You made it through DSME Accreditation!!

Now What? –A How to Guide for Pharmacists

Jonathan G. Marquess, PharmD, CDE, FAPhA President/CEOThe Institute for Wellness and EducationMultiple Independent Pharmacy OwnerPennsylvania Pharmacy Association – September 2019

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Learning Objectives:Describe the purpose and content areas of the DSME program.Describe how to integrate DSME services into a busy community pharmacy.Describe approaches used to tailor a DSME program for your community pharmacy.List the steps necessary to develop an effective DSME program.Identify the benefits, barriers and challenges that may be encountered when implementing a DSME program.Identify one new service that would bring value to your patients with Diabetes.

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Program Faculty

- Dr. Jonathan Marquess is the President of The Institute for Wellness and Education, a Disease Management Company. He is owner and diabetes educator at two AADE recognized Diabetes Education Centers in Atlanta. In Addition, Dr. Marquess, and his Pharmacist wife, Pam, are the owners of community pharmacies in Georgia. Before assuming his current position, Dr. Marquess was a Clinical Professor of Pharmacy Practice at Mercer University School of Pharmacy in Atlanta.

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Jonathan Marquess, PharmD, CDE, FAPhA

Faculty Disclosures

- Dr. Marquess does not (nor does any immediate family member have) have actual or potential conflict of interest, within the last twelve months, a vested interest in or affiliation with any corporate organization offering financial support or grant moniesfor this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias this presentation.

- Health Mart Independent Pharmacy Owner- Off-label use of medications will not be discussed during this presentation

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Our sites:East Marietta Drugs (EMD)- ADA recognized May 2004- AADE recognized in 2007- Independent in Community 50+ years- Professional Pharmacy & Compounding Center- One Stop Diabetes Shop

- Blood glucose meters, testing supplies, pump supplies- Diabetic footwear- Diabetes education !

Woodstock Pharmacy (WP)- Additional site to EMD – ADA recognized November 2005

(AADE Accredited 2008)- Independent in Historic Downtown Woodstock 40+ years- Professional Pharmacy & Compounding Center- One Stop Diabetes Shop

The picture can't be displayed.

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May 31, 2012Jonathan MarquessEast Marietta Drugs and Woodstock Pharmacy Diabetes Education Program1480 Roswell Road, Marietta, GA 30062

Dear Jonathan,

It is my pleasure to inform you that your Annual Status Report for AADE DSME/T Program Accreditation has been accepted. The review process revealed thatEast Marietta Drugs and Woodstock Pharmacy Diabetes Education Program, #198023 remains in compliance with the National Standards.

Please note, per the ‘Compliance Enforcement Policy’, that you are required to submit a ‘Change of Status Report’ to AADE within 30 days of each significant program change. You are also expected to continue submitting an ‘Annual Status and Performance Measurement Report’ on an annual basis.

AADE Diabetes Education Accreditation Program (DEAP) staff will be happy to address any questions or concerns related to your accreditation status. We strongly encourage you to periodically visit the accreditation program for links to all forms, instructions, news and updates at: www.diabeteseducator.org/accreditation.

Sincerely,Leslie Kolb, RN, BSN, MBADirector, Diabetes Education Accreditation ProgramAADE

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- Chronic Care Management- AADE Accredited Diabetes

Education- MTM- Med Sync- Adherence packaging- Immunizations (and travel)- CPESN pharmacy- Point of care testing- Compounding

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Follow Us on Twitter !!!SugarDetective1

For More Information:Jonathan G. Marquess, PharmD, CDE, FAPhA

jonathan.marquess@gmail.com

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PHARMACY BUSINESS CHALLENGES

Reductions in overall reimbursement

? ? ? Direct and indirect remuneration fees

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1. Growing Competition and Consolidation of Retail Pharmacy Chains

2. Growth of the Specialty Pharmacy Market3. Struggling to Make the Right Technology Choices4. Roadblocks to Achieving Provider Status5. Securing Collaborative Practice Agreements6. Declining Margins

Challenges Facing Community Pharmacy:

AlliantRx. (2019, March 8). The Top 6 Challenges Facing Community Pharmacy in 2019 - Are You Ready?. https://www.alliantrx.com/the-top-6-challenges-facing-community-pharmacy-in-2019-are-you-ready/

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https://www.alliantrx.com/the-top-6-challenges-facing-community-pharmacy-in-2019-are-you-ready/

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DSMES PROVIDES VALUE:

Your pharmacy does more than ensuring the right product goes to the correct patient

Defining the Standard of Care You Provide

Prescribers need to know: Start:

Proving the value of community pharmacy to change expectations of patients and prescribers

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Icebreaker

Do you teach patients how to use their blood glucose meters ?

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Audience ResponseWhat is the percentage of patients with

diabetes in the United States who aremonitoring their blood glucose levels?

1) 20 %2) 40 %3) 60 %4) 90 %5) Less than 20%

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Diabetes “Report Card”

Self-Monitoring of Blood Glucose Among Adults With Diabetes — United States, 1997–2006

Only ___ % of Americans with diabetes

measure their blood glucose levels!Centers for Disease Control and Prevention. Available at:

www.cdc.gov/mmwr/preview/mmwrhtml/mm5643a3.htm. Accessed January 25, 2017

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Marketing your Program

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Definition of Marketing- A common reason for business failure is the absence of an achievable marketing

plan that is customized to meet the needs of the target market.

- Marketing is the act of promoting and selling products or services, including market research and advertising. It is essential to create a marketing plan to effectively promote DSMES services and increase referrals.

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Marketing and Promotion of Your Program- Healthcare providers, diabetes educators, and other key stakeholders understand

that DSMES services have many benefits, including increasing satisfaction, improving clinical quality, enhancing clinical outcomes, and reducing costs. Nonetheless, participation in DSMES by people with diabetes is low.

- Although clinicians recognize that diabetes education is effective, some providers are not aware of existing DSMES services. Promoting DSMES and highlighting its value are critical to encourage referrals as well as ensure long-term sustainability. It is essential that healthcare providers understand a service’s scope and how it can improve health, but also how it can help them meet quality measures and increase productivity. Communication with providers is a good first step toward increasing awareness and referrals.

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Marketing and Promotion of Your Program

- According to research by the American Association of Diabetes Educators, diabetes education is generally highly regarded by providers; however, “it’s only recommended on average for just 62 percent of their patients.”56

- 56. American Association of Diabetes Educators. Tips for Reaching Prescribers. https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Tips_for_Reaching_Prescribers_Final.pdf

https://www.cdc.gov/diabetes/dsmes-toolkit/references.html#ref56https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Tips_for_Reaching_Prescribers_Final.pdf

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Marketing and Promotion of Your Program

- Diabetes educators are licensed health care professionals—registered nurses, registered dietitians and pharmacists, among others—who specialize in helping people with diabetes understand how to best manage their diabetes. The counseling and support that diabetes educators provide is known as diabetes education or diabetes self-management training (DSMT). Many of the healthcare professionals who provide these services also carry the designation Certified Diabetes Educator (CDE

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Marketing and Promotion of Your Program- Diabetes educators have a unique skill set and serve as essential support for

patients and providers. Diabetes educators can:- Increase your practice’s efficiency by assuming time-consuming patient training,

counseling and follow-up duties- Help you meet pay-for-performance and quality improvement goals- Track and monitor patients’ care and progress and provide you with status reports- Help delay the onset of diabetes with prevention and self-management training for

patients who are at high risk

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EATURES

STRUCTURE CONVERSATIONS AROUND

DVANTAGES

ENEFITS

FAB

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Partnerships Drive Value•Value is tied to our ability to help patients achieve positive health outcomes

•Value-based payment is replacing traditional fee-for-service•New incentive framework provides rewards for:

Relationships Create Value

Improved Quality

Health Outcomes Reduced Costs

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- Formally present yourself - Show you care about the patient that is under the physician’s

care- Grow your professional relationship and trust with local

physicians- Behave humbly and respectfully - Support your recommendation with data - DOCUMENT all interventions

Communicating with Physicians:

Pharmacy Times. (2016, October 5). Building Effective Physician-Pharmacist Communication. https://www.pharmacytimes.com/contributor/orlando-alvarado-rivera-pharmd-ms/2016/10/building-effective-physician-pharmacist-communication

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https://www.pharmacytimes.com/contributor/orlando-alvarado-rivera-pharmd-ms/2016/10/building-effective-physician-pharmacist-communication

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When looking at your own diabetes program, how do you define quality ?

What quality metrics is your program using today ?

What information do you need to help with conversations about quality of diabetes education ?

Will your pharmacy play a role in moving quality forward?

Partnering for Quality

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Ratings Matter

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Centers for Medicare and Medicaid Services (CMS) Star Rating- Annual rating system to grade Medicare plans- CMS assigns an overall rating on a 1 to 5 star scale

Star rating Performance Level

Poor

Below Average

Average

Above Average

Excellent

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Centers for Medicare & Medicaid Services. Prescription Drug Coverage — General Information. http://www.cms.gov/PrescriptionDrugCovGenIn/06 PerformanceData.asp. Accessed August 12, 2013.

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- Categories 1. Staying healthy 2. Managing chronic conditions3. Member experience 4. Member complaints and changes 5. Health plan customer service

Star Rating:Give an overall rating of the plan’s quality and performance for types of services in 5

categories

www.Mediare.gov Accessed June, 2019

http://www.mediare.gov/

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Instructions

1. Pair up with a person sitting next to you 1 minute

2. Discuss how you market your program3. Who will market your program ?

4. When and how often will you market your program

5. How will you evaluate your marketing ?

9 minutes

Activity 3: How will you Market Your Program ??

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10minutes

Chart1

Time

Grey area

Minutes

4

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Sheet1

Minutes

Time4

Grey area56

Total60

To update the chart, enter data into this table. The data is automatically saved in the chart.

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Discussion

Comments ? Questions ?

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Why DSME at Your Pharmacy ?- Professional Pharmacy

- Solid reputation in community- Excellent access to patients- Data shows we make a difference

- Diabetes Center = One Stop Diabetes Shop- Meter training- Diabetes testing and pump supplies- Diabetic footwear and foot care- Why not add Diabetes Education ?

The picture can't be displayed.

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What makes EMD/WP different ?- DSME Programs: The Norm

- Outpatient Hospital Classes- Large groups- > 6 month waiting list to enroll- Taught by nurses (RNs) with Certified Diabetes Educator (CDE)

credential- Limited availability- All modules taught in 1-2 day period (overwhelming!)

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What makes EMD/WP different ?EMD and WP DSME Programs

- Outpatient- Convenient Location and Parking- Individual and Small Group Settings- No more than 20 patients per class- Flexible scheduling- Centered around patient needs

Variety of Expertise = well rounded- 2 Pharm.D. Pharmacists (one with CDE)- 1 RN (Registered Nurse)- 1 RD (Registered Dietitian)- One module per week maximum encouraged

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EMD/WP Program Philosophy- The patient is the Most Valuable Player (MVP) of the Diabetes Care

Team- Our TEAM = THE PATIENT, the physician, the pharmacist, the nurse, the dietitian- Patient Centered and Patient Focused- Positive approach to successful self-management of disease

- Diabetes is NOT curable, but Diabetes IS MANAGEABLE !

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EMD/WPExpectations of Patients

- Lessons by Appointment Only- Arrive promptly- 24 hour notice requested if unable to attend- Missed appointment contract and fee

- MUST bring meter and log to every class- Be an ACTIVE Learner

- Listen and ask questions- Complete take home assignments- Participate in in-class activities

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EMD/WP Curriculum- Ten hours total DSME instruction- One module per week maximum encouraged

Visit Content InstructionHours

One Orientation Module 1: Blood Glucose Monitoring

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Two Module 2A: What is Diabetes?Module 2B: Diabetes Medications

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Three Module 3: Nutrition & Diabetes 2Four Module 4A: Preventing Complications

Module 4B: Exercise1.5

Five Module 5: Goal Setting, Problem Solving 1.5Six Comprehensive Review 1

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Outpatient Education

- Class- Day/Evening- 12 month follow-up included

- Individual Counseling- Carb-Counting Class- Support Group

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Conversation Starters- Did you use your meter to test your blood sugar today?

- Do you have any questions about testing your blood glucose?

- Do you know how many carbohydrates you should have at each meal?

Key BehaviorsYour Curriculum

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Resources and Tools are AvailableAADE7TM System:http://www.diabeteseducator.org/ProfessionalResources/AADE7/A7S.html

Online software package that allows you to:

- Collect and track your patients’ behavior change goals, clinical indicators, and medications

- Administer online patient self-assessments and follow-ups- Track information about your educational services- Generate reports on individual patient progress and your facility’s progress- Manage classes and group education sessions- Gather data needed for your program accreditation

http://www.diabeteseducator.org/ProfessionalResources/AADE7/A7S.html

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AADE7 Self-Care Behaviors- Healthy Eating- Being Active- Monitoring- Taking Medications- Problem Solving- Reducing Risks- Healthy Coping

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10 Critical Behaviors- Dental Care- Smoking Cessation- Preventive Screening Exams- Healthy Eating- Being Active- Healthy coping- Taking Medications (“Adherence”)- Blood Pressure Control- Lipid Management- BG Monitoring

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Exercise and Diabetes

- Diabetic patients should perform at least 150 min/week of moderate-intensity aerobic physical activity at 50-70% of maximum heart rate

- Type 2 patients are encouraged to complete resistance training three times per week

- Improves insulin sensitivity in older men with type 2 diabetes to the same or even a greater degree as aerobic exercise

Diabetes Care, Volume 34, Supplement 1, January 2016. S24. care.diabetesjournals.org

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- Elevated blood pressure: ≥ 140/90 mmHg

- Blood pressure goal with high cardiovascular risk:(10 year ASCVD risk >15%) < 130/80 mmHg

- Blood pressure goal with low cardiovascular risk: (10 year ASCVD risk

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- Looks at the likelihood that a patient will have a ASCVD event within the next 10 years: Coronary death, Nonfatal myocardial infarction, or Stroke

- Risk includes: age, sex, race, total cholesterol, HDL, SBP, Blood pressure medication, diabetes status, and smoking status

What is ASCVD Risk?

American Heart Association. (2014, June 24th). ASCVD Risk Calculator. https://professional.heart.org/professional/GuidelinesStatements/ASCVDRiskCalculator/UCM_457698_ASCVD-Risk-Calculator.jsp

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https://professional.heart.org/professional/GuidelinesStatements/ASCVDRiskCalculator/UCM_457698_ASCVD-Risk-Calculator.jsp

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Treatment Recommendations

ADA. Diabetes Care. 2019;42(suppl 1):S103-123

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- Albuminuria is when you find albumin (protein) in the urine - You can find out if your patient has Albuminuria by a physician

preforming a urine test- ACR: Albumin Creatinine Ratio

What is Albuminuria?

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Behavior #2: Lipid Management (Aggressive)

AgeASCVD or

10-year ASCVD risk >20%

Recommendedtreatment

40 No Moderate intensity statin

Yes High intensity statin*

* If ASCVD & LDL >70 despite maximally tolerated statin dose, consider addition of ezetimibe or PCSK9 inhibitor

ADA. Diabetes Care. 2019;42(suppl 1):S103-123

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Statin IntensityModerate-intensity(↓ LDL by 30–50%)

High Intensity (↓ LDL by >50%)

Atorvastatin 10–20 mgRosuvastatin 5–10 mgSimvastatin 20–40 mgPravastatin 40–80 mgLovastatin 40 mgFluvastatin XL 80 mgPitavastatin 2–4 mg

Atorvastatin 40–80 mgRosuvastatin 20–40 mg

ADA. Diabetes Care. 2019;42(suppl 1):S103-123

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Behavior #1- BG Monitoring Follow monitoring schedule Monitor more often Alternate Site Testing (AST) Monitor health status Pattern management Check Ketones

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Continuous Blood Glucose Monitoring

- Real-time continuous blood glucose monitoring- May be useful in helping lower A1C in T1DM- Supplemental tool to SMBG in patients with

hypoglycemia unawareness or frequent hypoglycemic episodes

- “Flash” continuous blood glucose monitoring- May be considered a substitute for SMBG in adults

requiring frequent blood glucose testing

ADA. Diabetes Care. 2019;42(suppl 1):S71-80

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New Continuous Glucose Monitors:

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$ $ $ $

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EMD/WPReimbursement for Services- Medicare requires AADE Recognition

- Part B benefit- Certificate required by Center for Medicare Services

(CMS)- Provider number assigned- Reimbursement

- 80% for 10 hours of DSME (once)- 2 hours DSME follow-up annually- Remaining 20% billed to 2nd insurance/Medicare

supplement

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Current Reimbursement

G0108

Diabetes outpatient self-management training services (DSMT); individual session, face-to-face with the patient, each 30 minutes of training $56.36 (increased from $23.45 in 2010)

G0109

Diabetes outpatient self-management training services (DSMT); group session (2 or more), face-to-face with the patient, each 30 minutes of training $15.50 (increased from $12.99 in 2010)

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- Q: How many hours of DSMT does Medicare cover?

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- Q: Is there a way to find out what if a Medicare patient has previously received DSMT under Medicare? For example, if a patient has recently moved, how many hours of services in other states have they received?

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- Q: What is the average reimbursement for education?

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- This is a “once-in-a-lifetime” Medicare benefit. A properly executed written or e-referral from the beneficiary’s treating diabetes provider (physician or qualified non-physician practitioner, such as a nurse practitioner, who is medically managing the beneficiary’s diabetes) is required.

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- Prior to the delivery of the initial DSMT, it is important to verify that the beneficiary has not received any initial DSMT in the past. This is because once the initial benefit is started, the 10 hours must be furnished within 12 consecutive months starting with the first date of service; after this time, any hours not furnished cannot be billed for Medicare payment.

- If the beneficiary has received initial DSMT paid by another health insurance company, he/she is still eligible to receive the 10 hours of initial DSMT as a Medicare benefit.

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- One hour of individual DSMT is payable in the initial episode of care, but the remaining 9 hours must be furnished as group services unless one of three specific conditions are met, which allows all 10 hours to be furnished individually. These conditions are:

- No DSMT group class is available for two months or longer from the date on the referral.

- The referring provider indicates on the referral that the beneficiary has one or more barriers to group learning; examples are: reduced vision; reduced hearing; reduced cognition; language barrier; non-ambulatory.

- The referring provider indicates on the referral that the beneficiary needs additional insulin training.

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- Important to note: If more than 10 hours of DSMT is billed in the first 12 consecutive months, the claim will be rejected by Medicare. If the beneficiary does not receive the entire 10 hours in the first 12 consecutive months, the balance of the 10 hours is forfeited.

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Pharmacy $$$$$$$- Medications- Diabetes (2-3)Meds + DSME $ 3200/yr- Lipids $ 800/yr- Hypertension $ 900/yr- Misc $ 600/yr- OTC products colds, moisturizers, dental, fungus, shaving, beauty, other personal care, etc $800/yr

Total: $6300.00/yr

Add 150 new diabetic patients = 1 MILLION Dollars in Volume (approx.)

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EMD/WPPractice Challenges

- Billing- Time consuming- Extremely detailed- Slow reimbursement

- Other Insurances- Tedious and lengthy process

- Many have internal diabetes management programs- Many only allow 1 preferred DSME provider per area

- Require more extensive prior authorization and patient documentation (billing = difficult!)

- Closed networks- Time for marketing

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EMD/WP Marketing- Physician detailing

- Office visits by Instructional Team/Staff- Thank you notes to MDs for referrals (reminder)- Mentioned to MDs by DM product reps

- Word of Mouth- “Graduates” of the education program- Loyal pharmacy patrons

- Store In-services- Fliers, bag-stuffers, label stickers- Pharmacist counseling

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EMD/WP DSMEFuture of the Program- Market to self insured employer groups

- DM Employee education- Decreased DM related missed work days- Increased employee productivity- Decreased insurance claims and costs- Free benefit to employee with incentives

- Open House/Meet and Greet

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The Path to Becoming a CDE- CDE eligible professionals

- Psychologist, RN, Occupational Therapist, Optometrist, Pharmacist, Physical Therapist, MD, podiatrist, RD, Social worker

- Minimum 2 years professional practice experience- Minimum 1000 hours DSME work- Current employment as a diabetes educator (minimum of 4 hours/week)- Study course HIGHLY recommended- Sit for the exam- 15 hours of CE related to diabetes every year

(75 hours in a 5 year period)

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Learn More About Diabetes and Diabetes Education

- Join professional organizations- American Diabetes Association (ADA)- American Association of Diabetes Educators (AADE)- Juvenile Diabetes Foundation (JDF)

- Read Journals- Diabetes Care (ADA)- Diabetes Forecast (ADA)- The Diabetes Educator (AADE)

- Continuing Education in Diabetes

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“You can’t build a reputation on what you are going to do.”

— Henry Ford

Questions?

ACTIVITY 4 Creating your action plan to measure success

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Discussion

Comments ? Questions ?

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Follow Us on Twitter !!!

SugarDetective1

For More Information:Jonathan G. Marquess, PharmD, CDE, FAPhA

jonathan.marquess@gmail.com

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You made it through �DSME Accreditation!! �Now What? – �A How to Guide for PharmacistsLearning Objectives:Program FacultyJonathan Marquess, PharmD, CDE, FAPhASlide Number 5Our sites:Slide Number 7Slide Number 8Slide Number 9Follow Us on Twitter !!!Slide Number 11Challenges Facing �Community Pharmacy: �Slide Number 13IcebreakerAudience ResponseDiabetes “Report Card”Marketing your ProgramDefinition of MarketingSlide Number 19Slide Number 20Marketing and Promotion of Your ProgramMarketing and Promotion of Your ProgramMarketing and Promotion of Your ProgramMarketing and Promotion of Your ProgramSlide Number 25Partnerships Drive ValueSlide Number 27Communicating with Physicians: Slide Number 29Ratings MatterCenters for Medicare and Medicaid Services (CMS) Star RatingStar Rating:�Give an overall rating of the plan’s quality and performance for types of services in 5 categories � Activity 3: How will you Market Your Program ??Slide Number 34DiscussionWhy DSME at Your Pharmacy ?What makes EMD/WP different ?What makes EMD/WP different ?EMD/WP �Program PhilosophyEMD/WP�Expectations of PatientsEMD/WP CurriculumOutpatient EducationSlide Number 43Conversation StartersKey Behaviors�Your CurriculumResources and Tools are AvailableAADE7 Self-Care BehaviorsSlide Number 4810 Critical BehaviorsSlide Number 50Slide Number 51Exercise and DiabetesSlide Number 53Behavior #3: Blood Pressure Control (Aggressive)�Treatment Goals Per ADA: What is ASCVD Risk? Treatment RecommendationsWhat is Albuminuria? Behavior #2: Lipid Management (Aggressive)Statin IntensityBehavior #1Continuous Blood Glucose Monitoring�New Continuous Glucose Monitors: $ $ $ $EMD/WP�Reimbursement for ServicesCurrent ReimbursementSlide Number 66Slide Number 67Slide Number 68Slide Number 69Slide Number 70Slide Number 71Slide Number 72Pharmacy $$$$$$$EMD/WP�Practice ChallengesEMD/WP MarketingEMD/WP DSME�Future of the ProgramThe Path to Becoming a CDESlide Number 78Learn More About Diabetes and Diabetes EducationQuestions?Slide Number 81DiscussionFollow Us on Twitter !!!Slide Number 84