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Changing Strategies for Diabetes Education: Improving Rural Community Access with Telehealth

Mia Painter, DNP, APRN, FNP-C

September 9, 2019

Objectives• Discuss research and other evidence on the use telehealth for

patient education • Discuss current state and national legislation and regulation for

telehealth services• Identify barriers to and methods to overcome them in the use of

telehealth for patient diabetes education • Discuss billing and coding strategy for telehealth reimbursement

Disclosures

I have NO financial disclosure or conflicts of interest with the material presented today.

Background• Glycemic and lifestyle

changes

• Hemoglobin A1C < 7%

• Lack of access

• Cost prohibitive

• Not sustainable

(CDC, 2017)

Diagnosed Diabetes by State Diabetes Prevalence by Year

National Financial Implications

• Potential reductions• $4 billion in hospitalizations• $735 million in emergency room (ER) visits• $8 billion in potential ER visits and hospitalizations annually

(“Challenges in Diabetes,” 2017)

• Total care cost reduction by $2,207 per patient/year (Juarez, et al., 2013)

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Percent of Texas Population with Diabetes

Telehealth Definition

“the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include video conferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communication”

(U.S. Department of Health and Human Services Health Resources and Services Administration [HRSA], 2019, pg. 1 para.3).

Telehealth Services

üDisease education (Vismara et al., 2013; Wainer & Ingersoll,

2015; Gerber et al., 2013; Graves et al., 2013)

üMedication administration and adherence (Saberi et al., 2013; Gerber et al., 2013)

üPatient motivation and satisfaction (Saberi et al.,

2013; Vismara et al., 2013)

üReduced costs (Graves et al., 2013)

üImproved access and outcomes (Graves et al., 2013)

TELEHEALTH EDUCATION

• Parental educational for autistic children (Vismara, et al., 2013; Wainer & Ingersoll, 2015)

• Medication education to HIV patients (Saberi, et al., 2013)

• Patient weight loss education (Gerber, et al., 2013)

• Patient knowledge and adherence in heart failure (Graves, Ford, & Mooney, 2013)

TELEHEALTH DIABETES EDUCATION

• Education literacy and personal self-care skills (Long & Gambling, 2012)

• Hemoglobin A1C (Lepard, Joseph, Agne, & Charrington, 2015; Worswick, et al., 2013)

• Increased patient access to care in rural settings (Lepard, et al., 2015)

ADDITIONAL CONSIDERATIONS• Improved patient care

satisfaction (Saberi, et al., 2013; Vismara, et al., 2013)

• Increased patient motivation (Maeder, Poultney, Morgan, & Lippiatt, 2015)

• Reduced health care costs• Improved health outcomes (Graves,

Ford, & Mooney, 2013)

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CONCEPTUAL MODELTelehealth in Chronic Disease (TECH)

• Engagement

• Coordination

• Partnership

• System interaction(Salisbury et al., 2015)

Sample Pilot Program• Online instructional DSME

• Instructional videos• Teleconference

• Outcome measures (quarterly)• Clinical outcomes• Participation• Program cost

DemographicsGroup Number of

ParticipantsAge

M(Range)Gendern(%)

F=FemaleM =M ale

Ethnicityn(%)

H=Hispanic NH=Non-Hispanic

BaselineHbA1C%M(Range)

Group class(Pre)

24 51(33 - 71)

13 (54) F11 (46) M

15 (63) H9 (37) NH

8.4(5.4 – 13.1)

Group class/Telehealth

11 51(23 - 72)

7 (64) F4 (36) M

7 (64) H4 (36) NH

8.4(5.4 – 14.1)

Telehealth –Online only

20 43(20 - 67)

13 (65) F7 (35) M

15 (75) H5 (25) NH

9.5(6.3 – 14.0)

Telehealth –Online/

teleconference

35 51(29 - 70)

23 (66) F12 (34) M

26 (74) H9 (26) NH

9.9 (5.8 – 15.5)

Telehealth –Total (Post)

66 49(20 - 72)

43 (65) F23 (35) M

48 (73) H18 (27) NH

9.6(5.4 – 15.5)

7.9%

9.6% Non-parametric Analysis

No difference at baseline (CI 95, p=0.063)

Statistically significant at 3 months(n=42, p<0.001)

Statistically significant at 6 months (n=22, p=0.001)

Mean Improvement 1.7%

Limitations

Sample size

Duration

Evaluation• Did the intervention improve HgA1C levels at initial 3 month follow up?

Yes

• Was the change sustainable?

Inconclusive

• Did the intervention improve patient access?

Yes

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Discussion

• Individualized telehealth education• Unique one on one interaction• Access vulnerable populations• Decrease medication need• Reduce healthcare cost

C ourtesy o f A bbey O yetun ji, SM E digest.com

Texas Telehealth Regulation

• Coverage Parity• Reimbursement Parity• Standard of care• Patient consent• Site regulation

Courtesy Michael Idemudia

Barriers to Practice

• Reimbursement and coding• Certification requirements• Staff training • Time constraints

Methods for Implementation

• Electronic health record/patient portal• Learning management systems• Remote patient monitoring• Secure/encrypted phone system• Store and forward educational materials

Billing• Originating site

• Distant site

• Performing provider

• CPT codes

• Modifiers

Coding• 98960 -98962– Patient education and training (each 30 min)• 99211-99215 – Office or outpatient visit established patient• G0108/ G0109 – Individual and group DSME • G0459 – Pharmacologic management• G0270 (97802-04) – Individual and group medical nutritional therapy

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Coding

• GQ – Via asynchronous telecommunications systems• GT – Via interactive audio and video telecommunications systems• 95 – Synchronous telemedicine service rendered via a real-time

interactive audio and video telecommunications system • POS – Place of service codes

Conclusion

ReferencesAmerican Diabetes Association. (2017) Statistics about Diabetes. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/

Centers for Disease Control. (2017) Maps of trends in diagnosed diabetes. Retrieved from

https://www.cdc.gov/diabetes/statistics/slides/maps_diabetes_trends.pdf

Central Texas Medical Center. (2016). Community Health Needs Assessment. Retrieved from

https://www.ctmc.org/Portals/7/docs/community%20benefits/2016%20Community%20Health%20Needs%20Assessment%20

Central%20Texas%20Medical%20Center%20.pdf

Challenges in Diabetes Mangement: Glycemic control, medication adherence, and healthcare costs. (2017). American Journal of Managed Care. Retrieved from file:///Users/miapainter/Downloads/AJMC_A773_08_2017_DiabetesManagement_Faculty.pdf

Community Commons. (2014). Community Health Needs Assessment: Advancing Community Health and Well Being, Hays Core Health Indicators Report. Retrieved from http://bvcasa.org/prc/wp-content/uploads/2014/05/Hays-Core-Health-Indicators-Report.pdf

Gerber, B. S., Schiffer, L., Brown, A. A., Berbaum, M. L., Rimmer, J. H., Braunschweig, C. L., & Fitzgibbon, M. L. (2013). Video telehealth for weight maintenance of African-American women. Journal of Telemedicine & Telecare, 19(5), 266-272. doi:10.1177/1357633X13490901

Graves, B. A., Ford, C. D., & Mooney, K. D. (2013). Telehealth Technologies for Heart Failure Disease Management in Rural Areas: An Integrative. Online Journal of Rural Nursing & Health Care, 13(2), 56-83.

Juarez, D., Goo, R., Tokumaru, S., Sentell, T., Davis, J., & Mau, M. (2013). Association between sustained glycated hemoglobin control and healthcare costs. The American Journal of Pharmacy Benefits. Retrieved from https://www.ajpb.com/journals/ajpb/2013/ajpb_marapr2013/association-between-sustained-hemoglobin-control-and-healthcare-costs

Lepard, M., Joseph, A., Agne, A., & Cherrington, A. (2017). Diabetes Self-Management Interventions for Adults with Type 2 Diabetes Living in Rural Areas: A Systematic Literature Review. Current Diabetes Reports, 15(6). doi: 10.1007/s11892-015-0608-3.

Long, A. F., & Gambling, T. (2012). Enhancing health literacy and behavioural change within a tele-care education and support intervention for people with type 2 diabetes. Health Expectations, 15(3), 267-282. doi:10.1111/j.1369-7625.2011.00678.x

REFERENCESMaeder, A., Poultney, N., Morgan, G., & Lippiatt, R. (2015). Patient Compliance in Home-Based Self-Care Telehealth Projects. Journal of Telemedicine & Telecare, 21(8), 439-442. doi:10.1177/1357633X15612382

Saberi, P., Yuan, P., John, M., Sheon, N., & Johnson, M. O. (2013). A Pilot Study to Engage and Counsel HIV-Positive African American Youth Via Telehealth Technology. AIDS Patient Care & STDs, 27(9), 529-532. doi:10.1089/apc.2013.0185

Salisbury, C., Thomas, C., O’Cathain, A., et al. (2015) Telehealth in CHronich disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation. British Medical Journal Open, 5:e006448. Doi: 10.1136/bmjopen-2014-006448

Tang, T. S., Funnell, M. M., & Oh, M. (2012). Lasting effects of a 2-year diabetes self-management support intervention: outcomes at 1- year follow-up. Preventing Chronic Disease, 9, E109-E109.

Titler, M., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, C., & ... Goode, C. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics Of North America, 13(4), 497-509.

United States Department of Health and Human Services. (2017). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws

Vismara, L. A., McCormick, C., Young, G. S., Nadhan, A., & Monlux, K. (2013). Preliminary Findings of a Telehealth Approach to Parent Training in Autism. Journal of Autism & Developmental Disorders, 43(12), 2953-2969. doi:10.1007/s10803-013-1841-8

Wainer, A., & Ingersoll, B. (2015). Increasing Access to an ASD Imitation Intervention Via a Telehealth Parent Training Program. Journal of Autism & Developmental Disorders, 45(12), 3877-3890. doi:10.1007/s10803-014-2186-7

Worswick, J., Wayne, C., Bennett, R., Flander, M., Mayhew, A., Weir, M., Sullivan, K., & Grimshaw, J. (2013). Improving Quality of Care for Persons with Diabetes: An Overview of Systematic Reviews – What Does the Evidence Tell Us? Systematic Review, 2(26). doi: 10.1186/2046-4053-2-26.

Questions or Comments?

Contact informationMia M. Painter, DNP, APRN, FNP-Cmia@linuxbrew.com290 Ladybug LaneMartindale, Texas 78655512-736-8328