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Diabetes Care for High Risk Populations:

Lessons from a Community Based

Program

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Software Screen

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Today’s Speakers

Marie Laboissonniere RN Med CDOE CVDOEand

Susanne Campbell RN MS

St Joseph Center for Health and Human Services

Providence, RI

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Learning Objectives Participants will be able to:

•Describe resources available that enable uninsured/vulnerable patients to obtain medications, supplies and material support needed to work toward positive treatment options.

•Identify strategies to maximize internal/external resources to provide patients with nutritional, mental health and additional chronic care services.

•Identify educational and peer support opportunities to engage patients in taking a significant role in managing their own care.

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The Diabetes Resource Center (DRC)

Established in 1991 to meet the needs of people with diabetes who:

• Have limited or no resources• Are under – or uninsured

Have diabetes-related needs for :• Medications• Accessing primary care, specialty care, mental

health and case management services• Diabetes education

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Primary Goals

Patients will be able to manage their condition and improve clinical outcomes through access to :

• Primary Care • Podiatry, Ophthalmology • Medications• Diabetes Supplies • Mental health and case management • Nutritional services • Individual and group education

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Main Partners

• Rhode Island Dept of Health Chronic Care Collaborative (Diabetes and CVD)

• Colleges and Universities (student interns for pharmacy, nutrition, nursing, medical assistants);

• Funders (Blue Cross/Blue Shield, Rhode Island Foundation, Churches . Private Charities)

• Systemetrics (Pharmacy Assistance Software) • Drug companies • CMS-contracted QI Organization (Quality Partners• Private physicians that donate time • Volunteers (registry data entry, patient follow up)• Peer Navigator (Rhode Island Parent Information

Network)

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Challenges

• Growing number of uninsured patients • Employing professional staff that speak Spanish

(RD, Social Worker, RN) • Less grant funding opportunity with downturn in

economy • Place to come for “free care”• Free standing registry • Patient engagement and follow through

• Reimbursement for services

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Changes : Reduce Expenses, Improve Efficiency

• Integrated the DRC into the Adult Primary Care Program

• Implemented group diabetes classes (including mental health )

• Implemented peer support group • Implemented small group education • Automated the Pharmacy Assistance Program

(PAP) • Coordinated purchased supplies with PAP• Added Primary Care model requirement to

access other support services

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Changes: Team Expansion/Integration

• Co-located and integrated mental health • Expanded team to include RD, social worker,

Clinical Nurse Specialist, and peer navigator • Expanded relationship with Universities • Expanded community partnerships (exercise,

tobacco cessation, nutrition)• Expanded program to other chronic care

conditions • Collaboration with acute care: Diabetes Center

for Excellence

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Changes: Reimbursement

• Became ADA certified site and State recognized CDOE site

• Hiring RD who is can be reimbursed under Medicare and Medicaid

• Becoming a Patient Center Medical Home: Insurances paying more per member/month and pay for performance

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What Patients Need

Medications/strips: • Pharmacy Assistance Program : seeing 200

patients per month; • Increasing need for grant funded insulin and

supplies

• Increased need for Pharmacy samples

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What Patients Need

Mental Health • Resources for Basic Living Needs • Treatment for anxiety and depression • Peer support, particularly for Latino population

• Navigating the health care system

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What Patients Need

Access to Care • When becoming uninsured• When discharged from Hospital/ER • Earlier identification of pre-diabetes and

diabetes • Life Style Change Education, especially for

nutrition and managing conditions

• For management of chronic mental health conditions and co-morbid conditions

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Strategies

Medications/strips • Obtained grant through Rhode Island

Foundation to pilot bilingual Chronic Care Support position

• Implemented Pharmacy Assistance Program• Implemented Systemetics software• Improved clinical outcomes (total cholesterol,

LDL levels and HbA1c) • Reduced expenses for grant purchased

medication and supplies

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Strategies/Patient Resource Information

• For information on Pharmacy Assistance software (Systemetics) contact 888-593-1085 or info@rxassistplus.com

• For patients with insurance and high co pays, call Patient Advocate Foundation Co-Pay Release at 1-866-512-3861 (prompt “2” case management).

• Abbott and Roche offer glucose test strips, and meters for people who qualify for their program.

• For Abbott products: Call 1-800-222-6885 or visit www.abbottpatientassistancefoundation.org ;

• For Roche products: visit www.accuchek.com; and go to patient assistance program

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Strategies: Mental Health

• Obtained funding from Blue Cross/Blue Shield of RI for Project Access

• Blue Angel: Mission to integrate mental health and medical services

• Hired a bi lingual LICSW and CNS• Contracted with Psychologist for team support

and patient grand rounds• 320 patients screened by staff at Point of Care • Physician/patient discussion and referral for

case management, individual clinical intervention, support group

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Strategies: Mental Health

• Integrated social worker into Diabetes Education classes

• Implemented follow up peer support group • 452 patients with diabetes screened at point of

care; • 39% referred (60% Latino; 49% uninsured)• 72% improvement in HbA1C after interventions

• 59% established self management goal

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Strategies : Nutrition

• University Partnerships: URI Nutrition Science Program-student interns to obtain experience counseling patients with diabetes at no cost to patients

• Students providing educational resource packets • Reduced RN CDOE staff and replacing with RD• RI Neighborhood Pilot Project: referrals to St

Joe’s for medical, nutrition, education and pharmacy assistance; referral to Neighborhood partners for exercise, nutrition, social services and support groups

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Eye/Podiatry

• Hospital Collaboration: MD volunteer as part of staff privileges

• Once a month podiatry clinic• Once a month eye clinic (including specialty

referral and treatment)

• Increased referrals at earlier identification at “point of care” …take off socks, monofilament testing

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Strategies/Education

• Obtained a grant from Rhode Island Foundation to start diabetes education classes (on site and off site)

• Followed at ADA application guidelines when setting up program

• Obtained ADA recognition status for long term sustainability

• Partnered with hospital staff to provide Community Health Fair with over 200 people attending

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Strategies/Education

• Small patient group instruction for common skills-insulin injection and blood glucose monitoring

• Large group instruction for comprehensive diabetes education

• Telephone follow up to assess blood glucose patterns and titrate insulin to achieve blood glucose goals

• Follow up patient engagement to check on coping skills

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Strategies/Staff Education

• Staff nurses to obtain CDOE certification, and Tobacco Cessation Certification

• Nurses obtained CVD certification to expand from Diabetic Resource Center to Chronic Care Resource Center

• Partnered with Quality Partners for Chronic Kidney Disease resource education

• Integrated standards of care into the clinical note

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Strategies/Limited Resources

• Drug companies: Education for staff, patients and medication samples and strips; helped to underwrite costs of health fair

• Workforce Volunteer Program (AHEC): Placement of students and volunteer for career exploration and work experience (registry support, pharmacist student, medical assistant, nutrition

• Peer Navigator Program: Provides staff who can offer individual assistance for basic needs

• Churches and small foundations: medication/strips

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Future Plans

• Obtain Level 1 Patient Medical Home Status to position ourselves for better reimbursement

• Electronic Medical Record

• Expand to Pre-Diabetes

• Shared Medical Visit Pilot

• Shared Nutrition Visits

• Group follow up after CDOE classes

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Future Plans

• Through a Block grant, working with community groups to work on access to fresh fruits and vegetables in community markets and policy changes to address social determinants of health

• Working with SNAP program to offer on site Food Stamp application assistance

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Questions / Discussion

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Have additional questions?

Please contact us at info@rxassist.org