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2013 American Academy of Physician Assistants. Diabetes Leadership Edge. Presenter. Dwight Deter, PA-C, CDE, DFAAPA Southwest Endocrine Consultants El Paso, TX. Disclosures. Consultant Sanofi Daiichi-Sankyo Takeda Vivus BMS Genentech Honoraria Takeda Vivus Genentech.

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presenter
Presenter

Dwight Deter, PA-C, CDE, DFAAPA

Southwest Endocrine Consultants

El Paso, TX

disclosures
Disclosures
  • Consultant
    • Sanofi
    • Daiichi-Sankyo
    • Takeda
    • Vivus
    • BMS
    • Genentech
  • Honoraria
    • Takeda
    • Vivus
    • Genentech
educational objectives
Educational Objectives

Upon completion of this session, you should be able to:

Find and integrate national diabetes resources into your practice as part of a national quality improvement diabetes initiative led by physician assistants.

Define the role physician assistants can assume in leading a diabetes care team.

Engage other health professionals in shared patient-centered problem-solving.

Coordinate care of diabetes patients among multidisciplinary providers.

Engage in AAPA’s 12-week multimedia diabetes education opportunity.

q1 what proportion of diabetic patients does your practice refer out for medical management
Q1: What proportion of diabetic patients does your practice refer out for medical management?

0% (all treated in practice)

Less than 10%

Between 10 – 30%

More than 30%

slide6

Q2: How confident are you that you could treat an adult with long standing uncontrolled diabetes and multiple complex comorbidites?

Extremely confident

Very confident

Somewhat confident

Not confident

slide7

Q3. How prepared is your practice to handle more diabetic patients when the ACA expands insurance to 34 million previously untreated and undertreated Americans?

Very prepared

Moderately prepared

A little prepared

Not prepared

slide8

Q4. How well do you feel your co- workers function together as a team to treat and manage diabetic patients? (i.e. team coordination, communication)

Very well

Moderately well

Somewhat badly

Very badly

topics to cover
Topics to Cover

Four factors creating the Perfect Storm contributing to diabetes epidemic crisis

Recognition of PAs’Role in Primary Care

A New Model for Primary Care

Effective Team Management of Diabetes

topics to cover1
Topics to Cover

Four factors creating the Perfect Storm contributing to diabetes epidemic crisis

Recognition of PAs’Role in Primary Care

A New Model for Primary Care

Effective Team Management of Diabetes

Impact of Team Care on Diabetes Outcomes

Seven Steps to Building an Effective Diabetes Treatment Team

2013 Launch of Diabetes Leadership Edge

the perfect storm
The Perfect Storm

The Epidemic

The Uninsured

The Affordable Care Act

The Primary Care Physicians Shortage

the perfect storm1
The Perfect Storm

The Epidemic

The Uninsured

The Affordable Care Act

The Primary Care Physicians Shortage

diabetes epidemic in the u s
Diabetes Epidemic in the U.S.

CDC. National diabetes fact sheet. 2011

CDC. Diabetes data and trends. 2011

90–95% people with diabetes have T2D

Affects 25.8 million in the U.S. (8.3 %)

At least 79 million Americans have pre-diabetes

Prediabetics are at increased risk for T2D within 10 years

projected prevalence of t2d in the u s
Projected Prevalence of T2D in the U.S.

Prevalence (millions)

Year

CDC. National diabetes fact sheet. 2011

CDC. Diabetes data and trends. 2011

Boyle JP, et al. Popul Health Metr. 2010

slide15

Prevalence of T2D in Adults

Less than 4% 4-5.9% 6-7.9% 8-10% Greater than 10%

1995

Centers for Disease Control and Prevention. MMWR. Nov. 2012

slide16

Prevalence of T2D in Adults

Less than 4% 4-5.9% 6-7.9% 8-10% Greater than 10%

2000

Centers for Disease Control and Prevention. MMWR. Nov. 2012

slide17

Prevalence of T2D in Adults

Less than 4% 4-5.9% 6-7.9% 8-10% Greater than 10%

2005

Centers for Disease Control and Prevention. MMWR. Nov. 2012

slide18

Prevalence of T2D in Adults

Less than 4% 4-5.9% 6-7.9% 8-10% Greater than 10%

2010

Centers for Disease Control and Prevention. MMWR. Nov. 2012

diabetes epidemic in the u s1
Diabetes Epidemic in the U.S.

COMPLICATIONS

Cardiovascular Disease

Diabetic Eye

Diabetic Foot

Kidney Failure

Nerve Damage

Depression

Increased disability

Work days lost

School days lost

Unemployment

Increased use of healthcare services

CDC. National diabetes fact sheet. 2011

the cost of diabetes
The Cost of Diabetes
  • Total estimated cost of diagnosed diabetes in 2012 is $245 billion
    • $176 billion in direct medical cost
    • $69 billion in reduced productivity

Herman WH. Diabetes Care. 2013;(36):775-6.

the cost of diabetes1
The Cost of Diabetes
  • Total estimated cost of diagnosed diabetes in 2012 is $245 billion
    • $176 billion in direct medical cost
    • $69 billion in reduced productivity
  • Patients with diabetes:
    • Spend $7,900 on diabetes care annually (total expenditure $13,700)
    • Have medical expenditures about 2.3 times higher than people without diabetes

Herman WH. Diabetes Care. 2013;(36):775-6.

patients with diabetes are not at goal
Patients With Diabetes Are Not At Goal

Only 12% reach goals for A1C, blood pressure, and LDL cholesterol

Gakidou E, et al. NHANES Study. Bul WHO. 2011;89:172-183.

pediatric diabetes epidemic
Pediatric Diabetes Epidemic

Photograph: Ciaran McCrickard /Rex Features

Between 2001–2009 prevalence of T2D increased 21% in youth < 20 years of age

>75% youth with T2D have a first- or second-degree relative with T2D

Liese AD, et al. Pediatrics. 2006;118(4):1510-8.

pediatric diabetes epidemic1
Pediatric Diabetes Epidemic
  • Progression of insulin resistance to T2D faster in youth than adults
  • Associated with increased risk of:
    • Morbidity and mortality
    • Secondary obesity-related complications: metabolic syndrome, hypertension, nonalcoholic fatty liver disease, microvascular complications

Pinhas HO & Zeitler P. Lancet. 2007;369:1823-1831.

the perfect storm2
The Perfect Storm

The Epidemic

The Uninsured

The Affordable Care Act

The Primary Care Physicians Shortage

slide26

Uninsured Patients With Diabetes

50 Million Uninsured Americans

2.1 Million

Uninsured Diabetics

Robert Wood Foundation. Uninsured Americans with chronic health conditions. 2005

slide27

Uninsured Patients With Diabetes

  • Compared to insured patients with diabetes, uninsured diabetes patients are more likely to:
  • Have no medical or dental care (50%)
  • Go without prescriptions (50%)
  • Have no centralized care (32%)
    • Only 64% with diabetes saw their provider
  • Have no regular management (32%)
  • Be unscreened for comorbidities
    • No foot exam (78%)
    • No eye exam (68%)

2.1 Million

Uninsured Diabetics

Robert Wood Foundation. Uninsured Americans with chronic health conditions. 2005

the perfect storm3
The Perfect Storm

The Epidemic

The Uninsured

The Affordable Care Act

The Primary Care Physicians Shortage

impact of the affordable care act
Impact of the Affordable Care Act

50 Million Uninsured Americans

ACA

34 Million

Newly Insured

2.1 Million

Uninsured Diabetics

Robert Wood Foundation. Uninsured Americans with chronic health conditions. 2005

impact of the affordable care act1
Impact of the Affordable Care Act

34 Million

Newly Insured

20 million additional primary care visits annually

✓Untreated and undertreated diabetes

✓Complex comorbidities

✓Overweight or obese

✓Elderly

Robert Wood Foundation. Uninsured Americans with chronic health conditions. 2005

the perfect storm4
The Perfect Storm

The Epidemic

The Uninsured

The Affordable Care Act

The Primary Care Physicians Shortage

shortage of primary care physicians
Shortage of Primary Care Physicians

52,000 PCPs Needed in 2025

Aging & Retiring PCPs

34 mil. Newly Insured in 2014

16,000 PCPs Needed Now

Primary Care

Primary Care

American Academy of Family Physicians. Advancing Primary Care Report. 2010

Peterson S, et al. Annals of Family Medicine. 2012

the perfect storm5
The Perfect Storm

What’s the solution?

The Epidemic

The Uninsured

The Affordable Care Act

The Primary Care Physicians Shortage

increasing recognition of pas
Increasing Recognition of PAs

“…a proven model for delivering high-quality, cost-effective patient care.”

American College of Physicians and American Academy of Physician Assistants.

Joint Policy Statement. 2010

  • Training rooted in team-based care
  • PAs recognized in
    • Emerging health policy
    • Major national associations
      • American College of Physicians
      • American Academy of Family Physicians
      • American Medical Association
current model for primary care
Current Model for Primary Care

Wagner EH. Effective ClinPrac. 1998;1:2-4.

Bedenheimer T, et al. JAMA. 2002;288:(14):1775-9.

Carrier E, et al. Med Care. 2009;47(7):714-22.

Ericson CD, et al. J SchNurs. 2006;22(6):310-8.

  • Designed to manage acute problems
  • Does not address chronic conditions
  • Periodic face-to-face visits
a new model for primary care
A New Model for Primary Care
  • Chronic Care Model
  • Medical Home Model
  • Healthy Learner Model

Team Care is vital.

Wagner EH. Effective ClinPrac. 1998;1:2-4.

Bedenheimer T, et al. JAMA. 2002;288:(14):1775-9.

Carrier E, et al. Med Care. 2009;47(7):714-22.

Ericson CD, et al. J SchNurs. 2006;22(6):310-8.

effective team care of diabetes
Effective Team Care of Diabetes

Teamwork and Case Management

  • 2006 meta-analysis of 66 studies
    • 11 strategies for quality improvement
    • Only 2 strategies were associated with reduction of A1C of at least 5%

Shojania KG, et al. JAMA. 2006;296(4):427-440.

effective team care of diabetes1
Effective Team Care of Diabetes
  • Use of multidisciplinary teams
  • Shared care between PCP and team members who were specialists in diabetes treatment and management
      • Adding new members with expanded professional role – team coordination

Shojania KG, et al. JAMA. 2006;296(4):427-440.

impact of team based care
Impact of Team-based Care
  • Glycemic control
  • Lipid control
  • Blood pressure control
  • Lower risk for diabetes complications
  • Physician adherence to ADA recommendations
  • Timely patient follow-up

CDC. Preventing Chronic Disease. 2013

impact of team based care1
Impact of Team-based Care

Improved patient satisfaction

Improved patient knowledge

Improved patient empowerment

Improved patient readiness to change

Increased self-monitoring of blood glucose

Improved patient quality of life

Lower health care costs

Stellefson M, et al. Chronic Dis. 2013;10:120180.

how to build an effective team
How to Build an Effective Team

STEP 1: Ensure Commitment Of Decision-makers

  • Generate interest and mobilize colleagues, PCPs, payment specialists, office managers
    • Clinical benefits
    • Reimbursement benefits
  • Involve all team members early in clinical and organizational decision-making
  • Demonstrate team care on small scale, to assess feasibility, effectiveness, impact
how to build an effective team1
How to Build an Effective Team

STEP 2: Identify Team Members

  • Invite all team members to commit
  • Clarify roles to resolve issues related to leadership, role overlap/redundancy
  • Determine structure, scope of program, services
    • Risk-reduction counseling, self-management education
    • Lipid and hypertension management
    • Medical nutrition therapy
    • Coordination of follow-ups, referrals, resources
how to build an effective team2
How to Build an Effective Team

STEP 3: Identify Your Patient Population

  • Demographic characteristics, proportion of patients with type 2, gestational diabetes and geriatric onset
  • Risk factors, severity of complications, extent of comorbidities, use of health services, and delivery of preventive care
  • Stratify patients into groups according to intensity of services required
    • Limited diabetes vs. moderate to high complications or comorbidities
slide44

How to Build an Effective Team

STEP 4: Assess and Assemble Resources

  • Assemble current, user-friendly, culturally sensitivediabetes prevention and management tools, protocols, education materials
    • Standards of care and treatment guidelines
    • Protocols, algorithms, flowcharts
    • Patient education materials
    • Standing orders, chart stickers
    • Recording and reminder tools and systems
slide45

How to Build an Effective Team

STEP 5: Develop a System for Coordinated and

Continuous Care

  • Develop clear procedures to facilitate timely coordination of all required services
  • Use standard treatment algorithms
  • Reassess team functioning periodically to ensure continuity of care and patient satisfaction
  • Develop communication methods between team members
slide46

How to Build an Effective Team

STEP 5: Develop a System for Coordinated,

Continuous Care

  • Set clinical targets; blood glucose, lipid values, A1C, blood pressure, body weight, behavioral targets for food intake and physical activity
  • Develop and maintain consistent messages to patients from team members
  • Communicate and document information from team members
  • Use the same codes for reimbursement
slide47

How to Build an Effective Team

STEP 6: Evaluate Patient Status, make adjustments

  • Perform process and outcome evaluations to determine patients’ status
  • Determine success in meeting quality measures
  • Administer patient satisfaction and quality-of-life interviews or questionnaires to patients to get feedback
  • Document clinical, financial, and behavioral outcomes to show payers and other stakeholders the value of the services and return on investment
slide48

How to Build an Effective Team

STEP 7: Become a Diabetes Specialist and Leader

Free, self-paced, accredited by AAPA

Register online:

http://www.aapa.org/diabetes

three online modules
Three Online Modules
  • Each module contains:
    • Prerecorded didactic webinar
    • Prerecorded case-based webinar
    • Print monograph
  • Didactic - Enriches your knowledge base
  • Case-based - Applies what you’ve learned to interactive patient cases
  • Monograph – Pulls it all together
three online modules1
Three Online Modules
  • Each module also contains:
    • Downloadable checklists
    • Action steps reminders
    • Information on coding for reimbursement
    • Strategies to implement team-based care
module 1 medical treatment and management of diabetes
Module 1: Medical Treatment and Management of Diabetes

Screening for diabetes and pre-diabetes

Efficacy of available therapeutics

Selecting the right treatment

Proper dosing

Contraindications

Adverse effects

Patient education and self-management

Management of polypharmacy

module 2 managing complications and comorbidities of diabetes
Module 2: Managing Complications and Comorbidities of Diabetes
  • Common comorbidities and complications
    • Who gets them
    • How to screen for and diagnose them
  • Impact on diabetes care
  • When to refer
  • Identifying who should have aggressive vs. conservative treatment for glycemic control
module 3 patient centered diabetes care and prevention
Module 3: Patient-centered Diabetes Care and Prevention

Treatment goals

Healthy lifestyles

Diet and exercise recommendations

Strategies to motivate patients

Assessing patients’ readiness to change

Culturally sensitive care

How to create patient support groups

aapa learning central
AAPA Learning Central

Online education system for continuing education, quality improvement, and certification maintenance

On demand multi-media content

Track your learning; compare to colleagues

Social communities of practice

HIPAA compliant patient database

www.aapa.org ‘LEARNING CENTRAL’ tab

slide55
Q5: In your opinion, which of these factors will significantly affect your practice in the next 12 months?

The growing diabetes epidemic

34 mil. previously uninsured will enter the healthcare system

Shortage of primary care physicians

All of the above

q6 which of the following are you most likely to do when you get back to your practice
Q6: Which of the following are you most likely to do when you get back to your practice?

Discuss improving diabetes team care

with your co-workers

B. More closely identify health status

characteristics of your T2D patients

C. Clarify roles to resolve issues role

overlap and redundancy in T2D care

q7 how likely are you to enroll in diabetes leadership edge
Q7: How likely are you to enroll in Diabetes Leadership Edge?

Very likely

B. Somewhat likely

C. Not likely

american academy of physician assistants

American Academy of Physician Assistants

  • Register online at:
  • http://www.aapa.org/diabetes
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