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Creating Models for Health Care Delivery that Address Chronic Disease

Creating Models for Health Care Delivery that Address Chronic Disease. Linda Siminerio, PhD Senior Vice President, IDF University of Pittsburgh Diabetes Institute Associate Professor School of Medicine. Presentation Objectives:. Describe the Problem and Urgency

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Creating Models for Health Care Delivery that Address Chronic Disease

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  1. Creating Models for Health Care Delivery that Address Chronic Disease Linda Siminerio, PhD Senior Vice President, IDF University of Pittsburgh Diabetes Institute Associate Professor School of Medicine

  2. Presentation Objectives: • Describe the Problem and Urgency • Present the Chronic Care Model • Report on the “Pittsburgh Regional Initiative for Diabetes Education (PRIDE)” • Present the Innovative Care for Chronic Diseases Model • Highlight Global Projects

  3. Diabetes Worldwide Estimated number (in Millions) of people with diabetes, worldwide:* Increase in deaths from diabetes over next 10 years:† India 35% The Americas 80% the western Pacific and eastern Mediterranean regions 50% Africa >40% *Diabetes Prevalence. International Diabetes Federation, 2003. †Preventing Chronic Diseases: a vital investment, World Health Organization, 2005. 1985: 30 million 1995: 135 million 2003: 194 million 2025: 330 million

  4. Million 2003 2005 Pre-diabetes US Diabetes Facts • 20% increase past 20 yrs • 70% increase 30-39 yr. age range • 1 in 3 children born in 2003 will get diabetes • Type 2 in children is increasing • 14 million lost work days • Annual costs -- $132 billion

  5. Epidemiologic Transition Omran, A. The Epidemiologic Transition: A theory of the epidemiology of a population change. Milbank Q. 1971:49:509-538. Non-Communicable Disease Mortality Rates Infectious Disease Epidemiologic Transition More information available at http://www.pitt.edu/~super1/lecture/lec0022/007.htm

  6. Organization of Health Care(What it should be) • Evidence-based, planned care • Clinical Guidelines • Reorganization of practice (team approach) • Includes ancillary professionals with the patient as the most important member • Attention to patient needs (information) • Counseling, education, information feedback • Access to clinical expertise • Patient and provider education, access to specialists • Supportive information systems • Patient registries • Provider feedback on preventive service utilization

  7. Organization of Health Care(What it is) • Care is not necessarily based on evidence, but experience and training • Seldom is there a team approach…care is mainly driven by the physician alone • Paternalistic and directive approach with little attention to patients’ behavioral needs • Limited access to diabetes specialists • Insurer limitations • Reluctance of primary care referral • Fragmented access • Poor information systems • No computers • Poor tracking

  8. Transition in Health Care PARADIGM SHIFT ACUTE CARE CHRONIC CARE Focus: prevention Care: coordinated Focus: illness Care: fragmented

  9. Quality of Care for People with Diabetes in the United States A Diabetes Report Card for the United States: Quality of Care in the 1990’s. % (2.6mmol/L) Saaddine JB: Ann Intern Med. 136: 565-574, 2002

  10. University of Pittsburgh Medical Center The Challenges of Providing Access and Quality • 19 hospitals/ 200 primary care practices • 90,000 patients with diabetes • 90% diabetes care provided by PCPs • Poor adherence to guidelines • Lack of integrated technology • Daily decisions made by patient • Poor access for education and nutrition • Undefined relationships to the community

  11. Objective • By implementing a model for health care delivery we could: • Gain health system support • Demonstrate improvements in clinical outcomes, A1C, BP and Lipids • Demonstrate reimbursement for services • Expand number of resources in communities

  12. Health System • UPMC board initiative • Presentations to leadership • Pittsburgh Regional Initiative for Diabetes Education (PRIDE) • Patient/Provider/Community Community Health System Resources and Policies Organization of Healthcare Self-Management Support Delivery System Design Decision Support Clinical Information Systems Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Functional and Clinical Outcomes

  13. Community • Resource Identification • Focus groups with providers and patients • Community leaders • Local physicians • Government Functional and Clinical Outcomes

  14. Decision Support Evidence Based Guidelines • ADA Medical & Education Standards Functional and Clinical Outcomes

  15. Clinical Information Systems • Paper Charts • Excel spread sheets • Laboratory feedback • Electronic Medical Records • Management systems

  16. Clinical Information / Decision Support • Instituted ADA Guidelines • Physician education • Regional programs • System seminars • Integrating CDEs into practices • Office staff education • Clinical information • Continuous feedback • Comparative reports to peers

  17. Community Medicine Inc. (CMI)versus National Data DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574

  18. CMI vs National Data DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574

  19. UPMC Diabetes ManagementHbA1c Levels (2003-2006) Average HbA1c Levels Time

  20. Proportion of Patients with HbA1c Levels < 8.0% & 7.0% (2003-2006) % Time

  21. LDL Levels (2003-2006)

  22. Proportion of Patients with LDLc Levels < 130 mg/dL & 100 mg/dL (2003-2006)

  23. Delivery System Design • Diabetes Educators in Primary Care • Diabetes “Mini Clinics”

  24. Is this where we are going????

  25. Proportion of People Educated at PCP Office Compared to Hospital Based Outpatient DSME p<0.0001 % n=686/4332 n=9,334/89,760

  26. Nurse-directed protocols • Approved protocols for glycemic, hypertension and cholesterol management • Nurses used these protocols in management • Intervention in high-risk Hispanic community • Significant improvement in provider processes and patient outcomes Davidson, M., et al Effect of nurse-directed diabetes care in minority populations: Diabetes Care, 2003.

  27. Process measures Measure ADA guidelines Nurse-directed care Usual care P HbA1c Goal-yes, 1 per 6 months; Goal-no, 1 per 3 months 227/252 (90) 66/252 (26) <0.001 Lipid profile At least yearly 244/252 (97) 148/252 (59) <0.001 Eye exam At least yearly 240/252 (95) 200/252 (79) <0.001 Renal profile* Yearly 215/252 (85) 148/209 (71) <0.001 If dipstick negative/trace, measure albumin-to- creatinine ratio 54/183 (30) 76/174 (44) <0.01 If dipstick negative/trace, or albumin-to-creatinine ratio >30 mg/g, ACE treatment 19/28 (68) 59/93 (63) NS Foot exam At least biannually 245/252 (97) 202/252 (80) <0.001 2 visits At least biannually 248/252 (98) 241/252 (96) NS Diabetes education No frequency stated 239/252 (98) 122/252 (48) <0.001 Nutritional counseling No frequency stated 224/252 (89) 14/252 (6) <0.001 Davidson, M., et al Effect of nurse-directed diabetes care in minority populations: Diabetes Care, 2003.

  28. HbA1c (% ± SD) outcome measure Nurse-directed care Usual care P All patients  Percent of patients 249/252 (99) 201/252 (80) <0.001  Initial 13.5 ± 3.7 12.1 ± 3.1 <0.001 2 tests  Percent of patients 201/249 (81)* 145/201 (72) <0.05  Initial 13.3 ± 3.5 12.3 ± 3.4 <0.02  Final 10.3 ± 6.0 10.8 ± 3.2 NS  Change -3.0 ± 6.6 -1.5 ± 2.9 <0.01 6 months  Number of patients 120 145  Initial 13.3 ± 3.4 12.3 ± 3.4 <0.02  Final 9.8 ± 3.0 10.8 ± 3.2 <0.01  Change -3.5 ± 3.8 -1.5 ± 2.9 <0.001 Data are n (%) or means ± SD. * Some of these patients were followed for <3 months.

  29. Self-Management Support • Expanded Education sites • CDE in Primary Care • Traveling educator • AADE Outcomes System

  30. Behavior Learning ClinicalIndicators Health Status AADE Outcome System (IMPACT) System Measures Changes In…

  31. Healthy eating Being active Monitoring Taking medication Problem-solving Healthy coping Reducing risks AADE 7 Self-Care Behaviors

  32. Add New Individual Session

  33. Diabetes Prevention Program • 150 minutes of exercise/week • Healthy eating program • 7% reduction in weight • Results in: • Decreases in Blood pressure ( 130/85 mmHg) • Decreases in Waist circumference • Men < 40 inches; Women < 35 inches • Decreases in Triglyceride levels (< 150 mg/dL) • Decreases in Glucose (< 100 mg/dL) • Decreases in HDL cholesterol • Men > 40 mg/dL; Women > 50 mg/dL

  34. Average Weight Loss Over TimeDiabetes Prevention Program-Braddock Lifestyle Modification Program150 minutes of physical activity per week and a healthy eating program pounds

  35. Average Decrease in BMI Over TimeDiabetes Prevention Program-Braddock Lifestyle Modification Program150 minutes of physical activity per week and a healthy eating program

  36. Decreases in the Proportion of Subjects with Abdominal Obesity, Hypertension, and Hypertriglyceridemia Over TimeDiabetes Prevention Program - Braddock %

  37. Conclusions • The CCM provided a good framework for quality improvements in primary prevention and treament • Gained health system and community attention • Increased number of resources • Captured attention of state and federal policy makers • Improved insurance coverage • Decision support – clinical improvements • Clinical information systems afforded the opportunity for tracking populations • Self-management support – facilitated diabetes education and behavior change • System redesign • Improved access for education • Physicians and patients reported increased communication and satisfaction.

  38. MICRO LEVEL • Informed • Motivated

  39. MESO LEVEL • Organize & Equip • Coordinate • Community

  40. MACRO LEVEL • Leadership& Advocacy • Integrate policies • Consistent financing • Human Resources • Legislative frameworks • Partnerships

  41. Global Projects • Canada – Vancouver expanded CCM • Mexico – Veracruz project • Morocco – Nat’l. Government used ICCC • Russian Federation – ICCC for secondary prevention with 56 teams • Rwanda – ICCC HIV/AIDS project • United Kingdom – 10 yr. quality project

  42. Key Messages • Burden of chronic disease increasing • Most health systems not equipped • Patients do better with integrated system • Evidence supports organized systems of care • CCM has been successful in US • ICCC depicts complimentary process • CCM & ICCC need to be disseminated, implemented & evaluated Eppinger-Jordan, JE; Pruitt, SD, Bengoa, R., Wagner, E. Improving the quality of health care fore chronic conditions. Quality Safe Hl Care, 2004.

  43. Special Acknowledgement • Project team • Janice Zgibor, RPh, PhD • Sharlene Emerson, CRNP, CDE • Gretchen Piatt, PhD, CHES • Janis McWilliams, MSN, CDE • Kristine Ruppert, DrPH • Francis Solano, MD • University of Pittsburgh Diabetes Institute • University of Pittsburgh Division of Endocrinology and Metabolism • University of Pittsburgh Medical Center “This research was partially sponsored by funding from the United States Air Force administered by the U.S. Army Medical Research Acquisition Activity, Fort Detrick, Maryland, Award Number W81XWH-04-2-0030."

  44. WHO • JoAnne Eppinger-Jordan, PhD • Contact: K. Thompson • thompsonk@who.int

  45. When spider webs unite they can tie a lion.African Proverb

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