Community-Clinical Linkages to Prevent Type 2...

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Christopher Holliday, PhD, MPHDirector, Population Health and Clinical-Community Linkages

Community-Clinical Linkages to Prevent Type 2 Diabetes

22nd Annual Diabetes Fall Symposium for Primary Health Care ProfessionalsSeptember 22-23, 2016North Charleston, SC

© 2016 American Medical Association. All rights reserved. 2

Disclosure Statement

No disclosures to report.

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© 2016 American Medical Association. All rights reserved.

Objectives

• Describe the clinical practice burden and trends in type 2 diabetes

• Describe how the AMA is making the clinical-community connection for diabetes prevention

• Describe the components of the AMA-CDC Prevent Diabetes STAT toolkit and other tools for healthcare professionals

• Best practices for enabling physicians/care teams/consumers to assure sustained clinical-community linkages to prevent type 2 diabetes

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AMA strategic focus to improve health outcomes

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The AMA has promoted scientific advancement, improved public health, and invested in the doctor and patient relationship through three strategic focus areas:

• Helping physician practices thrive

• Creating the medical school of the future

• Improving patient health

Vision

Improved health of the

nation preventing

chronic disease

Mission

All primary care physicians

screening and referring

• Strategic partnerships• Remove barriers

• Increase awareness and demand

Key Activities


Key strategy for improving health outcomes

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Research & evaluate

Devise interventions

Implement & test

Reassess & adjust

Scale for impactCreate, validate and spread evidence-based, value-added tools and resources for physicians, care teams, residents and students

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AMA is helping to create solutions that…

• Summarize the evidence and best practices

• Improve assessment and measurement

• Connect practices with community-based resources

• Promote a culture of teamwork and reliability

• Can be used by busy physicians and care teams

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National Snapshot:Epidemiology & Clinical Burden of Prediabetes

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Chronic Disease Impact on Clinical Practice

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are for chronic disease management

is due to chronic conditions

50% of visits to primary care

~75% of health care spending

50% 75%


Financial and Health Impact of Diabetes

• In 2012, the economic cost of type 2 diabetes was $245 billion

– Diabetes costs approximately $2,700 per individual with newly diagnosed diabetes in the first year of treatment

• Compared to people without type 2 diabetes, adults with diabetes are:

– 2 times likely to develop hypertension

– 1.8 times more likely to be hospitalized for heart attack

– 1.5 times more likely to be hospitalized for stroke

– 1.7 times more likely to die from heart disease or stroke

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CDC: National Diabetes Statistics Report, 2014.

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Increasing Impact on Clinical Practice

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Over the next 5 years, a typical large clinical practice could experience a 32% increase in the number of patients with diabetes

23,57721,896

20,19818,483

16,75015,000

2015 2016 2017 2018 2019 2020Based on a panel size of approximately 100,000 patients

Slide courtesy of Ronald T. Ackermann, MD, MPH, Northwestern University Feinberg School of Medicine


Widespread Burden to Clinical Practice

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Menke et al. JAMA. 2015;314(10):1021-1029.

Number of Patients

Representative of U.S. Population

High Proportion of Racial/Ethnic

Minorities

Type 2 Diabetes 14,000 Up to 24,000

Prediabetes 36,500 Up to 40,000

Example: a large clinical practice with 100,000 patients

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Clinical-community Linkages: Making the connection for Diabetes Prevention

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Primary Care

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Etz et al. Am J Prev Med 2008;35(Suppl. 5):S390-S397.

Bridging the Gap

Primary Care• Capacity for risk

assessment• Ability for brief counseling• Capacity and ability to

refer• Awareness of community

resources

Community Resource• Availability of resource• Affordability of resource• Accessibility of resource• Perceived as value added

• Perceived as value added

Connecting Strategies


A model for clinical-community linkages

Patient–approved updates provided back to physicians

Practice/Health System: Query the EHRIdentify At-Risk Patients

Brief InterventionRefer to a diabetes prevention program

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Opportunities/Game changers Opportunities

• Health care payment models are moving away from fee for service

• Health care delivery is moving towards a patient-centered model

• Primary care physicians need to focus on managing increasing numbers of patients with more than one chronic disease

• Majority of chronic diseases are associated with lifestyle behaviors

• Physicians are not generally trained in lifestyle counseling and don’t have the time to provide intensive lifestyle counseling

Game Changers

• USPSTF screening recommendation, obese, 40-70, HgA1c of FPG / CPSTF recommendation

• Medicare coverage of the DPP (rulemaking process)

• PCMH alignment

• Diabetes screening quality measure – to be done

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USPSTF screening recommendationsP18

Population Adults aged 40 to 70 years who are overweight or obese

Recommendation Grade: B

Screen for abnormal blood glucose. Offer or refer patients with abnormal glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.

Risk Assessment Risk factors include overweight and obesity or a high percentage of abdominal fat, physical inactivity and smoking.

Screening Tests Hemoglobin A1c or fasting plasma glucose or an oral glucose tolerance test.

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CPSTF recommendationsP19

Combined Diet and Physical Activity Promotion Programs for Prevention of Diabetes: Community Preventive Services Task Force Recommendation Statement Nicolaas P. Pronk, PhD; Patrick L. Remington, MD, MPH, on behalf of the Community Preventive Services Task Force*

The Task Force recommends:• Use of combined diet and physical activity promotion programs by health

care systems, communities, and other implementers to provide counseling and support to clients identified as being at increased risk for type 2 diabetes.

• Economic evidence indicates that these programs are cost-effective.

Ann Intern Med. 2015;163(6):465-468. doi:10.7326/M15-1029


"This program has been shown to reduce health care costs and help prevent diabetes, and is one that Medicare, employers and private insurers can use to help 86 million Americans live healthier.”

- HHS Secretary Sylvia M. Burwell

Building a case for prevention – CMS expansion of Medicare benefits to include DPP

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• CMS agrees that the National Diabetes Prevention Program is a worthwhile investment!

• $2,650 medical cost savings in 15 months (Medicare)^

• $2,700 medical cost savings in 1 year (commercial)^^ per prevented case

^ Office of the Actuary, Centers for Medicare and Medicaid Services. “Certification of Medicare Diabetes Prevention Program”. March 23, 2016.^^ American Medical Association. 2009-2012 individual level data from the Truven Health MarketScan® Lab Database - a 4.4 million subsample of the Truven Health MarketScan® Treatment Pathways. MarketScan is a registered trademark of Truven Health Analytics Inc.

First ever preventive service model eligible for expansion under Medicare holds promise for employers, private insurers and patients

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Alignment with PCMH standards

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• The Practice Team

• Population Health Management

– Must-Pass: Use data for population management

– Critical-Factor: Implement evidence-based decision support

• Care Management and Support

– Critical-Factor: Identify patients for care management

– Support self-care and shared decision making

• Performance Measurement and Quality Improvement

– Measure clinical quality performance

AMA-CDC Prevent Diabetes STAT Toolkit

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www.preventdiabetesstat.orgP23


5 Steps to Preventing Diabetes

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1. Create awareness2. Identify patients with prediabetes3. Educate at-risk patients4. Refer patients with prediabetes

to an evidence-based diabetes prevention program

5. And, follow up on patient progress

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Step One – Create Awareness

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National Ad Campaign

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Step Two – Identify Patients

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DPP Program Eligibility: (Original)

• 18 years or older old, AND

• BMI >24; >22 if Asian, AND

• History of Gestational Diabetes, OR

• Blood test result in the prediabetes range:

• A1c: 5.7%–6.4% or

• Fasting plasma glucose: 100–125 mg/dL

DPP Program Eligibility: (Original)

• 18 years or older old, AND

• BMI >24; >22 if Asian, AND

• History of Gestational Diabetes, OR

• Blood test result in the prediabetes range:

• A1c: 5.7%–6.4% or

• Fasting plasma glucose: 100–125 mg/dL


Step Three – Educate at Risk Patients

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Key Messages • Your blood sugar is higher

than normal but not at the level of diabetes. This condition is prediabetes.

• Prediabetes is a serious condition: It raises your risk of heart attack and stroke and poses a very high risk of eventually progressing to full-blown diabetes.

• Prediabetes is treatable and reversible

• The goal is 5-7% weight loss

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Step Four – Refer

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Step Five – Follow-up

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Other tools in development and planned

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• Diabetes prevention cost-savings calculator for employers and payers – expansion of tool to include Medicaid and case studies for purchasers

• Interactive digital health solutions

• Prediabetes algorithm for use in EHRs and registries to support population health management

• Support STR – patient portals, referral orders, telehealth, HIEs to close referral loop


Working with the AMA to prevent diabetes in a busy practice

Park Nicollet Clinic collaboration with diabetes prevention program

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Strong national collaborations – Strong local impact

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With the CDC, we

Created a call to action to address prediabetes

(2012-present)

With the YMCA, we

Engage physicians & care teams to screen and refer

(2012-present)

With the Ad Council, we

Launched a public awareness campaign

(ADA, AMA, CDC)

(2016)


Best practices for enabling physicians/care teams/consumers to assure clinical-community linkages to prevent type 2 diabetes

• Identify champions through local medical societies and health systems

• Frame as a process or quality improvement initiative (QI strategy)

• With physician support, “automate” screening and referrals – tech solution

– Retrospective query to identify those at risk

– Criteria to identify those most at risk/likely to act/likely to be successful

– Referral through EHR / integrated into existing referral systems

• Build feedback loops so that physicians can discuss progress with their patients

• Provide on-the-ground support in the practices

• Raise awareness among physicians, care teams and patients through marketing campaigns, grand rounds, webinars and CME – comprehensive comms strategy

• Diabetes prevention is a team sport – It takes us all

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Christopher Holliday, PhD, MPHDirector, Population Health & Clinical-Community Linkages

[email protected]

Community-Clinical Linkages to Prevent Type 2...

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