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PATIENT SELF-MANAGEMENT & PLANNED CARENOVEMBER 2014 – JUNE 2015 PILOT
Maine Chronic Disease Improvement Collaborative (CDIC)
Learning Session #2
Welcome & Introductions
DON’T WORRY…
We won’t have you share your favorite Valentine’s Day song BUT….
Chronic Disease is at the of our aim!
National Front Local Front
Chronic disease is the number one cause of
death.
32% of mortalities in Maine in 2010
Diabetes rates have risen from 6% to 8.7% in 10 years
92,000 adult residents living with diabetes
Why we are here…
Funder: Maine Centered for Disease Control (CDC) 1305: State Public Health Actions to Prevent & Control Diabetes, Heart Disease &
Obesity Project Partners:
Maine Quality Counts: project leadership, practice coaching, PCMH expertise Maine CDC: grantee and partner Partnership for Health: evaluation partner Stakeholder Advisory Group including
MMC Diabetes Collaborative Maine Cardiovascular Health Council Medical Care Development/Public Health HealthCentric Advisors Quality Improvement Organization QIO) Spectrum Generations (AAA) Maine Nurse Practitioner Association
About the Project
Our Goals
Expand knowledge on evidence based, safe, cost effective care
Implement/spread best practices and algorithms across the state
Improve quality, cost and safety
Teach and spread science of quality improvement
Drivers for Improving Chronic Care
Drivers for Improving Chronic Care
Supporting Patient Self-Management Pat Watson, MS,RD,LD,CDENathan Morse, CHES, TTS-C2/26/15
Goals of our Discussion
• Practices will identify barriers to engaging their patients in behavior change to help prevent the onset of T2DM and manage their existing T2DM
• Practices will increase awareness of programs and resources available to support patient self-management in areas of diabetes prevention and T2DM.
Opportunities: Prevention
Helping to prevent onset of Type 2 DM
http://www.cdc.gov/obesity/data/prevalence-maps.html
Barriers to Change/ Success: Your Narrative
• What has your practice identified as challenges to engaging your patients to help prevent T2DM?
• What are your successes?
Close to Home: Moving Forward
Questions for your team:
• How do you share your patient’s risk for developing T2DM with them?
• How do your patients set their goals related to preventing the onset of T2DM?
• Do your patients have the tools necessary to turn the tide and reduce their risk?
Your office:
• How does your office identify patients ready for change?
• What referrals do you make?• What are your patient barriers?• Who is following these patients?
Opportunities: Evidence- Based (and fun)
Prevention: National Diabetes Prevention Program
http://www.cdc.gov/diabetes/prevention/newsroom.htm
http://www.cdc.gov/diabetes/prevention/features.htm
Community Resources: NDPP
Exciting/ Evidence-based/ Proven:
http://rethinkdiabetes.org/resources-and-tools/Maine’s National Diabetes Prevention Program (NDPP) Information Portal
• Locating a local program/finding a partner• Advertising strategies for your practice • Lowering participation barriers• Sharing success• Resources
T2DM: Supporting Patient Self-Management
In your office, who:• Talks with patients about DSMT?• Encourages patient participation in DSMT?• Asks patients about barriers to attending DSMT?
Your local diabetes educator:• Partnering with local programs to reduce patient education
barriershttp://www.maine.gov/dhhs/mecdc/population-health/dcp/educationprogram.htm
Thank You
Optimizing Collaboration between the Primary Care Provider and the Specialist for Co-Managing
High Risk Patients
John Devlin, MD Endocrinologist
Collaborative Care
Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 2014
A team with a shared mission
using improved clinical systems todeliver improved care to a patient population
supported by operational and financial systems.Such care is continuously evaluated through
improvement processes and effectiveness measurement.
Population Management
Population ManagementCommunity Hospital, Grand Junction, CO
Comprehensive Primary Care Initiative (CMS): IHI Triple Aim
• Decrease unnecessary ED visits and hospitalizations
• Improve transitions of care
At Risk clients
1. Stratification (Low, Medium, High) based on stages of current (chronic) diseases
2. Implementation of a care management program to manage condition(s)
Murray D. American Diabetes Association Annual Conference, San Francisco, 2014
Level A Level B Level C Level D
• HbA1c ≥ 9• DM plus 1 or more
uncontr comorbid*
• In NON-SELF Management
• HbA1c 7-8.9• DM plus 1-3 co-
morbidities*
• Independent SELF Management State
• HbA1c < 7• DM plus 1-3 stable
co-morbidities*
• Hospice or SNF• Receives services
elsewhere• Patient Opted Out
• Requires BOTH physician and RN assessment
• RN Care Coordinator
• Health Coach Assessment
• Health Coach Assessment
N/A
Requires DSMT DSMT applicable with Primary Educational Activities + DSM Plan
DSMT applicable with Primary Educational Activities + DSM Plan
N/A
Tipping Point ≥ 4 out of 7
Tipping Point > 3 out of 7
Tipping Point ≤ 2 out of 7
Population Management:Risk Stratification Behavior Change
* May include: CHF, CAD, HTN, open wounds, neuropathy, nephropathy, retinopathy, gastroparesis
Population Management
Assessment
Care Coordination
Support
Wiegert K. ADA Annual Conference, San Francisco 2014
• Conduct Needs Assessment
• Assess Safety• Create Plan of Care
• Coordinate Services• Navigate Transitions
of Care• Prevent Unnecessary
Care
• Provide Education and Guidance
• Goal Setting• Encourage DSM
techniques
Population Management
“The focus of the population management process is to proactively manage the health of each patient through a coordinated team effort”
Diabetes management:
• Improve quality outcomes• Identify gaps in delivery of care• Advance clinical processes using efficient utilization of resources • Decrease avoidable episodic events with chronic conditions• Improve access to health care services by providing PCMH and
collaborative medical visits• Standardize care processes for disease specific conditions
Murray D. ADA Annual Conference, San Francisco 2014
Standardize Care Processes
Antihyperglycemic therapy in type 2 diabetes: general recommendations.
Inzucchi S E et al. Dia Care 2015;38:140-149
©2015 by American Diabetes Association
Victor Montori, Shared Decision-Making
Considerations in Medication Choice
• Efficacy• β cell function
• Hypoglycemia Risk
• Weight
• Side effects• Cardiovascular
• Cost
Glucose(mg/dL)
50 –
100 –
150 –
200 –
250 –
300 –
350 –
0 –
50 –
100 –
150 –
200 –
250 –
-10 -5 0 5 10 15 20 25 30
Years of Diabetes*IFG=impaired fasting glucose.Burger HG, Loriaux DL, Marshall JC, Melmed S, Odell WD, Potts JT, Jr., Rubenstein AH. 2001. Diabetes Mellitus, Carbohydrate Metabolism, and Lipid Disorders. Chap. in Endocrinology. 4th ed. Edited by Leslie J. DeGroot and J. Larry Jameson. Vol. 1. Philadelphia: W.B. Saunders Co. Originally published in Type 2 Diabetes BASICS. (Minneapolis, International Diabetes Center, 2000).
RelativeFunction
(%)
Fasting Glucose
Postmeal Glucose
Obesity IFG* Diabetes UncontrolledHyperglycemia
Insulin Resistance
-cell Failure
Can the Course of Type 2 Diabetes Be Altered?
Beta
-cel
l Fun
ction
(%)*
PostprandialHyperglycemia
IGT† Type 2DiabetesPhase I
Type 2DiabetesPhase II
Type 2DiabetesPhase III
Years from Diagnosis
Patients Treated with Metformin and/or Sulfonylureas (SUs)‡
Can The Decline Be Altered?UKPDS: Beta-cell Decline Over Time
25 –
100 –
75 –
0 –
50 –
l-12
l-10
l-6
l-2
l0
l2
l6
l10
l14
ADOPT: Treatment effect on primary outcome
Kahn SE et al. N Engl J Med. 2006;355:2427-43.
40
30
20
10
0
Glyburide
Metformin
Rosiglitazone
0 1 2 3 4 5
Years
Cumulative incidence of
mono-therapy failure*
(%)
Hazard ratio (95% CI) Rosiglitazone vs metformin, 0.68 (0.55–0.85), P < 0.001 Rosiglitazone vs glyburide, 0.37 (0.30–0.45), P < 0.001
N = 4351
*Time to FPG >180mg/dL
ADOPT: Treatment effect on insulin sensitivity and β-cell function
Kahn SE et al. N Engl J Med. 2006;355:2427-43.*At 4 years†Homeostasis model assessment (HOMA 2)
Insulinsensitivity†
(%)
50
60
40
30
0
Years
70
-Cell function†
(%)
80
90
70
60
0
Years
100
543210
GlyburideMetforminRosiglitazone
Treatment difference* (95% CI)
Rosiglitazone vs metformin12.6 (8.1 to 17.3), P < 0.001
Rosiglitazone vs glyburide41.2 (35.2 to 47.4), P < 0.001
Treatment difference* (95% CI)
Rosiglitazone vs metformin5.8 (1.9 to 9.8), P = 0.003
Rosiglitazone vs glyburide-0.8 (-4.7 to 3.1), P = 0.67
543210
UKPDS• Newly diagnosed type 2
diabetes; intensive versus conventional policy; primary report published September 1998
• Follow-up observation published October 2008
Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.
Post-Trial Changes in A1C
UKPDS resultspresented
Mean (95%CI)
Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.
MI Hazard RatioFatal or Non-Fatal MI or Sudden Death)
Intensive (Sulfonylurea/Insulin) Versus Conventional Glucose Control
HR (95%CI)
Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.
Glycemia Reduction Approaches in Diabetes:A Comparative Effectiveness Study (GRADE)
• Metformin 1000-2000 mg daily• HbA1c 6.5-8.5%• Duration < 10 years• Randomize:
• Glimepiride (SU) N = 1500• Sitagliptin (DPP-4 inhibitor) N = 1500• Liraglutide GLP-1 agonist N = 1500• Glargine insulin N = 1500
• Follow-up over 7 years
http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf+html
Figure 3
Getting to insulin
• Overcoming “psychological insulin resistance”• Patient• Provider
• Overcoming therapeutic inertia• Insulin initiation• Insulin titration
Basal Insulin
• Glargine vs. NPH
• Starting dose
• Combination with oral hypoglycemic drugs
• Titration
The Treat-to-Target TrialRiddle MC, et al. Diabetes Care 2003;26:3080-86
Randomized addition of glargine or human NPH insulin to oral therapy of
type 2 diabetic patients
Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 2003; 26: 3080-6
Riddle MC, et al. The Treat-to-Target TrialDiabetes Care 2003; 26: 3080-6
Riddle MC, et al. The Treat-to-Target Trial Diabetes Care 2003; 26: 3080-6
Riddle MC, et al. The Treat-to-Target TrialDiabetes Care 2003
Hypoglycemia: Events per patient per year
All Symptomatic
Events
Confirmed ≤ 72 mg/dL
Confirmed ≤ 56 mg/dL
Glargine 13.9 9.2 3.0
NPH 17.7 12.9 5.1
http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf+html
Initiating insulin
• Typically begin at low dose 0.1-0.2 units/kg/day
• In more severely hyperglycemic 0.3-0.4 units/kg/day
Clinical Case
89 y.o. gentleman has had acceptable glycemic control until recently, on metformin 1000 mg BID and glipizide ER 5 mg daily.
• S. creatinine 1.12 (eGFR 58 ml/min/1.73m2)
Lately, he has had higher glucose readings overnight, with bedtime BGs in 200-260 mg/dl range. He admits to having desserts at night.
• Nocturia every 2 hours• S. creatinine increased to 1.3 (eGFR 48 ml/min/1.73m2)• His nephrologist tells him this is due to dehydration, and
advises him to drink more water
Your advice?• Stop eating dessert• Drink more fluids• Stop metformin• Start insulin
Multiple Chronic Medical Conditions
Health Services Models
Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 2014
Team approaches have been shown to improve quality of care and outcomes of patients with:
• Depression
• Diabetes
• Asthma
• Hypertension
• CHF
Medicare Patients
Ciechanowski PS. ADA Annual Conference, San Francisco 2014
Multiple morbidity is the norm:
• 80% of those with CHF
• 71% of those with Depression
• 56% of the with Diabetes
have 4+ Chronic Conditions
Health Services Modes for Natural Clusters of Illness
Ciechanowski PS. ADA Annual Conference, San Francisco 2014
Diabetes
HTN CAD
Depression
AHRQ Multiple Chronic Conditions (MCC) project
American Diabetes Assn. Annual Scientific Sessions, Chicago, June 22, 2013
48.9% of Cohort has a Behavioral Health Disorder
MCC Behavioral Health Group
Number Distinct Members
No BH 32,272
SA Only 1,610
MH Only SMI 5163
MH Only non-SMI 12,002
Dual (MH and SA) 7,861
MR/DD/TBI 4,233
OVERALL TOTAL 63,141
AHRQ MCC project, presented at Am Diabetes Assn, June 2013
118%
91%
80% 80% 77%
52%48%
-8%
-35%
Factors predicting developing complications: Persons with uncomplicated diabetes at baseline
Percent more likely…
Improved Continuity of Care
Improved Mental Health
AHRQ MCC project, presented at American Diabetes Association, June 2013
Selected statistically significant independent variables in regression
Clinical Vignettes
1.) Schizophrenic patient hearing voices that were telling him that starting insulin would cause cancer. CDE had to also provide education to the voices to correct misinformation so patient would feel comfortable starting insulin.
2.) Another patient with type 1 and thought disorder felt Novolog and Humalog caused his hair to smell like broccoli; CDE able to patiently work with him to restart analog insulin based on discussion that doing so would improve running/biking times (no ketones=faster times)—creativity at it’s best. Meet people where they are.
3.) When new patient referrals are triaged and it is determined that they will likely need to start insulin or transition to MDI, they are scheduled with CDE immediately following MD appointment to reduce barriers for doing so (strike while the iron is hot). Provider updates CDE on plan and off we go. F/U with CDE can be more frequent to ease transition, answer questions, make insulin adjustments prn.
4.) Otherwise, we accommodate pts as best we can at time of appointment when insulin or other injectable is unexpectedly needed rather than having them return (or cancel/no show) on a different day to do so.
To address lack of treatment intensification
Schmittdiel et al. J Gen Intern Med 2008;23(5):588-594
Study: 161,697 patients (Kaiser Permanente)
• HbA1c > 7%• Systolic BP > 130• LDL > 100
Adequate ad-herence
Poor adherenceClinical Inertia30-47% lacked treatment
intensification by healthcare team
20-23%
Literature Review
Ciechanowski PS. ADA, San Francisco 2014
Problems with patients:
• Poor collaboration• Non-adherence • Missed appointments• Dissatisfaction with care• Do-it-alone approach• Poor self-care• Stress, anxiety and depression
providers
Collaborative Care
Ciechanowski PS. ADA Annual Conference, San Francisco 2014
PatientPCP
Psychiatric and Medical Case Review
CareManager
Multi-Condition Collaborative Care
Ciechanowski PS. Am Diabetes Assn Annual Conference, San Francisco 2014
Program goals:• Improve depression care
• Behavioral activation• Antidepressants
• Improve medical disease control• A (A1c)• B (Blood Pressure)• C (LDL-Cholesterol)• D (Depression)
• Improve self-care• Diet, exercise• Smoking cessation• Glucose monitoring
Multi-Condition Collaborative Care
Ciechanowski PS. ADA Annual Conference, San Francisco 2014
Identify Goals
SupportSelf-care
Monitor Progress
Treat-to-Target
Systematic
Case Review
CareCoordina
tion
Core Components
Multi-Condition Collaborative Care
Ciechanowski PS. ADA Annual Conference, San Francisco 2014
Nurse training:• Motivational interviewing/enhancement
• Problem solving
• Behavioral activation
• Antidepressants
• Treat-to-Target• HbA1c• Blood Pressure• LDL
Multi-Condition Collaborative Care
Ciechanowski PS. ADA Annual Conference, San Francisco 2014
Treat-to-Target:• Treatment titration
• Frequent and consistent• Relentless, incremental increases/changes
• Always• Increase/change to next step• If not, document why not!
• Treat-to-Target Algorithm• Simplified and uniform approaches across
conditions to achieve targets• Riddle, Diabetes Care 2003• Kaiser Permanente, Care Management Institute
Approach to starting and adjusting insulin in type 2 diabetes.
Inzucchi S E et al. Dia Care 2015;38:140-149
©2015 by American Diabetes Association
Pre-mixed insulins
Target: FPG 100 mg/dLSubjects (n = 364) were randomized to:
Insulin glargine once daily + continued OADs
Pre-mixed insulin 70/30 BID
Baseline Endpoint
Time (wk)0 24
Treatment Regimen
*Sulfonylurea +metforminOAD=oral anti-diabetic drugJanka HU et al. Presented at: American Diabetes Association 64th Scientific Sessions; June 4-8, 2004; Orlando, FL; Abstract 548-P; Study 4027
Insulin Glargine Plus OADs vs Twice-Daily Pre-Mixed Insulin
OADs*
Change in A1C From Baseline to Study Endpoint
Janka HU, et al. Diabetes Care. 2005;28:254-259
8.85 8.83
7.157.49
5
6
7
8
9
Insulin Glargine + OAD Pre-mixed
P<0.0005
A1c
Superior HbA1c Reduction With Glargine Plus OADs vs Twice-Daily Pre-Mixed Insulin
Baseline
24 week
Documented Hypoglycemic Episodes Per Patient-Year
Less Hypoglycemia With Glargine Plus OADs vs Twice-daily Premixed Insulin
Average dose = 28.2 IU with G + OAD vs 64.5 IU with premixed insulinWeight Gain: 1.4 ± 3.4 kg with G + OAD vs 2.1 ± 4.2 kg with pre mixed insulin
Janka HU, et al. Diabetes Care. 2005;28:254-259.
4.1
9.9
0
2
4
6
8
10
# of Episodes
Per
Patient-Year
P<0.0001
Insulin Glargine + OAD Premixed
Three-year efficacy of complex insulin regimens in Type 2 Diabetes
Holman RR, et al. N Engl J Med 2009;361:1736-47
Treating to Target in Type 2 Diabetes (“4-T”)
• Suboptimal HbA1c while taking metformin and sulfonylurea
• Randomly assigned to receive biphasic insulin b.i.d., prandial aspart t.i.d., or basal detemir once daily (or b.i.d. as needed)
• Target BG: ac 72-99 mg/dl, and 2-h pc 90-126 mg/dl
Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med 2009; 361: 1736-47
Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med 2009; 361: 1736-47
Basal insulin: titration
• Glargine dose can be increased every 5-7 days based on SMBG
• At doses above ~ 50 units daily, it may be more effective to split the dose into twice daily injections
• Doses above 1 unit/kg/day are unlikely to offer additional benefit, and addition of prandial insulin should be considered
Basal to “Basal Plus 1”
A strategy of adding bolus insulin to an existing basal insulin regimen in a stepwise manner
• Add a single daily bolus injection with the largest meal of the day
• Add further bolus injections at additional meal(s) if necessary
Rosenstock J et al. The CADRE Handbook of Diabetes Management. New York, NY: Medical Information Press; 2004:145-168.
Starting Basal/Bolus Therapy
• Starting insulin dose is based on weight–0.2 x wgt. in lbs. or 0.5 x wgt. in kg
• Bolus dose (aspart/lispro) = 20% of starting dose at each meal
• Basal dose (glargine/NPH) = 40% of starting dose at bedtime