Accessing Diabetes Education Through

Telehealth

M. Dianne Brown, MS, RDN, LD, CDEOU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center

Cynthia Scheideman-Miller, MHSAHeartland Telehealth Resource Center

Oklahoma Telemedicine Conference 2014October 16, 2014

Objectives:

1. Discus the benefits of a diabetes telehealth program for

patients and how it can be partnered with provider education to improve diabetes management

2. List processes involved when selecting a diabetes telehealth program for your patients

3. Outline key components of a diabetes telehealth program including patient and provider site

requirements.

Why Diabetes Tele-education?

2011 2013

Prevalence* of Self-Reported Obesity Among U.S. Adults, by State, BRFSS

State Prevalence Confidence Interval

Oklahoma 32.5 (31.2, 33.9)

26

millionAmericans

have

diabetes7th

leading

cause of

death in

the U.S.

79 millionAmericans have

pre-diabetes

Diabetes by the Numbers

People with Diabetes

• Don’t follow through on referral

• Are emotional / shocked at diagnosis

• End up relying on family / friends

• Believe they know enough / can handle it on their own

Providers

• Know importance of DE, but don’t necessarily prescribe – or don’t prescribe definitively enough

• Sometimes forget to follow up with patients to encourage attendance

The research shows:

Diabetes Education Patient Benefits Studies have shown people who receive diabetes education

Use primary care /

prevention services

Take medications as

prescribed

Control glucose, blood pressure, LDL cholesterol

Have lower health costs

Diabetes Education Process

Patient Diagnosed

with Diabetes

PCP refers patient for DE

Patient assessed by

CDE

*DSMT Class

(10 hours)

**MNT3 hours (by RD)

Year 2

Year 1

2 hour Refresher Classes

*DSMT - 2 hours &

**MNT -2 hours (by RD)

*Diabetes Self-Management Training (DSMT)

**Medical Nutrition Therapy (MNT)

Prevalence of Diabetes(2011 Overall)N/A2.25% or Less2.26% - 3.35%3.36% - 5.04%5.05% - 6.74%6.75% - 8.44%8.45% - 10.14%10.15% - 11.84%11.85% - 14.00%14.01% or Greater

Where most Certified Diabetes Educators (CDEs) Live in Oklahoma

34- Recognized by the American Diabetes Association (ADA)

17- Accredited by American Association of Diabetes Educators (AADE)

Recognized or Accredited Diabetes Education Programs in Oklahoma

Telehealth benefit # 1

Provides access- multiple sites maybe used

patients other health care providers

Telehealth benefit #2

Saves money patient & CDE saves “gas” money remote site “borrows” CDE informed patients reduce hospital admission

Telehealth benefit #3

Saves time patients & CDE do not lose

time with travel and information is delivered in “real time”

CDE can see more patients, reducing service wait time for patients

Telehealth benefit #4 Helps to address cultural diversity which

contributes to challenges of education, patient compliance, and cooperation with treatment regimens

Increased ability for participation with diabetes care team

Telehealth Concern #1Budget Considerations

technology set up on remote and originating sites

Telehealth Concern #2Time needed for set up

Training Staff Patient teaching tools and resources at remote

Telehealth Concern # 3 Services are only reimbursable by Medicare if the

services were provided to a Medicare or Medicaid beneficiary at an acceptable originating site.

Selecting a Diabetes Tele-education Program

Define what you want vs need ADA program for Medicare reimbursement

Champions

Technology – fits in your needs and budget

A program that is right for your organization and population served

Sales pitches can be misleading

Selecting a program

Is this a program you want as a partner in patient care or contract with for total delivery?

Do they follow the same State laws, Hospital by-laws as on-site programs are required to supply?

What are their references?

Are the providers (distant site) in Oklahoma?

Double Check the Contract

What if expectations aren’t met?

Who is responsible for what?

What staff will be needed at the originating site before, during, after the classes?

Who gets the data?

Who tracks patient satisfaction?

Is there training for staff at the patient site?

No-Show policy

Telehealth Consent Form – who is responsible to get this signed prior to services?

Developing a Diabetes Tele-Education Program

Early Development

Champion Support Administration Providers

Originating Site Distant site

Delivery Model Multiple sites or single site Contract vs direct billing Individual sessions conducted remotely or on-site

Early Development, con.

Program Components

Understand current process flow and staffing:

Multiple sites or single Optimal number and arrangement Mandatory documentation – define the who, where,

how

Resources Consider health literacy & culture What resources go with the patient or stay

Budget

Budget Start up costs

Equipment

Broadband

Marketing

Staff time Contract development

Liaisons

Staff prep for sessions

Consultants

Technology

Software

Reliable

Image quality

ASC X12 encryption standard

Compatible with other software

Linkage of older to newer technology

Split screen capable

Transmission requirements

Technology Distant (Provider) End

Computer High-definition camera

Monitors – single will work, dual is better

Speaker/microphone

Projector

Software – some have split screen capabilities

Desktop – Self-contained High quality image

Split screen capabilities

Frees up computer for EHR

Technology Originating (Patient) Site

Patient Cart High-quality image

Can be wheeled to patient bedside

Multi-purpose

Issue: mobility vs larger monitor

Wall-mounted Monitors High quality image

Split screen capabilities

The closer to “real” size, the better

Medicare

• ADA approved program

• Service must be real time using interactive audio/video

• Eligible originating (patient) site – rural HPSA – online tool to determine eligibility

• Codes:

• 99201 GT modifier

• HCPCS codes G0108 & G0109

Medicaid

• ADA approved program

• Service must be real time using interactive audio/video

• Eligible originating (patient) site

• Codes: 99201, 97802-97803 GT modifier

• Must be delivered using appropriate equipment and meet HIPAA, privacy & security requirements

Reimbursement:

Medicare

• Eligible originating site

• Office of physician/practitioner

• Hospital

• CAH

• RHC

• FQHC

• Eligible provider

• Registered Dietitian

• Advanced Registered Nurse Practitioners

• Nutrition professional

• Clinical Social Worker

Medicaid

• Eligible originating site

• Office of physician/practitioner

• Hospital

• CAH

• RHC

• FQHC

• School

• I/T/U

• Eligible Provider

• Registered Dietitian

• Advance Registered Nurse Practitioners

Reimbursement (con.):

Handouts such as: My Carbohydrate Guide

Food Models

Organize the classroom-Pens, highlighters,

sharpies-Ketone chart and

strips-Glucose wands-Food models-Sample of fast

acting glucose-Etc.

Diabetes Education Tele-health Patient Take Home Resources

• Have topics organized by title and number the file (or computer files)

• Have reference list to find resource topics quickly.

Final Development

Staff training User training Cheat Sheet Troubleshooting Guide Help Desk Contingency Plan Helpdesk visit 3rd level vendor support

Patient recruitment Marketing material

tele-health brochure internal web page

Clinician invitation Patient Mailing Telehealth Patient Consent Form

Diabetes Tele-education Pilot

Instructors Dietitian at one rural location, nurse specialist

at the other

Diabetes tele-education delivered at a lower cost

LOS shorter for those who attended class –reduced hospital costs

Pre- and Post-tests comparable to on-site classes

High patient and provider satisfaction

Rapport between class attendees unforeseen plus

Telemedicine Patient Satisfaction Survey

Question Score_________How comfortable did you feel? 4.2 ± 1.2 (19)(0, very comfortable; 5 very comfortable)

How convenient was the encounter? 4.4± 1.0 (19)(0, not at all convenient ; 5 very convenient)

Was the lack of physical contact acceptable? 4.3 ± 1.3 (19)(0, not acceptable; 5 very acceptable)

Concerns about privacy? 1.1± 1.7 (19)(0, no concerns; 5 very concerned)

Overall satisfaction? 4.3± 1.3 (19)(0, not at all satisfied; 5 very satisfied)

Would you do it again? (yes/no) 16/3

Diabetes Care, Vol. 26, No 4, April 2003

Quality Checks: Metrics

Utilization Satisfaction Sustainability Outcomes

By location patient financial health

By service provider support care plan

By provider staff champions no-show

Rynn Geier, MBA, RD, LD, CDE presented at AADE annual meeting Aug 6-9 2014

Summary:

Establish goals for a telemedicine program

Gain champion support

Develop a budget

Choose a vendor

Take time for clinical training and well-planned program deployment

Develop strategies for program “buy –in”

Build into your program

Measure your outcomes: metrics

Don’t Forget Diabetes Education for Providers

Providers have the same information as their patients

Increases provider’s confidence that they have

the latest diabetes information

Reinforcement – patient’s hear the same message

Providers have a contact/mentor

“Prior to the study it was almost impossible for this type of patient to get the consultation and specialized care that is not accessible in a small rural community.” Rural Home Health Administrator

Who knows what future telehealth will look like?