Creating Models for Health Care Delivery that Address Chronic Disease

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Creating Models for Health Care Delivery that
Address Chronic Disease

• Linda Siminerio, PhD
• Senior Vice President, IDF
• University of Pittsburgh Diabetes Institute
• Associate Professor
• School of Medicine

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Presentation Objectives

• Describe the Problem and Urgency
• Present the Chronic Care Model
• Report on the Pittsburgh Regional Initiative for
  Diabetes Education (PRIDE)
• Present the Innovative Care for Chronic Diseases
  Model
• Highlight Global Projects

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Diabetes Worldwide

• Estimated number (in Millions) of people with
  diabetes, worldwide
• Increase in deaths from diabetes over next 10
  years
• India 35
• The Americas 80
• the western Pacific and eastern Mediterranean
  regions 50
• Africa gt40
• Diabetes Prevalence. International Diabetes
  Federation, 2003.
• Preventing Chronic Diseases a vital
  investment, World Health Organization, 2005.

1985 30 million 1995 135 million 2003 194
million 2025 330 million
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US Diabetes Facts

• 20 increase past 20 yrs
• 70 increase 30-39 yr. age range
• 1 in 3 children born in 2003 will get diabetes
• Type 2 in children is increasing
• 14 million lost work days
• Annual costs -- 132 billion

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Epidemiologic Transition
Omran, A. The Epidemiologic Transition A theory
of the epidemiology of a population change.
Milbank Q. 197149509-538.
Non-Communicable Disease
Mortality Rates
Infectious Disease
Epidemiologic Transition
More information available at http//www.pitt.edu/
super1/lecture/lec0022/007.htm
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Organization of Health Care(What it should be)

• Evidence-based, planned care
• Clinical Guidelines
• Reorganization of practice (team approach)
• Includes ancillary professionals with the patient
  as the most important member
• Attention to patient needs (information)
• Counseling, education, information feedback
• Access to clinical expertise
• Patient and provider education, access to
  specialists
• Supportive information systems
• Patient registries
• Provider feedback on preventive service
  utilization

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Organization of Health Care(What it is)

• Care is not necessarily based on evidence, but
  experience and training
• Seldom is there a team approachcare is mainly
  driven by the physician alone
• Paternalistic and directive approach with little
  attention to patients behavioral needs
• Limited access to diabetes specialists
• Insurer limitations
• Reluctance of primary care referral
• Fragmented access
• Poor information systems
• No computers
• Poor tracking

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Transition in Health Care
PARADIGM SHIFT
ACUTE CARE CHRONIC CARE
Focus prevention Care coordinated
Focus illness Care fragmented
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Quality of Care for People with Diabetes in the
United States
A Diabetes Report Card for the United States
Quality of Care in the 1990s.

(2.6mmol/L)
Saaddine JB Ann Intern Med. 136 565-574, 2002
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University of Pittsburgh Medical Center The
Challenges of Providing Access and Quality

• 19 hospitals/ 200 primary care practices
• 90,000 patients with diabetes
• 90 diabetes care provided by PCPs
• Poor adherence to guidelines
• Lack of integrated technology
• Daily decisions made by patient
• Poor access for education and nutrition
• Undefined relationships to the community

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Objective

• By implementing a model for health care delivery
  we could
• Gain health system support
• Demonstrate improvements in clinical outcomes,
  A1C, BP and Lipids
• Demonstrate reimbursement for services
• Expand number of resources in communities

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Health System

• UPMC board initiative
• Presentations to leadership
• Pittsburgh Regional Initiative for Diabetes
  Education (PRIDE)
• Patient/Provider/Community

Community
Health System
Resources and Policies
Organization of Healthcare
Self-Management Support
Delivery System Design
Decision Support
Clinical Information Systems
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
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Community

• Resource Identification
• Focus groups with providers and patients
• Community leaders
• Local physicians
• Government

Functional and Clinical Outcomes
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Decision Support

• Evidence Based Guidelines
• ADA Medical Education Standards

Functional and Clinical Outcomes
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Clinical Information Systems

• Paper Charts
• Excel spread sheets
• Laboratory feedback
• Electronic Medical Records
• Management systems

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Clinical Information / Decision Support

• Instituted ADA Guidelines
• Physician education
• Regional programs
• System seminars
• Integrating CDEs into practices
• Office staff education
• Clinical information
• Continuous feedback
• Comparative reports to peers

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Community Medicine Inc. (CMI)versus National Data
DM Report Card for USA Annals Internal Medicine
2002136 (8) 565-574
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CMI vs National Data
DM Report Card for USA Annals Internal Medicine
2002136 (8) 565-574
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UPMC Diabetes ManagementHbA1c Levels (2003-2006)
Average HbA1c Levels
Time
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Proportion of Patients with HbA1c
Levels lt 8.0 7.0 (2003-2006)

Time
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LDL Levels (2003-2006)
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Proportion of Patients with LDLc
Levels lt 130 mg/dL 100 mg/dL
(2003-2006)
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Delivery System Design

• Diabetes Educators in Primary Care
• Diabetes Mini Clinics

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Is this where we are going????
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Proportion of People Educated at PCP Office
Compared to Hospital Based Outpatient DSME
plt0.0001

n686/4332
n9,334/89,760
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Nurse-directed protocols

• Approved protocols for glycemic, hypertension and
  cholesterol management
• Nurses used these protocols in management
• Intervention in high-risk Hispanic community
• Significant improvement in provider processes and
  patient outcomes

Davidson, M., et al Effect of nurse-directed
diabetes care in minority populations Diabetes
Care, 2003.
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Process measures
Measure ADA guidelines Nurse-directed care Usual
care P HbA1c Goal-yes, 1 per 6 months
Goal-no, 1 per 3 months 227/252 (90) 66/252
(26) lt0.001 Lipid profile At least yearly 244/252
(97) 148/252 (59) lt0.001 Eye exam At least
yearly 240/252 (95) 200/252 (79) lt0.001 Renal
profile Yearly 215/252 (85) 148/209 (71)
lt0.001 If dipstick negative/trace, measure
albumin-to- creatinine ratio 54/183 (30) 76/174
(44) lt0.01 If dipstick negative/trace, or
albumin-to-creatinine ratio gt30 mg/g, ACE
treatment 19/28 (68) 59/93 (63) NS Foot exam At
least biannually 245/252 (97) 202/252 (80)
lt0.001 2 visits At least biannually 248/252
(98) 241/252 (96) NS Diabetes education No
frequency stated 239/252 (98) 122/252
(48) lt0.001 Nutritional counseling No frequency
stated 224/252 (89) 14/252 (6) lt0.001
Davidson, M., et al Effect of nurse-directed
diabetes care in minority populations Diabetes
Care, 2003.
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HbA1c ( SD) outcome measure
Nurse-directed care Usual care P All
patients  Percent of patients 249/252
(99) 201/252 (80) lt0.001  Initial 13.5 3.7 12.1
3.1 lt0.001 2 tests  Percent of
patients 201/249 (81) 145/201 (72) lt0.05  Initial
13.3 3.5 12.3 3.4 lt0.02  Final 10.3
6.0 10.8 3.2 NS  Change -3.0 6.6 -1.5
2.9 lt0.01 6 months  Number of
patients 120 145  Initial 13.3 3.4 12.3
3.4 lt0.02  Final 9.8 3.0 10.8
3.2 lt0.01  Change -3.5 3.8 -1.5 2.9 lt0.001
Data are n () or means SD. Some of these
patients were followed for lt3 months.
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Self-Management Support

• Expanded Education sites
• CDE in Primary Care
• Traveling educator
• AADE Outcomes System

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AADE Outcome System (IMPACT)
System Measures Changes In
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AADE 7 Self-Care Behaviors

• Healthy eating
• Being active
• Monitoring
• Taking medication
• Problem-solving
• Healthy coping
• Reducing risks

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Add New Individual Session
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Diabetes Prevention Program

• 150 minutes of exercise/week
• Healthy eating program
• 7 reduction in weight
• Results in
• Decreases in Blood pressure (? 130/85 mmHg)
• Decreases in Waist circumference
• Men lt 40 inches Women lt 35 inches
• Decreases in Triglyceride levels (lt 150 mg/dL)
• Decreases in Glucose (lt 100 mg/dL)
• Decreases in HDL cholesterol
• Men gt 40 mg/dL Women gt 50 mg/dL

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Average Weight Loss Over TimeDiabetes Prevention
Program-Braddock
Lifestyle Modification Program 150 minutes of
physical activity per week and a healthy eating
program
pounds
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Average Decrease in BMI Over TimeDiabetes
Prevention Program-Braddock
Lifestyle Modification Program 150 minutes of
physical activity per week and a healthy eating
program
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Decreases in the Proportion of Subjects with
Abdominal Obesity, Hypertension, and
Hypertriglyceridemia Over TimeDiabetes
Prevention Program - Braddock

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Conclusions

• The CCM provided a good framework for quality
  improvements in primary prevention and treament
• Gained health system and community attention
• Increased number of resources
• Captured attention of state and federal policy
  makers
• Improved insurance coverage
• Decision support clinical improvements
• Clinical information systems afforded the
  opportunity for tracking populations
• Self-management support facilitated diabetes
  education and behavior change
• System redesign
• Improved access for education
• Physicians and patients reported increased
  communication and satisfaction.

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• MICRO LEVEL
• Informed
• Motivated

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• MESO LEVEL
• Organize Equip
• Coordinate
• Community

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• MACRO LEVEL
• Leadership Advocacy
• Integrate policies
• Consistent financing
• Human Resources
• Legislative frameworks
• Partnerships

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Global Projects

• Canada Vancouver expanded CCM
• Mexico Veracruz project
• Morocco Natl. Government used ICCC
• Russian Federation ICCC for secondary
  prevention with 56 teams
• Rwanda ICCC HIV/AIDS project
• United Kingdom 10 yr. quality project

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Key Messages

• Burden of chronic disease increasing
• Most health systems not equipped
• Patients do better with integrated system
• Evidence supports organized systems of care
• CCM has been successful in US
• ICCC depicts complimentary process
• CCM ICCC need to be disseminated, implemented
  evaluated

Eppinger-Jordan, JE Pruitt, SD, Bengoa, R.,
Wagner, E. Improving the quality of health care
fore chronic conditions. Quality Safe Hl Care,
2004.
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Special Acknowledgement

• Project team
• Janice Zgibor, RPh, PhD
• Sharlene Emerson, CRNP, CDE
• Gretchen Piatt, PhD, CHES
• Janis McWilliams, MSN, CDE
• Kristine Ruppert, DrPH
• Francis Solano, MD
• University of Pittsburgh Diabetes Institute
• University of Pittsburgh Division of
  Endocrinology and Metabolism
• University of Pittsburgh Medical Center
• This research was partially sponsored by funding
  from the United States Air Force administered by
  the U.S. Army Medical Research Acquisition
  Activity, Fort Detrick, Maryland, Award Number
  W81XWH-04-2-0030."

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WHO

• JoAnne Eppinger-Jordan, PhD
• Contact K. Thompson
• thompsonk_at_who.int

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When spider webs unite they can tie a
lion.African Proverb