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Diabetes Care for High Risk Populations: Lessons from a Community Based Program 1 Software Screen 2 Today’s Speakers Marie Laboissonniere RN Med CDOE CVDOE and Susanne Campbell RN MS St Joseph Center for Health and Human Services Providence, RI 3 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. 4 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 5 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 6 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) 7 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 8 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 9 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 10 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 11 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 12 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 13 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 14 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 15 Strategies/Patient Resource Information • For information on Pharmacy Assistance software (Systemetics) contact 888-593-1085 or [email protected] • For patients with insurance and high co pays, call Patient Advocate Foundation Co-Pay Release at 1-866-5123861 (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 16 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 17 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 18 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 19 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 20 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 21 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 22 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 23 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 24 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 25 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 26 ? Questions / Discussion 27 Have additional questions? Please contact us at [email protected] 28