Effective delivery of Diabetes Self-Management Training through telehealth enabled services Katie Farrell, RD, CDE Lana Adzhigirey RN MN CPHQ Manager Diabetes Education RN Program Administrator VHS CHI Franciscan Health CHI Franciscan Health

April 16, 2016

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Patient and Population Health Perspective

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• Lana Adzhigirey declares that during the past 12 months neither she or any member of her family, has had another financial interest in a corporate organization providing support to this continuing medical education activity.

• Katie Farrell declares that during the past 12 months neither she or any member of her family, has had another financial interest in a corporate organization providing support to this continuing medical education activity.

Disclosure

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• Demonstrate how a telehealth-enabled diabetes management program can be integrated into diabetes education centers

• Discuss outcomes and lessons learned about patient engagement, in-home technology, and program staffing

• Summarize the patient, clinician, health system, and payer benefits associated with a telehealth-enabled diabetes management program

Learning Objectives

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CHI Franciscan Overview The premier health system in Pacific Northwest

Presentation Title 5

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System of Care

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Virtual Health Services & Clinical Operations Center

Acuity

Services across our patient’s care continuum

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Virtual Health Services Care Transformation Services - Growth

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Other Services (New and developing)

Hospital Patient Monitoring Services (Telemetry, Virtual ICU, Virtual Companion)

Care Transformation Services (VUC, Chronic Disease Mgmt, Post Discharge Care )

Telehealth Consults (Provider to Patient, Provider to Provider, Patient to patient, Community )

Patient Navigation Services (Operators, Interpreters, Central Staffing)

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Virtual Healthcare Model Framework

Clin

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Info

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Care Transformation Services - Partnership

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Virtual Diabetes Management The Vision

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“Being diagnosed with diabetes is like being placed in a raft and

thrown in the middle of the ocean with two oars.”

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FHS Patient Centered Care Model Example Care Transformation Services - Growth

Patient Engagement

Care Continuum

1. Patient education program coordination

2. Patient experience/service recovery coordination

Care Transition

Post Discharge

1. Calls: all discharged patients (Inpatient, ED, SDS, etc)

2. Follow up care (d/c instructions, f/u appointments, meds)

3. Option for remote monitoring for 30 days

4. Option for Virtual Follow up visits by PCP

Health Promotion

Chronic Disease Program

1. Same as care transition but 60 days

2. Expand to multiple chronic conditions 3. Additional d/s specific

modules: Virtual Diabetes Management – CDE, health coaches

Access to Care

Population Health

1. Virtual Urgent Care to decrease avoidable ED costs

2. Patient Access Team: Connect general population with Primary Care

3. Predictive Analytics?

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Innovation What we THINK it is:

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Innovation What it REALLY is:

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Innovation The typical first response:

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Diabetes Care

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Most people with diabetes do not get education in that first year of diagnosis

Fewer than 7% of persons received DSMT within 1 year after

diagnosis with diabetes.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6346a2.htm?s_cid=mm6346a2_e

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Diabetes Management

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Diabetes Self-Management Education/Training Reimbursement Toolkit, 2013.

3 year retrospective claims analysis of 4

million covered lives, average cost savings $135 per month of

those who completed DSME

YET DSME use remains

very low

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VDMP: Virtual Diabetes Management Program

The challenge is reaching those who do not receive diabetes education. We had an opportunity with CHI

division of innovation, to try a different way of delivering education.

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Technology changed faster than we could plan our program

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Virtual Diabetes Management Program VDMP

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So many reasons to quit!

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We lost our virtual health care provider partner, once we overcame that obstacle,

another major roadblock.

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Just Start

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One of our team members (Tina) at a critical decision making point reminded us

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Extensive Planning

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Workflows Workflows Workflows And then … Just Start! WADE 2016

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• Implement a Virtual Diabetes Management Program and enroll patients with diabetes that is difficult to control

• Provide them with home monitoring equipment and 1:1 coaching for 6 months

• Improve Hgb A1C results and compliance with DM pathway

Virtual Diabetes Management Program: VDMP

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10

14

Gender

Male

Female

Age Range (years)

Average Age (years)

37 to 80 58

• March – December 2014 • Last patient to enroll equipment

install: July 8, 2014 • Every patient enrolled for 6 months

• Final enrollment: 25

• 22 patients completed program • 3 unenrolled

• One at patient request • Two for non-participation

VDMP

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• Most patients made significant improvements in diabetes self-management, lifestyle behaviors, and adherence to their care plans: • Diet • Activity • Medications • Glucose monitoring • Health maintenance rate improved from 52%

to 85% (20 measures)

VDMP

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VDMP: Virtual Diabetes Management Program

9.51%

7.18%

0

1

2

3

4

5

6

7

8

9

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HgbA1c Pre HgbA1c Post

VDMP Results

Notes: Absolute Reduction: 2.33% Relative Improvement: 25% Goal: A1c less than 7% (BS 150) Behavior change making a huge impact on diabetes control

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Improving Blood Glucose Trends

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Virtual Diabetes Management

0

20

40

60

80

100

120

140

Total BG Alerts Hypo BG Alerts Hyper BG Alerts

Alerts

Alerts

110 alerts

9 alerts

5 minutes after I checked my blood sugar, got a call

immediately. Got upset at first, then realized it was good

to have someone on your shoulder.

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Challenges: • Significant technology challenges • Cellular not a reliable approach for all patients

Lessons Learned: • Adds significant clinical value • Patients learning improves (diet, activity and taking medications) • Contributes to rapid behavior changes • Identifies co-morbidities • Cellular glucometers appear to be reliable • Auto data reporting much more reliable than self- reporting • Teachable moments, real time learning very valuable,

Recommendations: • Re-examine how patient BPs are monitored and managed • Work toward reimbursement for telehealth services • Continue to look for creative ways to reach people with diabetes

Remote Home Monitoring

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• Patients rated program highly overall: avg. 9.0/10 • #1 Value: Creating accountability for their actions;

encouraging them to change; reassuring them that someone cares

• There were ZERO unplanned hospitalizations, ER or Urgent

Care visits related to diabetes • Four previously unknown cases of HTN identified

Virtual Diabetes Management Case Study 2. Patient Interviews

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VDMP: Virtual Diabetes Management Program Lessons Learned

Why was it so difficult to enroll participants? Time commitment Unsure about all the types of technology that we would be using Fear of the unknown: both providers and patients Staffing constraints Started with patients of 2 physicians, ended with 11 physicians Reason patients did enroll: Wanted to refocus on their health Help getting back on track Doctor recommended it Accountability

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VDM3 Virtual Diabetes Management, Monitoring & Maintenance

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Continue to follow VDMP participants

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VDM3: Virtual Diabetes Management, Monitoring and Maintenance

30 minute phone call with CDE once per month

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#2 VDM3 Follow up for subpopulation of VDMP

• 10 patients • Monthly phone calls

Hgb A1C levels per Participant

Participant 1 2 3 4 5 6 7 8 9 10

Dropped out

Pre- VDMP 9 11.4 11.5 7.2 8.8 8.2 Intake 8.2 8.7 7.6 8.7 11.2 16.5 9.3 8.9 8.1 8.9 12.0 Discharge 6.0 7.1 6.4 6.9 7.9 6.5 6.8 7.4 6.3 7.7 7.1

Post-VDMP 8.9 6.3 9.2 8.0 7.7 8.2 7.6

VDM3 9.4 7.2 7.4 6.9 7.6 7.7 6.5 7.5 7.3

Mid Program 7.8 6.8 6.8 6.6 6.6 6.9 7.2

6.9 6.5 7.6

VDM3 Discharge 6.5 7.9

One of the patients has lost 50 pounds in the past 9

months and has discontinued all of his diabetes medications (while maintaining an A1c of

6.5%)

Before

Now

•BG monitoring •Increased activity •Weight loss

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VDE Virtual Diabetes Education

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Partnership with HealthSlate

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VDE: Virtual Diabetes Education

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Partnership with HealthSlate

• 1:1 Counseling/Coaching

• Education and Skills Development

• Self-Management Tools

• Peer Support

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• The 1:1 counseling provided virtually by

CHI Franciscan CDE

• Communication tools to include: video, writing on patient’s screen, pictures sent from phone and text messages

• Patient uses smart phone or tablet; CDE uses PC

1:1 Counseling/Coaching

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VDE Scalability Assessment

• As discovered in a previous Virtual Diabetes Management Pilot, high touch, high intensity programs though effective (significant decrease in HgbA1 over a six month period in 22 patients) are not easily scalable

• This VDE program offers a broader, more inclusive

selection criteria, lower touch and lower intensity approach

• This approach allows for greater scalability by

reducing equipment requirements to a tablet or a smartphone with access to the Internet

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VDE Selection Criteria

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Outpatient Recruitment

• A Diabetes Registry list pulled to identify patients who meet the criteria

• Patients will be identified by the Franciscan PCP and/or his or her

clinic staff using the enrollment criteria as specified

• A personal letter will be sent from the primary care provider telling the potential enrollee about the opportunity to participate

VDE Recruitment Strategy

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VDE Detailed results

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1 2 3 4 5 6 7 8 9 10 11

Initial A1c 11.6% 10.0% 9.8% 9.7% 8.9% 8.6% 8.2% 8.2% 8.1% 8.0% 6.9%

Follow-up A1c 9.2% 8.1% 6.4% 7.3% 9.1% 7.6% 8.8% 7.0% 6.6%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Hgb

A1

C

VDE Results

Patient reports phone issues

Patient seeing endo, started GLP-1

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Virtual Diabetes Programs Comparison Results

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VDMP VDM3 VDETraditionalDE 2014/15

Pre 9.7% 8.0% 8.6% 8.5%

Post 6.9% 7.3% 7.8% 7.5%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Hgb

A1

C

Hgb A1C Comparison

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Same Great Care Delivered in a new way

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How do we get paid? Reimbursement strategies

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Reimbursement Implications Who has the answers?

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Virtual Diabetes Management PRELIMINARY Cost Savings

All Charges and Reimbursement for Diabetes related servicesCY2014, grouped by Unique patients, with Facility and Pro charges, reimbursement combined

Patient assigned to most recent payor

Patient Group Patients Chg/Month Pymt/Month

VDMP Patients 22 $1,338.00 $374.30

High Risk (A1c >8.0) 490 $2,434.49 $587.36

Other Diabetes Patients 43,585 $2,677.65 $742.22

Grand Total 44,097 $2,674.28 $740.32

Charge Savings

VDMP vs. High Risk 45.0%

VDMP vs. All Diabetes Patients 50.0%

Payment Savings (includes all payer with very different rates)

VDMP vs. High Risk 36.3%

VDMP vs. All Diabetes Patients 49.6%

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Yeah, but how much does this cost? Hypothetical example

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And who is paying? Who could be paying?

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• Approached 7 major payers

• Typical response: – This is incredible

• Typical follow up: – Let’s meet again soon

• A better approach - legislation

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American Medical Association Adopts Telemedicine Policy to Improve Access to Care for Patients June 2014

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"Whether a patient is seeing his or her physician in person or via telemedicine, the same standards of care must be maintained. Telemedicine can strengthen the patient-physician relationship and improve access for patients to receive health care services remotely as medically appropriate including care for chronic conditions, which are proven ways to improve health outcomes and reduce health care costs.“

– AMA President Robert M. Wah, M.D., June 2014

Accessed online on May 7, 2015 at http://www.ama-assn.org/ama/pub/news/news/2014/2014-06-11-policy-coverage-reimbursement-for-telemedicine.page

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Washington state telemedicine law: SB 5175

Health plans must reimburse providers for healthcare services delivered to a beneficiary through telemedicine for the following three reasons:

- If the plan would normally over that healthcare service if it were provide in person - If the service is medically necessary - If the service is recognized as an essential health benefit under the Patient

Protection and Affordable Care Act

An Act Relating to Telemedicine Passed in 2015 Regular Session

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Telemedicine bill 6519 passed the Senate If passes all, will be effective as of 1/1/2018

• Washington State Telemedicine law: SB 6519 • “Home” added as an originating site

- “3) An originating site for a telemedicine health care service subject to subsection (1) of this section includes a: • (a) Hospital; • (b) Rural health clinic; • (c) Federally qualified health center; • (d) Physician's or other health care provider's office; • (e) Community mental health center; • (f) Skilled nursing facility; ((or)) • (g) Home; or • (h) Renal dialysis center, except an independent renal dialysis center.”

• State Collaborative to ensure telemedicine services are reimbursed

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You could go online and learn all you want but until you have

someone to work with, it’s really hard.

Like reading about engines but you don’t really learn until you

get your hands on it.

The “pineapple juice bill”

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• Diabetes Self-Management Education and Training Among Privately Insured Persons with Newly Diagnosed Diabetes — United States, 2011–2012 Weekly November 21, 2014 / 63(46);1045-1049

• Rui Li, PhD1, Sundar S. Shrestha, PhD1, Ruth Lipman, PhD2, Nilka R. Burrows, MPH1, Leslie E. Kolb,

MBA2, Stephanie Rutledge, PhD1 (Author affiliations at end of text)http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6346a2.htm?s_cid=mm6346a2_e

• http://www.cmspulse.org/resource-center/health-topics/diabetes/documents/DSME-Toolkit.pdf

• “A systematic review with meta-analysis of 21 studies comparing group-based DSME with standard diabetes treatment, participants with Type 2 diabetes randomized to the group-based intervention showed improvement in clinical, lifestyle and psychosocial outcomes (14). In a three year retrospective claims analysis of 4 million covered lives, which included 250,000 Medicare beneficiaries, there was a reported Medicare average costs savings of $135 per month among those beneficiaries who completed a DSME program (15).”

• Tomky, D. (2013). Diabetes Education: Looking Through the Kaleidoscope. Clinical Therapeutics, 734-

739. • Chen, L., Chuang, C. et al. (2013). Evaluating self-management behaviors or diabetic patients in a

tele-healthcare program: longitudinal study over 18 months. Journal of Medical Internet Research, 15 (12), e266.

• http://www.geekwire.com/2015/log-your-meal-by-snapping-a-pic-healthslate-lets-diabetes-

patients-send-photos-to-food-coaches/

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Katie Farrell catherinefarrell@chifranciscan.org Lana Adzhigirey lanaadzhigirey@chifranciscan.org

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