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Diabetes and eye care and the benefits of working together as a team to deliver this care.
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Collaborative Diabetes CareCollaborative Diabetes CareMark G. Mitchell, OD, MBAMark G. Mitchell, OD, MBA
Reno, NevadaReno, Nevada
What my patients think of...What my patients think of...
==
What I think of...What I think of...
8.5%World
10.9%US
>50%Tohono O'odham
Int Diabetes Federation 2013; Tohono O'odham Community Action
Prevalence
We need to change our We need to change our diabetes visits to work diabetes visits to work
better as part of the teambetter as part of the team
It's really important to system● Costs● Benefits of early intervention● It's an epidemic
Demographics
African AmericanAfrican American Native AmericanNative American Hisp/LatinoHisp/Latino0%0%
5%5%
10%10%
15%15%
20%20%
25%25%
30%30%
ArizonaArizonaUSUS
10% of spending
10% of patients
QUALITY CAREQUALITY CARE
“All health professionals should be educated to deliver client-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”
Institute of Medicine, Health Professions Education: A Bridge to Quality (2003).
Sounds like Midwestern...
“All health professions schools have an obligation to educate future practitioners who are prepared both to assess and to meet the health needs of the public. This obligation entails…fostering greater inter-professional teamwork and collaboration.”
Macy Foundation, “Revisiting the Medical School Education Mission at a time of Expansion, 2009
DiabetesDiabetes
A great chance to collaborate and foster interdependence.
Oh...Oh...
And improve patient care.
Working togetherWorking together
Collaborative – includes concepts of shared responsibilities, shared decision-making, shared values, shared planning and intervention, and sharing of professional perspectives
Interdependent - mutual dependence rather than autonomous – arises out of common desire to address patient’s needs
• D'Amour, D., M. Ferrada-Videla, et al. (2005). "The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks." Journal of Interprofessional Care Supplement 1: 116-131.
Why don't they care?
Why don't they care?
● PCPs are trying to prevent:● MI, CVA, amputation, vision loss, etc● They are trying to follow current evidence-based
guidelines for– BP– Foot screening– Eye screening– Cholesterol– Education– And, it goes on and on
Why don't they care?
They're concerned with far more than the eye...
2013 US Costs2013 US Costs
US Primary Eyecare US Diabetes0
50
100
150
200
250
Bill
ion
s
Sources: Ken Research, American Diabetes Association
2013 US Costs2013 US Costs
US Primary Eyecare US Healthcare0
500
1000
1500
2000
2500
3000
Bill
ion
s
Sources: Ken Research, American Diabetes Association
2013 US Costs2013 US Costs
US Primary Eyecare US Healthcare0
500
1000
1500
2000
2500
3000
Bill
ion
s
Sources: Ken Research, American Diabetes Association
1%1%
We think of... They think of...
HEDIS
● Healthcare Effectiveness Data and Information Set ● NCQA ● Measure performance of health plans to allow
comparisons
HEDIS 2014
Out of 85 HEDIS measures
Only 2 eye measures
DM exams that's part of the Comprehensive DM Care measure
The other is glaucoma screening in older adults
What they really want from us?
IS IT TIME FOR IS IT TIME FOR LASER?LASER?
This isn't particularly collaborative.
We're small potatoes.
The Usual PCP Report
Do they have any DM findings?
What else have you done?
Do they need any tx?
When do they need to come back?
Who's the PCP?
MD
DO
NP
PA
Front desk staff?
Benefits of Medicine Collaboration
● Interprofessional relations● Valuable contribution of optometry students
● (we can't bill Medicare for their services anyway, why not put them in medicine clinic?)
● Oh, and the patients will benefit too● Save a visit● Get better care
Midwestern could be there...
● Collaboration● Optometry-Osteopathy
● A New Two O's
Diabetes care is comanagement
We are held to a medical standard
Same as ophthalmology
We need to do more.
Diabetes
● The standard of care is medical and involves:
● state of the art examination ● coordinated comanagement
with physicians● continuous patient
education ● timely referral when
complications occur.
● The timeliness of a referral is important, especially for patients with good vision and significant retinopathy. Failure to make a timely referral can result in litigation
The Diabetes Eye Visit
● a thorough history must be taken
● the examination should include:● measurement of visual acuity● refraction (as indicated)● tonometry and slit lamp evaluation● Dilated ophthalmoscopy and fundus biomicroscopy
● Ophthalmologists are sued by patients with diabetes more frequently than any other type of physician.
● Because loss of vision from diabetes is often preventable if timely diagnosis and treatment are provided, failure to refer appropriately can result in significant awards for damages.
Maybe if we help the PCP?Maybe if we help the PCP?
Maybe then they'll love us...Maybe then they'll love us...
What more could we do?
● Make the dilated eye exam more like their own office visit● BP, ask about compliance, any difficulties● Review medications● Go over self measurement logs...MDs don't have
time– And, reimbursement doesn't help
● Educate● Order screening blood tests for at risk patients
Get a blood test...
If at risk for diabetes or pre diabetes
Or...
● Have diabetes eye evaluations as part of a team effort with● Medicine● Podiatry● Education/Adherence● Blood draw
What more could we do?
Educate
● Optometrists should educate patients with diabetes concerning the risk of ocular complication and the need for periodic examination.
● Patients with retinopathy should be placed on a reasonable recall schedule or, if appropriate, referred to a physician.
● Recall schedules are based on the level of retinopathy observed.
ADHERENCE!
75% of patients don't take their medications as prescribed!
And, we're the ones who get sued?!
Source: M. Sokol et al., "Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost," Journal of Medical Care, 2005.
Return on Investment from Improved Medication Adherence: Diabetes
$1 more spent on diabetes medicines = $7.10 less spent on other services
Ave
rag
e A
nn
ua
l S
pe
nd
ing
R
ela
ted
to
Dia
be
tes
Adherence (%)
NONADHERENCE!
–Increases deaths, hospitalizations, and emergency room visits –Increases overall health care costs –Diabetes specific medications are not the only important thing
Patients, health care providers, and health care systems all play a role in creating the quality and outcome gap between current reality and optimal diabetes management.
Clinical Diabetes 2008;26:1 17-19.
Diabetes is a common and very costly chronic disease. There is broad-based agreement on how to manage diabetes, yet less than 40% of adults with diabetes achieve guideline-recommended levels of medical care.
Commonwealth Fund.
Change the exam a little
● Improve intraprofessional relations● Improve referrals to optometry● Improve patient care
The New Diabetes Eye Visit
● Vision, dilated exam, of course● Add blood pressure● More complete history
● Medication● Adherence/compliance● Any issues
● Education● Your choice on how extensive
The New Diabetes Eye Visit
● And, send a report● Send it right away...yes, right after or during visit● Consider other team members that might need it
– PCP, of course– Podiatry– Endocrine– Dental– Wound care– Even, the patient!
● MAKE SURE PATIENT IS IN THE LOOP
I can't do it!
● We have to...we're held to a medical standard● It doesn't take much time (and, you can train
your staff)● Standards for BP, glucose, a1c easy to learn● Patients accept this readily (they expect it!)● OK, so maybe education is hard, but we can
get better
The Business CaseThe Business Case
While there are questionable economic benefits for a health plan, there are real economic beneifts for private practitioners and other providers.
Increased referrals
Better interactions with PCPs
Increased recall effectiveness
More network opportunities
Faculty Development
Commitment to the value of IPE and IP collaborative practice
Knowledge of scope of practice of the professions
Effective teamwork skills
Teaching and managing large classes
Interactive learning
Small–group facilitating
What's best for the patient?What's best for the patient?
Working as part of the team.Working as part of the team.
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