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Kaiser Permanente Southern California Region ALL and ALL HEART Initiatives in the Safety Net Diabetes Care Management Models in Pasadena and Riverside, CA March 2014 BACKGROUND Providing coordinated care management for patients with diabetes is challenging, particularly for those with limited income and resources living in underserved areas. This case study describes how two ambulatory care sites within the safety net system implemented diabetes care management programs using resources and support from Kaiser Permanente Southern California Region Community Benefit’s ALL Initiative to improve care provided to patients suffering from diabetes. The ALL (Aspirin, Lisinopril, and Lipid-Lowering medication) Initiative was developed by Kaiser Permanente in 2003 to reduce cardiovascular disease among patients with diabetes over age 50 within the Kaiser Permanente system by systematically prescribing the ALL triad of medications. Based on the success of ALL, Kaiser Permanente Southern California Region Community Benefit began to support the translation of the Initiative to safety net clinics and providers. Since 2006, Kaiser Permanente Southern California Region Community Benefit has supported the implementation of ALL in over 60 community clinics, health centers, and hospital systems serving over 40,000 low-income, uninsured, medically underserved and vulnerable patients with diabetes. The most recent incarnation is ALL HEART. The HEART (Heart Smart Diet, Exercise, Alcohol Limits, Rx Medicine Compliance, Tobacco Cessation) aspect emphasizes care coordination, self-management, and health education, such as tobacco cessation, increasing physical activity, and other such lifestyle changes. This case study focuses on the diabetes care management established by Riverside County Health System (“Riverside”) and the City of Pasadena Public Health Department (“Pasadena”) through the ALL Initiative. At Riverside, the program is called ALL, and at Pasadena the program is called PACE (Prevention, Adherence, Collaboration and Education). METHODS The Center for Community Health and Evaluation (CCHE) conducted day-long site visits at Riverside County Health System and the City of Pasadena Health Department. We observed a provider and a diabetes educator conducting one-on-one health education with patients. We also conducted interviews with physician champions, clinical support staff (registered nurses and medical assistants), data or IT staff, and health education/care managers. In addition, we obtained diabetes outcome data to examine the impact of the program on patient clinical outcomes. ORGANIZATION DESCRIPTION The Riverside and Pasadena care management programs are organized in fundamentally different ways, reflecting the differences in the two health care systems. Riverside County Health System (“Riverside”) is an integrated county health care system with one hospital, 80 specialty care clinics and 10 Federally Qualified Riverside County Health System Health Center (FQHC) Look-Alike clinics. Riverside’s Diabetes Care Clinic was opened in 2010 with a grant from the ALL Initiative and is housed within the hospital along with the Family Care Clinic and Internal Medicine (the designated medical homes for primary care patients). When a patient with diabetes—in either the Family Care Clinic or Internal Medicine—has an uncontrolled hemoglobin A1c greater than 9%, they are referred to the Diabetes Care Clinic for intensive care management; once their diabetes is under control and the patient achieves an A1c of 7% or lower, they are returned to Family Care or Internal Medicine for continued care. Diabetes Care Management Models in Pasadena and Riverside, CA Page | 2 Pasadena Public Health Department (“Pasadena”) is a city-based public health department that provides infectious disease control, primary prevention, education, outreach, and other services. Pasadena, which does not provide primary care clinical services other than immunizations, partners with the largest FQHC provider in the city, Community Health Alliance of Pasadena (“ChapCare”), to send clients for primary care and dental services. ChapCare Health Center Pasadena Public Health Dept. ChapCare’s patients with diabetes who are ages 55 and older, are referred to Pasadena to be a part of the diabetes care management program, known as PACE. The PACE program is led by a physician champion and a program coordinator who are employees of the health department. The main role of the PACE physician champion is to ensure that ChapCare providers are trained on the ALL medication protocol and are prescribing the ALL medications to eligible patients with diabetes. The PACE program coordinator provides intensive care management to a panel of 100 patients with diabetes. After working with a patient, the program coordinator documents the results of the encounter into ChapCare’s electronic health record to maintain continuity of care. DIABETES CARE MANAGEMENT PROGRAMS Despite the differences in the structure of their organizations, the care management programs share a number of common elements: planned visits,* health education, coaching, care coordination, and specialty referrals (see Table 1). Table 1. Summary of Intensive Care Management Programs at Riverside and Pasadena Riverside (Diabetes Care Clinic) Overview: A team-based approach to care management where multiple staff members provide and coordinate components of care management. Number of patients with diabetes served: Over 800 unique patients since opening of the Diabetes Care Clinic, with an average of 1800-1900 visits annually. Pasadena (PACE) Overview: a team consisting mainly of a Provider Champion, and a Care Coordinator who leads a series of structured health education sessions and coordinated follow-up visits. Number of patients with diabetes served: Total number served as of October 2013 is 103, with 12 patients dropping out due to changes in primary care physician or relocation outside of Los Angeles/Pasadena. Eligibility criteria: • All individuals with diabetes A1c > 9 (age 50+ with diabetes is criterion specifically for ALL). • Provider/clinician initiated referral for any person with diabetes who can benefit from intensive intervention (e.g., patients who may need more intensive, coordinated care). Eligibility criteria: • Age 55+ with diabetes is target population for PACE, but staff will see any patient with diabetes who are interested in the program. Staffing involved in care management: • Medical Assistants (MA) • Registered Nurse (provide health education and care coordination) • Nurse Practitioner • Physicians • Dietician/Nutritionist • Retinal Photographer Staffing involved in care management: • Diabetes Care Coordinator – Health Department • Physician Champion – Health Department • Medical Assistants (MA) – ChapCare • Registered Nurses – ChapCare • Physicians – ChapCare Diabetes Care Management Models in Pasadena and Riverside, CA Page | 3 Riverside (Diabetes Care Clinic) Pasadena (PACE) Key components: • Planned visits* • Extended patient visit (30 minutes) • One-on-one health education provided during majority of patient visits • Coordinated referrals to specialists and other support • MA and scheduling staff call patients to remind them of their next visit at least twice • Lifestyle and self-management goals are discussed and established Key components: • Planned visits* with ChapCare providers • Three, one-on-one health education and coaching sessions, held at health department (1-2 hour per session) • Follow-up with ChapCare clinic staff and patient for referrals to specialists • Care Coordinator and student interns call patients to remind them of health education sessions or provide education over the phone if patient is unable to come in or repeatedly misses appointments • Lifestyle and self-management goals are discussed and established * A planned patient visit is initiated by the practice to focus on care management for chronic conditions as opposed to care provided at acute visits. These visits are typically scheduled at regular intervals and structured to deliver evidence-based care and patient support, such as health education, selfmanagement goal setting, and shared decision making (Bodenheimer T (2005). Helping Patients Improve Their Health-Related Behaviors: What System Changes Do We Need? Disease Management, 8(5):319-330). PATIENT OUTCOMES Based on early data, both Riverside and Pasadena care management programs are showing positive patient outcomes for control of diabetes. In both clinics, the percent of patients with hemoglobin A1c greater than 9% declined over time more in the care management programs than in patients seen in the usual primary care clinics. Figure 1 shows data from Riverside comparing patients’ first and last HbA1c test. There was a 20% drop (from 61% to 41%) in the number of patients with HbA1c greater than 9% for patients seen in the Diabetes Care Clinic compared to drops of 1% and 6% in Family Care Clinic and Internal Medicine, respectively. Figure 1. Riverside: Diabetes Care Clinic vs. Family Care and Internal Medicine Percent of Patients with HbA1c >= 9 70% 60% 50% 40% 61% 41% 30% 37% 26% 25% 31% First A1C Test Last A1c Test 20% 10% 0% Diabetes Clinic Family Care Internal Medicine Figure 2. Pasadena: Care Management Clients vs. ChapCare Diabetic Patients Percent of patients with A1c >= 9 50% 43% 40% 30% 29% 17% 20% 19% 10% 0% PACE Program ChapCare Time 1 (Sept 30, 2012) Time 2 (June 30, 2013) Figure 2 shows data from Pasadena at two time intervals. The results show that, for PACE patients, the percentage of patients with HbA1c greater than 9% dropped nearly 14%, from 43% to 29% compared to a trivial change among patients with diabetes not in the program. Diabetes Care Management Models in Pasadena and Riverside, CA Page | 4 SUMMARY & NEXT STEPS Using support from their ALL grants, both Riverside and Pasadena have successfully established integrated care management for patients with diabetes within their health systems, and these care management programs have improved outcomes related to control of diabetes. Both health organizations credited their participation in ALL as instrumental for helping them implement quality improvement activities and provide better patient care. Additionally, the organizations also identified other benefits of participating in ALL, such as promoting a team approach to care, using data and information technology to support decision making, and developing a culture that promotes continuous quality improvement. “Without ALL we wouldn’t have blossomed with what we are doing with diabetes care. The team has really focused on teaching patients skills so they can manage their diabetes and chronic conditions. We now have the Diabetes Clinic as a result of our participation in ALL, which is the most effective QI program we have currently.” – Dr. Leung (Chief of Family Medicine for Riverside) As for next steps and long-term sustainability, for Riverside, the care management is integrated within the clinic workflow and is part of the standard of care for the Diabetes Care Clinic. As such, the care management they provide is likely to be sustained. However, staff expressed some concern about the unpredictability of the funding environment, which could present challenges to sustaining the current level of staffing and resources needed for intensive care management. Similarly, Pasadena is exploring ways to continue PACE within a larger chronic disease management program and possibly training lowerlevel staff to provide care management with oversight from nurses. ChapCare is also planning to strengthen their care management for patients with diabetes, modeling after PACE by expanding the role of RNs and MAs. RNs will be used to teach diabetes courses at ChapCare sites, while MAs will provide self-management support proactively during patient visits. “PACE benefit patients by helping them build diabetes self-management skills, including patient-initiated goal-setting for lifestyle change. Although we measure our impact through improvements in glucose levels, we also see our patients making health attitude and behavior changes.” – Dr. Goh (PACE Provider Champion for Pasadena) The intended impact for ALL is to improve clinical outcomes and create sustainable changes in clinical quality improvement efforts in order to improve population health. These two health systems have reached this objective through different care management approaches. Not unlike most care management/care coordination programs, the sustainability of these programs will require ongoing funding to support a more robust, team-based staffing model to provide more intensive support to patients. Until reimbursement mechanisms for these types of activities are established, ongoing support—even at reduced levels—will be needed to sustain the current level of care management. For more information about Kaiser Permanente’s ALL and ALL HEART Initiatives, please contact Mercy Siordia, [email protected], (626) 405-4612. Prepared by the Center for Community Health and Evaluation Part of Group Health Research Institute www.cche.org