Comprehensive Diabetes Care and Control Austin Model

1
Comprehensive Diabetes Care and Control Austin
Model

• Phil Huang, MD, MPH
• Cindy Batcher, RN, BSN, PHN, CCM
• Karina Loyo, PhD, MBA
• Karen McAfee, MSN, RN
• Maria Guerra, BSN, RN

2
Overview

• Diabetes and Obesity System Dynamics Model
• Data Resources
• School/Community/Worksite Interventions
• Healthcare Interventions (Case Management)
• Wrap up

3
Questions Addressed by System Dynamics
ModelingExploring Strategies to Redirect the
Course of Change
Prevalence of Diagnosed Diabetes, US
40
Where?
30
What?
Million people
20
How?

• Markov Model Constants
• Incidence rates (/yr)
• Death rates (/yr)
• Diagnosed fractions
• (Based on year 2000 data, per demographic segment)

10
Who?
Why?
0
1980
1990
2000
2010
2020
2030
2040
2050
Honeycutt A, Boyle J, Broglio K, Thompson T,
Hoerger T, Geiss L, Narayan K. A dynamic markov
model for forecasting diabetes prevalence in the
United States through 2050. Health Care
Management Science 20036155-164. Jones AP,
Homer JB, Murphy DL, Essien JDK, Milstein B,
Seville DA. Understanding diabetes population
dynamics through simulation modeling and
experimentation. American Journal of Public
Health 200696(3)488-494.
4
Diabetes Model Diabetes Burden is Driven by
Population Flows
Developing
d
Inflow
Outflow
5
Diabetes Burden is Driven by Population Flows
Developing
d
Inflow
Outflow
6
Diabetes System Dynamics Modeling
ProjectConfirming Fit to Historical Trends (2
examples out of 10)
Diagnosed Diabetes of Adults
Obese of Adults
40
8
Obese of adults
Diagnosed diabetes of adults
30
6
20
4
Data (NHIS)
Data (NHANES)
10
2
0
0
1980
1985
1990
1995
2000
2005
2010
1980
1985
1990
1995
2000
2005
2010
7
The growth of diabetes prevalence since 1980 has
been driven by growth in obesity prevalence
Obese Fraction and Diabetes per Thousand
130
0.7
Diabetes Prevalence
85
0.35
Obesity Prevalence
40
0
1980
1990
2000
2010
2020
2030
2040
2050
Time (Year)
8
Baseline Scenario Obesity to increase little
after 2006, diabetes keeps growing robustly for
another 20-25 years
Obese Fraction and Diabetes per Thousand
Onset6.3 per thou
130
Estimated 2006 values
0.7
Diabetes Prevalence
Prevalence92 AND RISING
85
0.35
Death3.8 per thou
Obesity Prevalence
40
0
1980
1990
2000
2010
2020
2030
2040
2050
Time (Year)
With high (even if flat) onset, prevalence tub
keeps filling until deaths (4-5/yr)onset
Diabetes prevalence keeps growing after obesity
stops
WHY?
9
Unhealthy days impact of prevalence growth, as
affected by diabetes management Past and one
possible future
Unhealthy Days per Thou and Frac Managed
Obese Fraction and Diabetes per Thousand
500
Managed fraction
130
0.65
0.7
Diabetes Prevalence
375
85
0.325
0.35
Obesity Prevalence
Unhealthy Days from Diabetes
40
250
0
0
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
Time (Year)
Diabetes prevalence keeps growing after obesity
stops
If disease management gains end, the burden grows
10
A Sequence of What-if Simulations
Start with the base case or status quo no
improvements in diabetes management or
prediabetes management after 2006
People with Diabetes per Thousand Adults
Monthly Unhealthy Days from Diabetes per Thou
150
500
Base
450
125
Base
400
100
350
75
300
50
250
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
11
What if there were further Increases in Diabetes
Management?
Increase fraction of diagnosed diabetes getting
managed from 58 to 80 by 2015. What do you
think will happen?
People with Diabetes per Thousand Adults
Monthly Unhealthy Days from Diabetes per Thou
150
500
Base
Diab mgt
450
125
Base
400
Diab mgt
100
350
75
300
50
250
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
Keeping the burden at bay for nine years longer
More people living with diabetes
12
What if there was a huge push for Prediabetes
Management?
Increase fraction of prediabetics getting managed
from 6 to 32 by 2015. (Half of those under
intensive mgmt by 2015.) No increase in diabetes
mgmt. What do you think will happen?
People with Diabetes per Thousand Adults
Monthly Unhealthy Days from Diabetes per Thou
150
500
Base
450
Base
125
PreD mgmt
400
PreD mgmt
100
350
75
300
50
250
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
The improvement is relatively modestthe growth
is not stopped
13
Diabetes Model What if Obesity is Reduced?Two
Scenarios
What if it were possiblein addition to the
prediabetes mgmt intervention - to gradually
lower the fraction obese from 34 (2006) to the
1994 value of 25 by 2030? Or, to the 1984 value
of 18?
Obese Fraction of Adult Population
0.4
Base
0.3
Obesity 25
Obesity 18
0.2
0.1
0
1980
1990
2000
2010
2020
2030
2040
2050
14
Diabetes What if we Managed Prediabetes AND
Reduced Obesity?
What do you think will happen if, in addition to
PreD mgmt, obesity is reduced moderately by 2030?
What if it is reduced even more?
People with Diabetes per Thousand Adults
Monthly Unhealthy Days from Diabetes per Thou
150
500
Base
450
Base
PreD mgmt
125
PreD mgmt
400
PreD Ob 25
PreD Ob 25
100
350
PreD Ob 18
75
PreD Ob 18
300
50
250
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
The more you reduce obesity, the sooner you stop
the growth in diabetesand the more you bring it
down
Same with the burden of diabetes
15
What if Intervened Effectively Upstream AND
Downstream
With pure upstream intervention, burden still
grows for many years before turning around. What
do you think will happen if we add the prior
diabetes mgmt intervention on top of the
PreDOb25 one?
People with Diabetes per Thousand Adults
Monthly Unhealthy Days from Diabetes per Thou
150
500
Base
450
Base
125
PreD mgmt
PreD mgmt
400
All 3
100
Pred Ob 25
PreD Ob 25
350
All 3 -- PreD Ob 25 Diab mgmt
75
300
50
250
1980
1990
2000
2010
2020
2030
2040
2050
1980
1990
2000
2010
2020
2030
2040
2050
With a combination of effective upstream and
downstream interventions we could hold the burden
of diabetes nearly flat through 2050!
16
Obesity Dynamics Modeling Results of Simulated
Interventions
Obese fraction of Adults (Ages 20-74)

• Reduce caloric balances to their 1970 values
  by 2015 for selected age ranges
• Youth interventions have only small impact on
  overall adult obesity
• Slow decline in overall adult obesity, even when
  program covers all ages
• Targeted weight loss approach
• (obese lose 4 lbs per year, program terminated
  2020)
• Such a program could accelerate progress and buy
  time for environmental change (but first, need
  to find a cost-effective program with lasting
  benefitsminimal relapse)

50
40
30
Fraction of popn 20-74
20
10
0
1970
1980
1990
2000
2010
2020
2030
2040
2050
Base
SchoolYouth
AllYouth
SchoolParents
AllAdults
AllAges
AllAgesWtLoss
Need to assure caloric balance throughout all
ages, particularly adulthood. Contrast to
narrow focus on school-age youth. Also need
research on extent to which adult habits are
determined by childhood.
17
Activity/Sector Table
18
Have You Ever Had a Great Idea, that no one was
interested in?
What Does Data Provide?
19
Data Does What????

• Creates Your Focus
• Data illustrates that a problem or its solution
  exists
• Through maps
• Timelines
• History
• Clarifies your ideas by bringing reality to
  complex issues
• Demonstrates that the project will help the
  organization achieve its objectives.

20
Economic Barometer Finds Diabetes Costs United
States 218 Billion Annually Forbes Magazine
Highlights Impact to Employers Recently, the
National Changing Diabetes Program (NCDP)
released the results from its Economic Barometer
research. Group economic research that estimated
the direct and indirect costs of diabetes in the
U.S. at 174 billion annually. NCDPs new
economic research factored in the additional
costs to the nation for undiagnosed diabetes,
pre-diabetes and gestational diabetesbringing
the total price tag for diabetes in the United
States to 218 billion. The full results of the
Economic Barometer will be published in the
peer-reviewed journal Population Health
Management this spring.
21
(No Transcript)
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Known Cost of Diabetes per year 174 Billion
Unknown Cost of Diabetes per year 218 Billion
23
Where Diabetic Patients Live in Travis County!
24
Number of Emergency Room Visits by Diagnosis in
2005
Diabetes
88 patients with all four chronic
conditions ER visits from 1/1/05 thru 6/30/05 at
SHN, Brackenridge SDHP.
25
(No Transcript)
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HIE Data (ICare) Helps Providers

• Obtain useful information about medical history
  to use in diagnosis and treatment
• Determine what healthcare resources patients are
  using
• Assist patients who cant remember what medical
  procedures they received in other locations
• Determine what medications was prescribed by
  others
• Identify patients who could benefit from care
  coordination

Source Greenlights Interim Evaluation Report,
12-04
27
Case Study

• 44-year old African American male
• Medical Assistance Program, (MAP) participant
• Initial visit
• complaints of shortness of breath and wheezing
• post ED visit
• PMH Type 2 Diabetes
• Asthma
• multiple ED visits
• BMI 29.4 Kg/m2
• Medications prednisone taper, albuterol, and
  azmacort, not on diabetes medications

28
Interventions

• Enrolled in PharmCare on 12/28/05
• Interventions
• Discussed pathophysiology of asthma diabetes
  with the patient
• Created a plan of care
• Discussed the MAP medication program
• Enrolled patient in prescription assistance
  program (PAP)
• Assisted patient to establish and coordinate care
  at a Clinic for co-morbid care needs

29
Patient Results Based on ICare Data

• In the I-Care database since 5/14/2002
• Pharmacist started working with patient on
  12/28/05
• Resource use from 12/1/2003 to 12/31/2006

30
City of Austin Diabetes System
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Austin/Travis County Health and Human Services
Department

• Central Texas Diabetes Coalition
• DM Personal Guide
• DM Resource Guide
• Prescriptions for Healthy Living (New/planned)
• Department of State Health Services
• Diabetes Toolkit
• Treatment algorithms and
• Pateint education

32
Community Organizations

• Diabetes Self-management
• Do Well, Be Well with Diabetes -TxAgriLIFE
• DEEP ATCHHSD
• Healthy Eating
• The Happy Kitchen/La Cocina Alegre - SFC
• Nutrition Education Program TxAgriLIFE
• Farmers Markets-SFC
• Physical Activity
• Walk Texas - ATCHHSD
• Walk Across Texas -TxAgriLIFE

33
Schools

• Healthy Eating
• Vending machine changes
• Cafeteria food changes
• Expanded Nutrition Program Texas AgriLIFE
  Extension
• Community Gardens
• Physical Activity
• 150 minutes of PE/wk
• Walk Texas - ATCHHSD
• Walk for Diabetes ADA
• Walk across Texas Texas AgriLIFE Extension
• Active for Life
• Active Life (formerly Youth Interactive)
• 21st Century program
• Marathon Kids
• Diabetes
• Diabetes 101 for all staff
• Diabetes training for all PE, nursing and
  elective staff

34
Schools

• Obesity Prevention
• Professor Popcorn Texas AgriLIFE Extension
• Balance Texas AgriLIFE Extension
• General Health
• CATCH
• Coordinated School Health
• School Health Index
• Active SHACs
• Wellness Wednesday Program
• Wellness Policies
• District Health Policies
• Use of outdoor facilities by community after hours

35
Worksites

• Mayors Fitness Council Worksite Certification
• Capital Metro Wellness Program
• City of Austin PE Program
• Value-based Worksite Wellness Programs
• Farm to Work - SFC

36
Faith-based Organizations

• Programs
• Diabetes Days (ADA)
• Conozca Su Corazon (AHA)
• Train-the-trainer
• Power to Prevent (new/planned)
• Lifestyle Balance (new/planned)
• DEEP (new/planned)

37
Built Environment

• Steps to a Healthier Austin improvements
• Outdoor walkers, bikes, and other machines
• Completion of walking trains
• Community Gardens
• TxNEA Restaurant Survey

38

SETON COMMUNITY CLINICS DIABETES CASE MANAGEMENT
39
Overview of Seton Community Clinics

• 3 community clinics
• serving the working poor
• 13,000 patients served
• 1,244 patients with diabetes
• 60 completely unfunded
• 187 lives touched by Diabetes Case Management
  over past 3 years
• 2 RN Diabetes Case Managers

40
A Definition of Case Management

• Collaboration with the patient
  to facilitate coordination
  of a broad
  variety of services
  to help the patient to be
• able to better manage their disease
• Case Management is an interactive,
  collaborative, and ongoing process involving the
  patient and the case manager
• Case Management program is aligned with
  accepted national guidelines and standards of
  practice

41
Diabetes Case ManagementReasons for Referral

• uncontrolled diabetes and any combination of
  the following
• Multiple concurrent disease processes
• Barriers to self-care
• Frequent ED use
• Frequent hospitalization(s)
• Outside patients who have high/frequent
  utilization and no medical home
• Other situations as appropriate

42
Diabetes Case ManagementReasons for Referral

• uncontrolled diabetes and any combination of
  the following situations that are negatively
  impacting the patients diabetes
• Multiple concurrent disease processes (CHF, heart
  disease, renal disease)
• Barriers to self-care (depression or extreme
  anxiety, extreme financial hardship, unstable
  living situation, lack of food or housing,
  evidence of cognitive compromise/low literacy,
  mental health issues)
• Frequent trips to the emergency room
• Frequent and/or prolonged hospitalization(s)
• Outside patients who have high/frequent
  utilization and no medical home
• Patients with other situations as appropriate

43
Diabetes Case Management Goals

• Facilitate patient best practices
• Optimize utilization along the continuum of care
• Regular primary care provider visits
• Patient adherence
• Access to specialty care
• Access to blood sugar testing supplies and
  medications
• Cost-effective use of clinical resources
• Create a sustainable self-funded model

44
Diabetes Case Management Goals

• To facilitate patient best practices associated
  with optimal outcomes (ADA, TDH, IHI)
• To optimize the appropriate utilization along the
  continuum of care (i.e. Primary Care vs. ER)
• To assure regular attendance with primary care
  provider at the frequency recommended
• To facilitate adherence to best practices
  including diabetes self-management education,
  regular eye exams, vaccinations, dental care,
  foot exams, an annual opportunity to set
  self-management goals, and timely laboratory
  tests
• Facilitate access to specialty care as needed, as
  well as transition back to primary care
• Assure patient access to blood sugar testing
  supplies and to medications
• Ensure patient flow that encourages the most
  cost-effective use of clinical resources
• Build a sustainable model that will fund the Case
  Management Program through costs savings

45
Diabetes Case Management Patient Contract

• Patient as an equal team member
• Patient signs Case Management contract and agrees
  to
• Regular contact with a nurse case manger
• Diabetes education and nutrition classes
• Weekly support group attendance
• Keep all scheduled appointments
• Call the nurse case manager for assistance
• Call the clinic for an appointment if blood
  sugars lt70 or gt 200

46
Diabetes Case Management Patient Contract

• Patient understanding that they are an equal
  member of the team
• Patient signs Case Management contract and agrees
  to
• Allow regular contact with a nurse case manger as
  needed
• Take part in diabetes education and nutrition
  classes as recommended
• Taking part in a weekly support group as they are
  able
• Keep all scheduled appointments such as lab,
  doctor (including eye and foot specialists),
  classes, and other activities that may be
  developed
• Call the nurse case manager if they have
  difficulty with medication refills, appointments,
  or need other resources to help them manage their
  diabetes
• Call the clinic for an appointment if they have
  blood sugars lt70 or gt 200 so that medication
  regimen can be changed if needed

47
Diabetes Case Management Interventions

• Assess social, environmental and economic factors
  influencing diabetes
• Identify and remove barriers
• Problem-solving
• Coordinate interdisciplinary team
• Coordinate referrals to specialists
• Referrals for community resources
• Monitor medical history and activity via ICC data
  and Seton EMR
• Assure affordable access to supplies and
  medications

48
Diabetes Case Management Interventions

• Provide assessment including social,
  environmental and economic factors that may
  impact each patients diabetes
• Identify barriers (e.g. transportation, literacy,
  financial issues, access to medications and
  healthy foods, safety concerns, mental health
  issues) to patient adherence to the recommended
  plan of care
• Help the patient to problem-solve
• Coordinate interdisciplinary team (MD, RN,
  Diabetes Educator, Nutritionist, MA, Social
  Worker, PPAP, Health Promoter and Mental Health
  support as needed)
• Coordinate referrals to outside specialists
• Make referrals for community resources (Meals on
  Wheels,
• food banks, special transportation services,
  etc.)
• Monitor the case managed patients medical
  history and activity via ICC data and Seton EMR
• Assure affordable access to supplies and
  medications

49
The Diabetes Personal Guide

• Patient Empowerment
• Roadmap of Best Practices
• Labs, BP, EKG, BS, Vaccinations, A1c, Weight
• Medications list to track meds, dosage, schedule
  and allergies.
• Patient Goals
• Diabetes Nutrition Classes taken
• Signs of HIGH LOW Glucose levels
• First Aid for low blood glucose
• When to call the doctor
• Important Telephone Numbers
• Seton Community Clinic locations and contact
  information
• Created a community-wide version in collaboration
  with the Central Texas Diabetes Coalition

50
Diabetes Case Management Pre Post Intervention
Outcomes Among Case Managed Patients
51
Diabetes Case Management Audit Results
52
Financial Outcomes

• Decreased ER use and cost savings
• First Year Value Prop
• Target 100,000
• Actual 218,000
• Second Year Value Prop
• Target 100,000
• Actual 191,259
• Cost savings are used to fund
  the RN-Case Manager
  position

53
Questions?
54
For More Information

• Phil Huang, MD, MPH philip.huang_at_ci.austin.tx.us
• Cynthia Batcher, RN, BSN, PHN, CCM
  cbatcher_at_icc-centex.org
• Karina Loyo, PhD, MBA karina.loyo_at_ci.austin.tx.us
• Maria Guerra, BSN, RN mguerra_at_seton.org
• Karen McAfee, MSN, RN kmcafee_at_seton.org