kidney Early Evaluation

Program (KEEP) – Provides free kidney screenings using

glomerular filtration rate to measure how kidneys are filtering waste from the blood.

– Also screens for diabetes and high blood pressure

Secondary Prevention: PATH PATH (Michigan’s name for the Stanford

Chronic Disease Self-Management Program) Since 2006, NKFM has been at the forefront

of implementation and spread of PATH From 2007 to 2008, Michigan saw an 82%

increase in participants completing a PATH workshop

PATH outcomes: Improved exercise, symptom management and general health, and fewer emergency room and outpatient visits (See Stanford Ed web site)

People Completing PATH Workshops

107

894

1543

0

500

1000

1500

2000

# of People Completing PATH Workshop*

2007

2008

2009

Number of people completing PATH Workshop

Secondary Prevention: Enhance Fitness EF is an evidence-based physical activity

program specifically designed for older adults (60 and older) but has been shown to work for all adults.

NKFM has 3 EF trained fitness instructors and is in process of training more.

NKFM goal is to bring this program to Southeastern MI

Focus will be on individuals who have diabetes, hypertension and members of minority communities

Secondary Prevention: Diabetes Self-Management Education Programs NKFM and MDCH both provide support and

technical assistance to 89 statewide certified diabetes self-management education programs

These programs teach self-management to patients with diabetes and prediabetes:– How to manage blood glucose– How to make informed choices about nutrition and

exercise– How to treat complications of diabetes• Patients with diabetes provide about 98% of their own

care• These programs in Michigan reached more than 28,000

people in 2008.

Increase in diabetes educationreduces the incidence of CKD

* People with DSME in

Michigan

Tertiary Prevention eGFR Identification – Law passed in 2006 to

identify CKD early. All Medicaid patients must have an eGFR.

Continuous Quality Improvement – Working with managed care to identify CKD early (stage 3 and 4), educate primary care physicians on CKD, encourage referral to nephrologist for consult and focus on improving treatment (slow progression to kidney failure).

CKD: Classification by MDRD GFR Rationale for use

– GFR — direct measurement of kidney function

– GFR — best index of kidney function in health and disease

– GFR — correlates with pathologic severity of disease

– GFR — correlates functional level with risks of CKD progression and development of CV disease

* G Manjunath, et al. Postgrad Med. 2001;110(6):55–62.

<15 or dialysisKidney failure5

15–29Severe ↓ GFR4

30–59Moderate ↓ GFR3

60–89*Mild ↓ GFR2

> 90Chronic kidney damage with normal or ↑ GFR

1

GFRDescriptionStage

<15 or dialysisKidney failure5

15–29Severe ↓ GFR4

30–59Moderate ↓ GFR3

60–89*Mild ↓ GFR2

> 90Chronic kidney damage with normal or ↑ GFR

1

GFRDescriptionStage

NKF CKD Stages 1–5

* Kidney/Dialysis Outcomes Initiative. Am J Kidney Dis. 2002;39:S1–S266.

eGFR Outcomes in Michigan

CKD Testing is increasing in Michigan

* CKD Test Increasing

MCO Review of CKD Cost Data

MCO Results

* Improved Lab Results

RESULTS: Michigan’s Strategic Plan Primary, Secondary and Tertiary

Interventions in Michigan– Increase in kidney failure decreased by

over half – ESRD prevalence rates dropped

significantly– Incidence rates for ESRD for people with

diabetes dropped significantly

18192021222324252627282930313233

Year

Perc

ent

Michigan Florida Ohio New York National

32.2%

20.2%

1992 - 1997 1998 - 2003

ESRD PREVALENCE RATES

-12.0% -9.3% -8.7% -8.2% -5.4%

Incidence of ESRD for Patients with Diabetes

05

101520253035404550

0 1Year

Perc

ent

Michigan Florida New York Arkansas National

44.9%

14.8%

-30.2% -18.4% -20.0% -16.3% -23.9%

1993 - 1998 1999 - 2004

2005 HEDIS* Measures in Commercial Health PlansShow Michigan Providing Superior Diabetes Care

0102030405060708090

HB A1C testing Hb A1C Control(lower is better)

Eye Exam Lipid Control(LDL<130)

Kidney Testing

MichiganRegionNational

Source: National Committee for Quality Assurance (NCQA)*HEDIS - Health Plan Employer Data Information Set

Brief History of Our Partnership DCPC provided funding in 1993 for a “State Kidney

Plan” which was developed in concert with the Kidney Community

DCPC created an RFP for $25,000 to focus on kidney disease prevention in 1994

The Michigan Legislature provided funding for the State Kidney Plan for $300,000 in 1995.

These dollars were increased to $500,000 in 1997 due to positive results. (Created Diabetes/Kidney Disease state budget line!)

History (Continued) The Kidney Foundation received a Robert Wood Johnson

Foundation grant with the help of the DPCP to provide primary prevention community-based initiative (an African American Salon program) in 2000

Over the next several years, additional funding came from the DPCP, the Cardiovascular Section, private foundations and federal sources for this prevention program and others (Barbershop Initiative and Head Start Initiative)

A New State Kidney Plan was released in 2005. Focused also the Healthcare System through

eGFR/Managed Care and Innovative Community Programs

The Kidney Foundation was given the contracts for the Diabetes Outreach Networks in three regions.

Keys to Partnership Disease relationship – overlap of

diabetes with kidney disease Mutual funding

– Healthy Michigan Funds– Diabetes/Kidney Disease state budget line– Legislative advocacy by NKFM

Keys to Partnership Shared staff (Dialysis Nurse) Shared data, surveillance, materials, programs

(e.g., Diabetes Outreach Networks (DONs), CQI, Renal Plan, Strategic Plans)

Shared culture (e.g., Champions of Hope, Legislative Day, Diabetes Statewide Coalition)

Shared contracts (e.g., MDCH funding & NKFM matching funds, mutual objectives, evaluation

Keys to Partnership Consistent communication (including

non-crisis, face-to-face) Mutual trouble-shooting Stable leadership Mutual partners

Cultivating trust

Future Plans

Healthy Families-Statewide spread-Add pol/environmental change -Establish evidence base

Spread of evidence-based programs-PATH-Enhanced Fitness-DPP-based programs

Future Plans Add key community partners

-”Y”s-Arab Chaldean group

-Managed care health plans-Aging networks

CQI-MDRTC/UM -Key health plans

Future Plans Maintain 2 DONs (Grand Rapids, Det.)

Michigan’s budget crisis