Tuesday, 21 July 2015 05:09

A VBP-Centric, All-Encompassing Approach to Diabetes Management

Written by Robert Fortini, PNP and Patti Lipes

 “Motivation is what gets you started. Habit is what keeps you going.” – Jim Ryun, Olympic track star

This quote could serve as a mantra for those living with diabetes. But patients facing the challenges of living well with this disease need much more than motivation and good habits. They need help navigating the complexities of coping with a serious chronic condition. They need physicians and medical care teams who are experts in the management of diabetes. Bon Secours Medical Group Virginia (BSMG-VA) has that expertise. 

BSMG-VA is a leader in the management of multiple forms of chronic disease. Nowhere is this more apparent than with its multi-disciplined approach to diabetes management. During the  12-month period ending in July 2015, BSMG-VA providers treated over 37,000 distinct patients with a diabetes diagnosis. Primary care is provided to these patients utilizing the Patient Centered Medical Home model, (PCMH), certified by the National Committee for Quality Assurance (NCQA). Seventy-four percent of BSMG-VA primary care practices have obtained NCQA Level III certification, and a team of clinical managers and nursing educators is busy completing applications and providing training in the team care model for the remaining 26 percent of practices. The health system has a goal of 100 percent certification by December 2015. 

Under PCMH, each patient is the center of his or her care. Treatment is offered by a team of highly skilled clinicians working in collaboration with a primary care physician. Patients have access to nurse navigators (registered nurses with case management certification, and in many cases, advance degrees), registered dieticians, pharmDs, and licensed clinical social workers, and all the services each of these disciplines provides. Knowing that approximately 9.3 percent of the U.S. population has diabetes, which equates to 29.1 million children and adults, access to effective, team-based care is critical if we are to control what can be a devastating disease. 

One aspect of this team care is the formal diabetes patient education classes that are held in the Richmond and Hampton Roads markets monthly. In Richmond, a three-part series,  Diabetes 101, Diet and Medications, is offered by nurse navigators, RDs, and pharmDs. Classes are currently offered at the three practice locations with the highest concentration of patients with a diagnosis of diabetes. Locations are expanded as needed. Richmond’s classes tend to fill rapidly, and at this time only patients with diabetes, pre-diabetes, and their family members are invited. These sessions provide easy access to a support group-like atmosphere, and all patients are offered a one-on-one follow-up appointment if desired. In Hampton Roads, a four-part series is offered, covering topics including understanding diabetes, nutrition, nutrition wrap-up, and medications/foot care. These classes are open to patients and their family members, recent hospital discharges, employees, and the general public. 

While the formal classes have been a great success, they do not take the place of informal diabetes education offered to patients on an as-needed basis.  Often done in conjunction with a provider visit or during a Medicare annual wellness visit, these sessions also allow patients the opportunity to enlist a pharmD for a comprehensive medication review. During these visits, patients obtain a better understanding of insulin administration, adverse medication-related effect avoidance/management, glucometer and blood sugar monitoring, self-care, and hypoglycemia. Patients have more time to ask questions and obtain one-on-one education within their home practice without traveling to another location. An important member of the care team is the registered dietician (RD). The majority of BSMG-VA embedded RDs are certified in diabetes case management and are available at many practices to provide one-on-one nutritional counseling. Along with pharmDs and RDs, nurse navigators are located in every PCMH practice, and many are also certified in diabetes case management, assisting with overall disease management education on a daily basis.  

In true PCMH spirit, pharmDs also provide diabetes medication management through a collaborative practice agreement with physicians in some BSMG-VA locations. Under the collaborative practice agreement, and with signed informed consent of the patient, the pharmD works within the context of a defined protocol to administer, initiate, adjust, and discontinue diabetes medications as well as order lab tests recommended to monitor the safety and efficacy of these diabetes-related medications. Patients are referred to the pharmacist by their primary care provider if they have an A1c greater than 8 percent. Advantages for patients are quicker access to visits than typically found if scheduling with an endocrinologist, longer and more flexible appointment times, in-depth medication counseling/education, and follow-up that may allow for faster medication adjustments. Physicians at several practices routinely refer patients with worsening diabetes control to a pharmacist member of the PCMH team. During the pharmacy appointment, medications and potential treatment options are discussed with the patient and a recommended plan of care is implemented following collaboration with the patient’s primary care provider. Phone follow-up with patients helps reinforce understanding of changes in medication and blood sugar monitoring and provides opportunity for additional education. 

A recent encounter clearly showed the advantages of the team approach used in diabetes treatment:

A 57-year-old male was referred for a pharmacy visit to review his diabetes regimen after lab results showed a worsening in his A1c. The patient had a past medical history of diabetic nephropathy and retinopathy, stroke, hypertension, and hyperlipidemia. His medication regimen consisted of 12 scheduled medications, twice-daily Lantus, and Humalog sliding scale insulin, which he was taking after meals with a final dose nightly at 10:30 p.m. The patient and his sister expressed concern over his fluctuating blood sugars and frequent nocturnal hypoglycemic episodes – a frightening and potentially life-threatening situation. The pharmacist explained how each of his insulins worked, covered the best times to administer the injections, and gathered information on his daily routine. After consulting with the patient’s primary care provider, the team came up with a plan to transition the patient to a scheduled insulin regimen with administration of the Humalog prior to meals that would decrease the risk of nocturnal hypoglycemia. The patient was educated on the need for frequent follow-up while his insulin regimen was being adjusted. The pharmacist continued to follow up with the patient with weekly phone calls during insulin titration, and all recommendations were discussed with the patient’s physician. After six weeks, the patient was able to maintain stable blood sugar levels with four instead of five insulin shots per day and had no nocturnal hypoglycemic episodes. The patient’s response to this level of care says it all: “not once in the 25 years that I have been diabetic has anyone ever paid such attention to my blood sugars.” A patient who felt like his life revolved around blood sugar testing and insulin administration became fully engaged with his care team and no longer struggles with his treatment plan since he became involved in the entire process. 

Better patient care and quality-of-life certainly drives clinical decisions, but one cannot lose sight of the necessity of revenue to pay salaries and keep the lights on. As health systems continue along the continuum from fee-for-service to payment for value, they must strengthen partnerships with commercial payors. BSMG-VA participates in many quality contracts with major insurers and is part of the Centers for Medicare & Medicaid (CMS) Medicare Shared Savings Plan (MSSP). Appropriate diabetes management is addressed in all of BSMG-VA’s commercial payor quality incentive contracts and was chosen as a quality incentive element within the Primary Care Quality Incentive Program (PCQIP) rolled out in the 2015 fiscal year. PCQIP awards providers with a bonus for meeting important quality measures, meeting and maintaining meaningful use, and achieving appropriate patient satisfaction and citizenship measures. Five diabetic quality measures from the MSSP ACO were chosen to represent the quality measures portion of the bonus plan. Significant improvement over 2014 was noted in management of diabetic patients’ A1cs, lipid panels, and blood pressure as shown below:

Knowing that diabetic eye exams were becoming an important quality measure for MSSP patients in 2015, Bon Secours Medical Group entered into a collaborative effort with a major eye care provider in the Richmond market to ensure ease of access. The project team piloted workflows in the five practices with the greatest diabetic populations. It has been shown that at least 10 percent of patients with diabetes likely will develop visual impairment secondary to diabetic retinopathy. Patients critically need annual eye exams, but referring them to eye care providers is not enough. Some patients cannot or will not see a vision provider due to various barriers such as problems involving transportation, additional co-pays, or work schedules. A project team is currently evaluating equipment that would allow for screening of patients within the primary care setting. If implemented, this workflow would allow patients to be screened in conjunction with a primary care visit, eliminating travel time and providing cost savings. 

To further reinforce the important role the patient has in self-management, BSMG-VA recently formed a Patient and Family Engagement Council in a busy primary care practice to more accurately capture and address the voice of the patient. The patient-led council has offered suggestions on how staff and providers can meet the needs of patients with diabetes and improve care, and therefore quality of life and clinical outcomes. A model has been developed that can be used by all primary care practice locations wishing to form and run their own patient and family engagement councils to address specific disease states or general patient concerns.  

Other PCMH teams are working on projects to utilize people, processes, and technology with laser focus.  Clinical orientation has been updated to incorporate more information regarding diabetes measurements, and ongoing education is being provided via daily staff huddles and a formal nursing preceptors program. Teams are running clinical diabetes registries centrally and identifying those patients who can benefit from a Medicare wellness visit or more intensive education. The electronic medical record (EMR) build team is working on improvements in the patient-level detail report drill-downs available to providers to show patient improvement opportunities. As the PCMH teams continue to implement effective solutions to allow for better diabetes management, we will see a healthier population living well with a serious chronic disease. 

About the Authors

Robert Fortini, PNP, is the VP and Chief Clinical Officer for Bon Secours Virginia Medical Group, Home Health and Hospice is responsible for facilitating provider adoption of EMR, coordinating clinical transformation and facilitating advances in Population Health initiatives. Robert has extensive experience in Operations and Clinical Policy development, and experience in workflow re-engineering and CQI in ambulatory care. He has recently advanced Bon Secours’ efforts in “Good Help for Life” by leading efforts in Advance Care Planning and Behavioral Health Integration into Primary Care, promoted access by the expansion into the retail clinic and Telehealth arenas and developing a workforce equal to the task.

Patti Lipes is a Senior Clinical Operations Project Administrator for Bon Secours Virginia Medical Group, and is responsible for coordinating and facilitating project plans within the knowledge areas of Analytics, Patient Centered Medical Home, Population Health and Quality. Patti is Lean Six Sigma Green Belt trained and is an active member of the Virginia Chapter of the Project Management Institute. She is certified in mass care, disaster services and shelter management through the Red Cross and worked in Mississippi and Louisiana with City Impact following Hurricane Katrina.   

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Last modified on Wednesday, 22 July 2015 03:32