PATHS: Providing Access to Healthy Solutions

An Analysis of Opportunities to Enhance Type 2 Diabetes Prevention and Management

Maggie Morgan and Sarah Downer

The Center for Health Law and Policy Innovation

Harvard Law School

May 30, 2014

PATHS Structural AnalysisPATHS Structural Analysis

• Food• Physical Activity

Disease Prevention

• Access• Quality

Disease Management

TYPE 2 DIABETES: PREVENTION

Economic Access to Healthy Food

Nutrition and Cooking Education

Geographic Access to Healthy Food

Early Childhood, School Food, and

Wellness Programs

Physical Activity/ Built Environment

Diabetes Type 2 Prevention ThemesDiabetes Type 2 Prevention Themes

• Ease of application• Improved online services• EBT at farmers marketsParticipation

(SNAP)

• Invest in interagency pilot programs

• Scale up successful programsInteragency Collaboration

SNAP and WICSNAP and WIC

Healthy Food RetailersHealthy Food Retailers

New Food Retailers• Grants and loans to

incentivize in low-access areas

• Zoning policies

Existing Food Retailers• Tax Incentives for

offering healthy food

Farmers Markets• Development in new

areas• EBT acceptance

Transportation• Invest in sidewalks

and public transportation

• Leverage existing transportation

Results from Study Committee on Food Desert Zones

Results from Study Committee on Food Desert Zones

Snap Ed Implementation

Local Government

ActionSchool Gardens

School Breakfast Further study

Complete Streets vs. Transportation Funding

Health Impact Assessments

Sidewalk Requirements

Data Collection

Built EnvironmentBuilt EnvironmentC

omm

unity

Aw

aren

ess

and

Phy

sica

l Act

ivity

Info

rmat

ion

Early Childhood InterventionsEarly Childhood Interventions

Best practices

Home visiting programs

Revise Star Rated License

SystemFinancial

Incentives for Centers that

Excel

Direct Certification

School Breakfast

Community Eligibility

Technical Assistance

Summer Feeding

Programs

School FoodSchool Food

Wellness Policy Implementation

Shared Use Agreements

Tax Credits for Workplace

Wellness Programs

WellnessWellness

TYPE 2 DIABETES: MANAGEMENT

Goal: Whole-Person Patient Centered Diabetes Management

Goal: Whole-Person Patient Centered Diabetes Management

Primary Care Specialty Care

Lifestyle Modification

and Management

Services

Community Resources

Access to Key Services

Managing Health

Disparities

Access to Providers

Healthcare Delivery System

Whole-Person Diabetes Care

Teams

Type 2 Diabetes Management ThemesType 2 Diabetes Management Themes

Expanding Access to Key ServicesExpanding Access to Key Services

Diabetes Equipment &

Supplies

Innovative Use of Health

Technology

Diabetes Self-Management

Programs

Behavioral Health Services

Diabetes Prevention

Program

Diabetes Prevention Program Diabetes Prevention Program

5-7% weight loss

150 min/week physic

al activit

y

58% Reduction

in Diabetes

NC Recommendations: Diabetes Prevention Programs

NC Recommendations: Diabetes Prevention Programs

Medicaid reimbursement

Increase state funds for targeted,

evidence-based prevention efforts

Extend postpartum Medicaid benefits

beyond 60 days

Increase support for clinical practices through funding for AHEC, Office

of Rural Health, etc

Durable Medical Equipment, Supplies and Insulin

Durable Medical Equipment, Supplies and Insulin

Cost-Sharing; Quantity Limits; Brand ChangesNeed to Test Frequently

NC Recommendations: DME and Insulin NC Recommendations: DME and Insulin

Provide assistance to help patients with

copays and coinsurance to access insulin

Lower costs of testing supplies for patients who

follow best-practices approaches to diabetes

management

Expand access to health insurance for low-income people

Need for Statewide and

Local Coordination

Billing and Reimbursement

Challenges

NC Successes in DSME, DSMP and

MNT Continuing

Barriers to Access

Diabetes Self-Management ProgramsDiabetes Self-Management Programs

NC Recommendations: Diabetes Self-Management Education and Support NC Recommendations: Diabetes Self-Management Education and Support

Establish statewide Diabetes Self-

Management Task Force

Recognize “gold seal” diabetes

education programs

Develop strong DSME care

teams

Offer reimbursement for clinical practices

Behavioral Health Services and Diabetes Management

Behavioral Health Services and Diabetes Management

Three Highlights1. Poor behavioral health lowers patient’s

ability to provide effective self-care2. Integrating behavioral care into patient’s

primary care improves health outcomes3. Two barriers to integration:

Shortage of behavioral health providers

Lack of coordination between primary care and

behavioral health care systems

NC Recommendations: Behavioral Services NC Recommendations: Behavioral Services

(1) Expand the use of

telepsychiatry

(2) Implement Pay-for-Performance

incentives to improve provider coordination

(3) Incentivize behavioral health providers to join

the state’s Health Information Exchange

(4) Better incorporate behavioral health

education into diabetes care

Health Information Exchange

Technical Assistance to Clinical Practices

Telemedicine Opportunities

Geographical Mapping-Durham Diabetes Coalition Project

Innovative Use of Health Information Technology

Increasing Access to ProvidersIncreasing Access to Providers

Enrollment and Recruitment of Providers

• In-state physician recruitment and retention • Recruitment of minority providers • Incentives for primary care providers• Nursing/nurse practitioner shortages

Promoting comprehensive health care teams

• Opportunities for valuable providers such as pharmacists to serve on diabetes care teams• Role of community health workers

Focus on undeserved areas and areas with high health disparities

• Geographic and racial disparities • Transportation • Promise of Telemedicine

NC Recommendations: Retention and Recruitment

NC Recommendations: Retention and Recruitment

Expand current residency programs

and create new ones

Target in-state residents for medical school and residency

programs

Expand the number of Primary Care NPs

within the state

Maintain increased Medicaid

reimbursement rates

Encourage recruitment of minorities into

medical and nursing schools

NC Recommendations: Promoting Comprehensive Healthcare Teams NC Recommendations: Promoting Comprehensive Healthcare Teams

Support Medication Therapy Management ProgramsFurther Embed Clinical Pharmacists into NC MedicaidIncorporate Pharmacists into NC’s Medicaid Chronic Health Homes

PHARMACISTS

Increase Financing of CHW Programs Gather Data on CHW Certification Programs

COMMUNITY

HEALTH WORKERS

NC Recommendations: Reduce Health Disparities

NC Recommendations: Reduce Health Disparities

Expand the use of promising

telemedicine programs

Promote successful loan

repayment/incentive programs

Explore transportation challenges and opportunities

• Shift towards shared savings and bundled payments may help diabetes prevention and management

• Medicaid Health Homes through CCNC; Patient-Centered Medical Homes

• Opportunities for Provider Coordination

• Increased Health Outcomes??

Financial Incentives for

Providers

Coordinated Care Models

for People with Diabetes

Health Information Technology

Accountable Care

Organizations

Healthcare Delivery System

QUESTIONS?