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M. Dianne Brown, MS, RDN, LD, CDE OU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center Cynthia Scheideman-Miller, MHSA Heartland Telehealth Resource Center Oklahoma Telemedicine Conference 2014: Telehealth Transition October 16, 2014
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Accessing Diabetes Education Through
Telehealth
M. Dianne Brown, MS, RDN, LD, CDEOU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center
Cynthia Scheideman-Miller, MHSAHeartland Telehealth Resource Center
Oklahoma Telemedicine Conference 2014October 16, 2014
Objectives:
1. Discus the benefits of a diabetes telehealth program for
patients and how it can be partnered with provider education to improve diabetes management
2. List processes involved when selecting a diabetes telehealth program for your patients
3. Outline key components of a diabetes telehealth program including patient and provider site
requirements.
Why Diabetes Tele-education?
2011 2013
Prevalence* of Self-Reported Obesity Among U.S. Adults, by State, BRFSS
State Prevalence Confidence Interval
Oklahoma 32.5 (31.2, 33.9)
26
millionAmericans
have
diabetes7th
leading
cause of
death in
the U.S.
79 millionAmericans have
pre-diabetes
Diabetes by the Numbers
People with Diabetes
• Don’t follow through on referral
• Are emotional / shocked at diagnosis
• End up relying on family / friends
• Believe they know enough / can handle it on their own
Providers
• Know importance of DE, but don’t necessarily prescribe – or don’t prescribe definitively enough
• Sometimes forget to follow up with patients to encourage attendance
The research shows:
Diabetes Education Patient Benefits Studies have shown people who receive diabetes education
Use primary care /
prevention services
Take medications as
prescribed
Control glucose, blood pressure, LDL cholesterol
Have lower health costs
Diabetes Education Process
Patient Diagnosed
with Diabetes
PCP refers patient for DE
Patient assessed by
CDE
*DSMT Class
(10 hours)
**MNT3 hours (by RD)
Year 2
Year 1
2 hour Refresher Classes
*DSMT - 2 hours &
**MNT -2 hours (by RD)
*Diabetes Self-Management Training (DSMT)
**Medical Nutrition Therapy (MNT)
Prevalence of Diabetes(2011 Overall)N/A2.25% or Less2.26% - 3.35%3.36% - 5.04%5.05% - 6.74%6.75% - 8.44%8.45% - 10.14%10.15% - 11.84%11.85% - 14.00%14.01% or Greater
Where most Certified Diabetes Educators (CDEs) Live in Oklahoma
34- Recognized by the American Diabetes Association (ADA)
17- Accredited by American Association of Diabetes Educators (AADE)
Recognized or Accredited Diabetes Education Programs in Oklahoma
Telehealth benefit # 1
Provides access- multiple sites maybe used
patients other health care providers
Telehealth benefit #2
Saves money patient & CDE saves “gas” money remote site “borrows” CDE informed patients reduce hospital admission
Telehealth benefit #3
Saves time patients & CDE do not lose
time with travel and information is delivered in “real time”
CDE can see more patients, reducing service wait time for patients
Telehealth benefit #4 Helps to address cultural diversity which
contributes to challenges of education, patient compliance, and cooperation with treatment regimens
Increased ability for participation with diabetes care team
Telehealth Concern #1Budget Considerations
technology set up on remote and originating sites
Telehealth Concern #2Time needed for set up
Training Staff Patient teaching tools and resources at remote
Telehealth Concern # 3 Services are only reimbursable by Medicare if the
services were provided to a Medicare or Medicaid beneficiary at an acceptable originating site.
Selecting a Diabetes Tele-education Program
Define what you want vs need ADA program for Medicare reimbursement
Champions
Technology – fits in your needs and budget
A program that is right for your organization and population served
Sales pitches can be misleading
Selecting a program
Is this a program you want as a partner in patient care or contract with for total delivery?
Do they follow the same State laws, Hospital by-laws as on-site programs are required to supply?
What are their references?
Are the providers (distant site) in Oklahoma?
Double Check the Contract
What if expectations aren’t met?
Who is responsible for what?
What staff will be needed at the originating site before, during, after the classes?
Who gets the data?
Who tracks patient satisfaction?
Is there training for staff at the patient site?
No-Show policy
Telehealth Consent Form – who is responsible to get this signed prior to services?
Developing a Diabetes Tele-Education Program
Early Development
Champion Support Administration Providers
Originating Site Distant site
Delivery Model Multiple sites or single site Contract vs direct billing Individual sessions conducted remotely or on-site
Early Development, con.
Program Components
Understand current process flow and staffing:
Multiple sites or single Optimal number and arrangement Mandatory documentation – define the who, where,
how
Resources Consider health literacy & culture What resources go with the patient or stay
Budget
Budget Start up costs
Equipment
Broadband
Marketing
Staff time Contract development
Liaisons
Staff prep for sessions
Consultants
Technology
Software
Reliable
Image quality
ASC X12 encryption standard
Compatible with other software
Linkage of older to newer technology
Split screen capable
Transmission requirements
Technology Distant (Provider) End
Computer High-definition camera
Monitors – single will work, dual is better
Speaker/microphone
Projector
Software – some have split screen capabilities
Desktop – Self-contained High quality image
Split screen capabilities
Frees up computer for EHR
Technology Originating (Patient) Site
Patient Cart High-quality image
Can be wheeled to patient bedside
Multi-purpose
Issue: mobility vs larger monitor
Wall-mounted Monitors High quality image
Split screen capabilities
The closer to “real” size, the better
Medicare
• ADA approved program
• Service must be real time using interactive audio/video
• Eligible originating (patient) site – rural HPSA – online tool to determine eligibility
• Codes:
• 99201 GT modifier
• HCPCS codes G0108 & G0109
Medicaid
• ADA approved program
• Service must be real time using interactive audio/video
• Eligible originating (patient) site
• Codes: 99201, 97802-97803 GT modifier
• Must be delivered using appropriate equipment and meet HIPAA, privacy & security requirements
Reimbursement:
Medicare
• Eligible originating site
• Office of physician/practitioner
• Hospital
• CAH
• RHC
• FQHC
• Eligible provider
• Registered Dietitian
• Advanced Registered Nurse Practitioners
• Nutrition professional
• Clinical Social Worker
Medicaid
• Eligible originating site
• Office of physician/practitioner
• Hospital
• CAH
• RHC
• FQHC
• School
• I/T/U
• Eligible Provider
• Registered Dietitian
• Advance Registered Nurse Practitioners
Reimbursement (con.):
Handouts such as: My Carbohydrate Guide
Food Models
Organize the classroom-Pens, highlighters,
sharpies-Ketone chart and
strips-Glucose wands-Food models-Sample of fast
acting glucose-Etc.
Diabetes Education Tele-health Patient Take Home Resources
• Have topics organized by title and number the file (or computer files)
• Have reference list to find resource topics quickly.
Final Development
Staff training User training Cheat Sheet Troubleshooting Guide Help Desk Contingency Plan Helpdesk visit 3rd level vendor support
Patient recruitment Marketing material
tele-health brochure internal web page
Clinician invitation Patient Mailing Telehealth Patient Consent Form
Diabetes Tele-education Pilot
Instructors Dietitian at one rural location, nurse specialist
at the other
Diabetes tele-education delivered at a lower cost
LOS shorter for those who attended class –reduced hospital costs
Pre- and Post-tests comparable to on-site classes
High patient and provider satisfaction
Rapport between class attendees unforeseen plus
Telemedicine Patient Satisfaction Survey
Question Score_________How comfortable did you feel? 4.2 ± 1.2 (19)(0, very comfortable; 5 very comfortable)
How convenient was the encounter? 4.4± 1.0 (19)(0, not at all convenient ; 5 very convenient)
Was the lack of physical contact acceptable? 4.3 ± 1.3 (19)(0, not acceptable; 5 very acceptable)
Concerns about privacy? 1.1± 1.7 (19)(0, no concerns; 5 very concerned)
Overall satisfaction? 4.3± 1.3 (19)(0, not at all satisfied; 5 very satisfied)
Would you do it again? (yes/no) 16/3
Diabetes Care, Vol. 26, No 4, April 2003
Quality Checks: Metrics
Utilization Satisfaction Sustainability Outcomes
By location patient financial health
By service provider support care plan
By provider staff champions no-show
Rynn Geier, MBA, RD, LD, CDE presented at AADE annual meeting Aug 6-9 2014
Summary:
Establish goals for a telemedicine program
Gain champion support
Develop a budget
Choose a vendor
Take time for clinical training and well-planned program deployment
Develop strategies for program “buy –in”
Build into your program
Measure your outcomes: metrics
Don’t Forget Diabetes Education for Providers
Providers have the same information as their patients
Increases provider’s confidence that they have
the latest diabetes information
Reinforcement – patient’s hear the same message
Providers have a contact/mentor
“Prior to the study it was almost impossible for this type of patient to get the consultation and specialized care that is not accessible in a small rural community.” Rural Home Health Administrator
Who knows what future telehealth will look like?