web seminar series diabetes: practical approaches to ... · to preventing diabetes complications in...

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Diabetes: Practical Approaches to Preventing Diabetes

Complications in Vulnerable Populations

Welcome to the Disparities Solutions Center’s Web Seminar Series

Thursday, March 22, 20123:00PM – 4:30PM ET

This web seminar will start momentarily

Diabetes: Practical Approaches to Preventing Diabetes Complications in Vulnerable Populations

Joseph R. Betancourt, MD, MPHDirector, The Disparities Solutions Center at MGH

Presenters

Athena Philis-Tsimikas, MD Corporate Vice President for the Scripps Whittier Diabetes Institute

Robert Havasy, Project Specialist and mHealth Strategist at the Center for Connected Health at Massachusetts General

Hospital

Facilitator

Lenny Lopez, MD, MDiv, MPH Senior Faculty at the Disparities Solutions Center at Massachusetts General

Hospital

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HRET/DSC Web Seminar

This web seminar will highlight activities being taken by healthcare leaders to assure that they are training their staff, and building the systems needed so that their organizations are culturally competent and prepare to meet the needs of diverse populations.

Improving Quality and the Patient Experience: Creating Culturally Competent Healthcare Organizations

Thursday, May 3rd, 20123:00 - 4:30 pm EST2:00 – 3:30 pm CST1:00 – 2:30 pm MST12:00 – 1:30 pm PST

To stay posted, please go to Upcoming Events page on our website and register for updates by e-mailing [email protected] with your Name, Title, Organization, and E-mail address.

Feel free to share with others who may be interested in attending.

The Healthcare Quality and Equity Action Forum

September 25 & 26, 2012 Le Meridien Hotel, Cambridge, Massachusetts

To stay posted, please go to the forum webpage and register for updates by e-mailing [email protected] with your Name, Title, Organization, and E-mail address.

Feel free to share with others who may be interested in attending.

The Forum is designed for leaders that are active in health care delivery—including those from health plans, hospitals, and health centers across the country—who focus on quality improvement. It will provide participants with implementation strategies, tools, and skills to identify and address racial and ethnic disparities in health care within their organization, as well as techniques to transform organizations to focus on quality and equity.

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We received external funding for scholarships for public hospitals, Medicaid plans and community health centers. We are extending the application deadline for any of these organizations and who are interested in applying for the 2012-2103 class. This year-long executive education program is designed for leaders from hospitals, health plans and other health care organizations who wish to implement practical strategies to identify and address racial and ethnic disparities in health care, particularly through quality improvement.

DLP 2012-2013 Application Extension

Please go to our website at www.mghdisparitiessolutions.org for more information.

Athena Philis-Tsimikas, MDAthena Philis-Tsimikas, MD was named Corporate Vice President for the Scripps Whittier Diabetes Institute in May of 2008. Dr. Tsimikas is a board certified Endocrinologist. She received her research training from the University of California, San Diego, and clinical fellowship training from Scripps Clinic and Research Foundation. She served as a clinical endocrinologist on the staff of the Scripps Clinic Medical Group for 10 years from 1994 to 2004. She assisted in establishing the community wide, nationally recognized diabetes program, Project Dulce, in 1997 and subsequently joined Scripps Whittier Diabetes Institute to assist in the design and implementation of diabetes disease management programs for Scripps Health. She leads the Community Engagement section for the NIH supported Scripps Clinical Translational Science Award.

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Robert HavasyRobert Havasy is a Project Specialist and Operations Manager at the Center for Connected Health (CCH), part of the Partners Healthcare System in Boston, Massachusetts. With more than a decade of experience in telecommunications and computer networking, Mr. Havasyspecializes in making communication technologies accessible to patients while integrating them into clinical workflows. At CCH Mr. Havasy is responsible for customer service and charting the Center’s technology strategy. Mr. Havasy is a member of the Healthcare Information and Management Systems Society, the American Medical Informatics Association, the Society for Participatory Medicine, and sits on the Board of Directors of the Continua Health Alliance.

Lenny Lopez, MD, MDiv, MPH

Lenny Lopez, MD, MDiv, MPH is Senior Faculty at the Disparities Solutions Center. Dr. Lopez is an internist trained at the Brigham and Women's Hospital (BWH) and is an Assistant at the Mongan Institute for Health Policy at Massachusetts General Hospital (MGH). Dr. Lopez completed the Commonwealth Fund Fellowship in Minority Health Policy at the Harvard School of Public Health and received his MPH in 2005. He joined the Institute for Health Policy in 2008 after his two year fellowship in epidemiology and statistics at the Harvard School of Public Health. His research interests extend across a range of issues relating to racial and ethnic disparities including language barriers and patient safety, quality measurement and improvement in hospital care and the impact of health information technology on disparity reduction.

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Diabetes disproportionately affects minorities in the United States. 10.4% of Latino and 11.8% non-Latino black adults carried a diagnosis of diabetes compared to 6.6% of non-Latino whites in 2007.10

Disparities in prevalence, management, morbidity and mortality by race/ethnicity and socioeconomic status.1, 2

Prevalence is expected to increase in the context of the concurrent obesity epidemic,3 with overall diabetes prevalence expected to double by 2050.11

Type 2 Diabetes

Type 2 Diabetes

The largest increase in new cases is expected among minorities and especially Latinos.11

Latinos in the U.S. have the greatest risk of developing diabetes compared to whites and other minority groups5 and Latinos have higher diabetes-related mortality rates compared to whites.12

Accounted for about $127 billion in health care costs in 2007 (1in every 10 health care dollars is attributed to diabetes and 1 in 5 is attributed to someone with diabetes).13

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References Cited

1. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage. Ann Intern Med. 2009;150(8):505-515. PMCID 19380852.

2. Miech RA, Kim J, McConnell C, Hamman RF. A growing disparity in diabetes-related mortality U.S. trends, 1989-2005. Am J Prev Med. 2009;36(2):126-132. PMCID 19062239.

3. Field AE, Coakley EH, Must A, Spadano JL, Laird N, Dietz WH, Rimm E, Colditz GA. Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Arch Intern Med. 2001;161(13):1581-1586. PMCID 11434789.

5. Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. Jama. 2003;290(14):1884-1890. PMCID 14532317.

10. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: U.S.: Department of Health and Human Services; 2008.

11. Narayan KM, Boyle JP, Geiss LS, Saaddine JB, Thompson TJ. Impact of recent increase in incidence on future diabetes burden: U.S., 2005-2050. Diabetes Care. 2006;29(9):2114-2116. PMCID 16936162.

12. Gentile NT, Seftchick MW. Poor outcomes in Hispanic and African American patients after acute ischemic stroke: influence of diabetes and hyperglycemia. Ethn Dis. 2008;18(3):330-335. PMCID 18785448.

13. American Diabetes Association. Economic costs of diabetes in the U.S. In 2007. Diabetes Care.2008;31(3):596-615. PMCID 18308683.

Project Dulce: Diabetes Care and Self Management Activation in Diverse

Ethnic Communities

Athena Philis-Tsimikas, MDCorporate Vice President

Scripps Whittier Diabetes InstituteLa Jolla, CA

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Diabetes Excellence Across Communities:Nurse Case Management and Peer Educator Models for

Improving Diabetes Care

• Established 1997

• Primary Care setting

• Centralized registry and quality management

• Partnership between community health centers and diabetes experts

Black10%

Hispanic52%

Asian/Other14%

White24%

Four Pillars of Chronic Care

Improved Health Status and Quality of

Life

Electronic Registry

Nurse-led Team

Peer Education and Support

Standards of Care;

Algorithms

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Key Elements

Project Dulce Model

Empowered Patients

Multidisciplinary Team ApproachNurse-led

Peer education(Promotoras)

Pilot Program 1997

• 1/3 MediCal, 1/3 County, 1/3 uninsured

• Female (73%)

• Latino (72%)

• Type 2 DM (82%)

• Annual income below $10,000 (68%)

• 8th grade education or lower (51%)

Philis-Tsimikas et al. Diabetes Care 2004:27;110-115

January 2004

Philis-Tsimikas et al. Diabetes Care 2004:27;110-115

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Standards of Care met 81-100% of

the time

Positive treatment satisfaction (p=.001)

SBP 128 → 123 mmHg

Economic modeling over 3 years projects

savings of $1,216/patient

Shift to stronger internal locus of control (p = .04)

TC 232 → 198 mg/dl

Saved 60% in ER/Hospital costs

in 1 year

Improved diabetes knowledge (p=.001)

HbA1c 12→8%

Economic Outcomes

BehavioralOutcomes

Clinical Outcomes

Philis-Tsimikas et al. Diabetes Care 2004:27;110-115Gilmer T, Philis-Tsimikas A, Walker C. Ann Pharmacother 2005;39;817-22

Promotoras – Peer Educators• Competency-based training

program

• Stipends and/or reimbursement

• Continuing education

• Supervision and support

• Standardized curriculum

• Support of the health care team

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Cultural Divide: Providers and Patients

• Providers:– Science is the only

truth

– Stereotyping

– Cultural myths need to be discarded

– People will do what I tell them

– Non-compliance –patient’s problem

• Patients:– Severity of disease not

understood

– Fatalismo – Act of God

– Stories from family or friends

– Fear

– Language

– Insurance

– Immigration status

Bridging the Divide

• Recognize that culture influences health practices

• Meet patient in the middle—accommodate their beliefs

• Respect and learn from our patients

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What do Diabetes Peer Educators do?

– Teach diabetes education

– Facilitate behavior change– Encourage interaction

• Solve problems• Support gains

– Empower

San Diego County’s ProgramFinance Model

• Reimbursement for services provided by RN/CDEs, RDs, and peer educators

• Maximum service/year (for high risk):

– 1 RN/CDE initial and 8 follow-up visits;

– 1 RD initial assessment and 1 follow-up;

– 12 hours group education by peer educators

Improved Health Status and Quality of

Life

Electronic Registry

Nurse-led Team

Peer Education and Support

Standards of Care;

Algorithms

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Standardized Diabetes Education Materials

Diabetes Education Handbook Multilingual Handouts

© 2012 Center for Connected Health – All Rights ReservedContent Confidential – DO NOT DUPLICATE.

Diabetes Self-management System – Technical ArchitectureRobert HavasyOperations Manager, Partners Center for Connected Health


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Technology is an enabler to provide care remotely

Benefits include improved engagement, outcomes, and efficiencies

Mission is to facilitate the adoption of Connected Health

About the Center for Connected Health

Source: Wired 6/19/11

Harnessing the Power of Feedback Loops

1. EvidenceThe radar-equipped sign flashes a car’s current speed.

2. RelevanceThe sign also displays the legal speed limit–most people don’t want to be seen as bad drivers.

3. ConsequencesPeople are reminded of the downside of speeding, including traffic tickets and the risk of accidents.

4. ActionDrivers slow an average of 10 percent–usually for several miles.

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Reminder group

No Reminder Group

Medication Reminders

Encouraging Prenatal Care

Support While Battling Addiction

The Power of Simple Reminders

Tues.

Sunny. High 68, Low 53.

Please apply your sunscreen

today.

1009080706050403020100

Per

cen

t A

dh

eren

ce

Weekly Adherence Rates (mean +/- SEM)

© 2012 Center for Connected Health – All Rights Reserved Content Confidential – DO NOT DUPLICATE.

Suboxone Treatment:

•88% — Helped to remember their medical appointments

•75% — Felt supported by their nurse

Prenatal Care for at-risk pregnant women:

•74% — Helped to learn to take care of themselves and their babies

•85% — Felt supported by the OB team

Mobile Technology Supports Diverse Patient Populations

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Activity Monitoring as a Public Health Application

• Activity tracking using a pedometer

• Automatic data upload

•Incorporates educational feedback

•Gaming and competitions

• Students had a consistent “dip” during school vacation week

• “Boost the energy” events may have contributed to regaining momentum

• Fifield’s overall average daily steps declined, likely due to end of school closing

Step Counts — All Schools

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Using Activity Monitoring and Text Messaging for Behavior Change in a Diabetes Self-Management

Program

Lenny López, MD, MDiv, MPHKamal Jethwani, MD

Center for Connected Health Team

Mongan Institute for Health PolicyThe Disparities Solutions Center Massachusetts General Hospital

The authors have no financial disclosures

Diabetes

• Incidence of type 2 diabetes is increasing in the US, particularly among racial/ethnic minorities

• Long term chronic disease management approach– Patient engagement and empowerment– Lifestyle and behavior changes– Diabetes self-management education

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Diabetes Self-Management Education

• American Diabetes Association (ADA)– National standards

• Multidimensional curriculum• Continual tailored use is associated with

improved outcomes• Only about 60% of patients are able to achieve

all their goals• Difficult to sustain long term behavior change

Funnell et al. National Standards for Diabetes Self-Management Education. Diabetes Care 2008;31(Suppl 1):S97-S104

Diabetes Self-Management Education

• Disease Education• Glucose monitoring• Medication Use• Behavior change techniques• Lifestyle changes

– Physical Activity– Losing Weight– Diet

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Focusing the Intervention

• Multidimensional challenge• Need to pick one or at most two dimensions

to focus your intervention• Good place to start is to work from what

programming is already in place• Patient and clinician centered needs

assessment surveys and/or interviews

Picking an Outcome

• Length of Intervention• Are there standard measures that

are easily collected?• Cost• Training• Clinical Outcomes• Behavioral Outcomes

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Project Overview

• To evaluate the effect of personalized text messages and daily step count monitoring – Physical activity behavior change

• Pedometer step count • Intensity of engagement with program

– Clinical outcomes• Hemoglobin A1C

• 6-month randomized controlled trial• Community health center patients in

medically underserved areas

Why Text Messaging?

• Widespread technology and thus less of a ‘digital divide’ problem for vulnerable populations

• Low cost and sustainable

• Personalized messaging

• One and two way communication

• Provide long term support needed for behavior change

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Text Messaging

• Creating a text messaging bank– We created 900 !– Multiple stakeholder input

• Clinicians and diabetes educators

– Time intensive for developing• Content• Character limitation (160 characters)

Text Messaging

• Generalized messages vs. stage of change appropriate messaging

• Trans-Theoretical Model of Behavior Change– Pre-contemplation, Contemplation, Preparation,

Action, Maintenance

• Increase likelihood of appropriateness

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Text Messaging and Minority Populations

• Need for tailoring to the target audience• Need for psychosocial and cultural tailoring

– Neighborhood and weather challenges

• Translation into Spanish– Expert translation and review– Literacy and health literacy– Cost

Monitoring Use and Effectiveness

• You need to assure that the participants are using the technology– Use of pedometers, uploading data, responding to

texts– Standardization of follow-up to maintain

engagement– Need staff to reach out to those not engaged– Need staff to be available for IT support and to

call those with questions– Need staff to follow-up on 2 or 3 way texting

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Diabetes Self-management System – Technical ArchitectureRobert HavasyOperations Manager, Partners Center for Connected Health



Research Project Goal

Collect stepsProcess dataBuild customized SMS messages

Do this:SecurelyFollowing HIPAA / IRB Requirements


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3 Components

Wireless Pedometer

•Long battery life (6+ months)

•Wireless offload

•No buttons / batteries / display / cords

Database

•RMDR – Remote Monitoring Data Repository

•MS SQL

•Core IS infrastructure –hosted in Partners data center

SMS Messages

•Available on any device – minimal training required

•Robust messaging engine

•Administrative control & data

•Customizes messages based on data

Database icon courtesy RRZEicons under Creative Commons license.



Build or Buy? Critical Considerations

Pedometers•Rugged & reliable•Minimum intrusion into patient’s life•Low technology barrierBottom line: We chose a device with which we have past experience from a vendor with whom we have a good relationship.

Data Handling•Privacy & security•Availability of data for researchBottom line: We built upon an existing platform to ensure data availability and to speed development. This system could be bypassed if the right pedometer/text messaging platform were selected.

Text Messaging•Someone who understands carrier compliance•Robust logic platform•Willing to integrate with other systemsBottom line: Having a knowledgeable vendor is key to a robust, reliable platform and quick deployment.

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Privacy & Security

No PHI transits the networkOnly common identifier is an ID assigned by research staffAll servers / systems are enterprise-class with physical and administrative safeguards



Integration


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Integration


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Question and Answer Period

Please submit your questions online by typing them into the Question box on the right side of the screen and clicking the “Send” button. The panelists will try to answer the questions as succinctly as they can.

Depending on the size of the audience, we may not be able to answer all questions.

Diabetes: Practical Approaches to Preventing Diabetes Complications in Vulnerable Populations

Joseph R. Betancourt, MD, MPHDirector, The Disparities Solutions Center at MGH

Presenters

Athena Philis-Tsimikas, MD Corporate Vice President for the Scripps Whittier Diabetes Institute

Robert Havasy, Project Specialist and mHealth Strategist at the Center for Connected Health at Massachusetts General

Hospital

Facilitator

Lenny Lopez, MD, MDiv, MPH Senior Faculty at the Disparities Solutions Center at Massachusetts General

Hospital

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Remember!

• HRET/DSC Web Seminar

• The Healthcare Quality and Equity Action Forum

• DLP 2012-2013 Application Extension

www.MGHDisparitiesSolutions.org

Thank you for your participation!

web seminar series diabetes: practical approaches to ... · to preventing diabetes complications in...

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