GO! Diabetes Train the Trainer Program

1. GO! DiabetesTrain the Trainer Program

2. Role of the Clinical Diabetes Educator Amparo Gonzalez, RN, CDE Global Institute for Health SolutionsEmory University Immediate Past President AADE

3. Diabetes Education • Diabetes education • is a collaborative process • develop knowledge and skills needed to change behavior • successfully self-manage the disease and its related conditions • Goals of education • achieve best health possible • better quality of life • reduce the need for costly healthcare • Diabetes Educators • Prepared in diabetes knowledge • Use principles of teaching, learning, and counseling • Behavior change for successful self-management

4. TM Healthy eating Being active Monitoring Taking medication Problem-solving Healthy coping Reducing risks

5. Measuring the Effectiveness of DSME • To prove the worth of diabetes education, AADE: • Collects data from educators about: • Interventions • Clinical and behavioral measures • Program processes • Provides tools for CQI

6. Program Outcomes Patient Data Input and Report Tools SRF® Site Registration Form D-SMART® Diabetes Self Management Assessment and Reporting D-ET® Diabetes Educator Tool Reports

7. Incidence of Diabetes 40 Cumulative incidence (%) 30 20 10 0 0 1 2 3 4 Years from randomization Behavioral Treatment Outperforms Pharmacy Treatment for Diabetes • Diabetes Prevention Project - DPP •  A RCT to prevent Type 2 Diabetes •  Evaluated the efficacy of 3 treatments Lifestyle (n=1079, p<0.001 vs. Metformin , p<0.001 vs. Placebo) Placebo (n=1082) Risk reduction 31% by metformin 58% by MODEST lifestyle change SUSTAINED for 4 years Metformin (n=1073, p<0.001 vs. Placebo) SOURCE: The DPP Research Group, NEJM, 2002;346:393-403

8. Defining the Value of the Diabetes Educator in the Community • AADE Commissioned a study in 2008 to assess the impact of diabetes educators in diabetes education • A study of claims data • Define their role in decreasing costs and improving outcomes

9. Value of the Diabetes Educator: Study Hypothesis • Patients who participate in diabetes education are more likely to adhere to recommended care than similar patients who do not participate in diabetes education, and • Claims of patients who participate in diabetes education are lower than those of than similar patients who do not participate in diabetes education. Source: Solucia Consulting Interim Report for AADE, Aug 2008

10. Value of the Diabetes Educator: Study Population • Commercial health plan population with approximately 4M members including 250,000 Medicare advantage members over 3-year period. • Diabetes was identified from claims each year using diagnosis and drug codes. • Diabetes education identified from CPT and HCPCS codes. • Risk adjustment performed using DxCG prospective model. • Socioeconomic status and urban/rural designation imputed from member zip code on coverage records. • Study is cross-sectional approach for 3-year period. Members are classified each year based on applicable criteria for the particular comparison. Source: Solucia Consulting Interim Report for AADE, Aug 2008

11. Value of the Diabetes Educator: Methods Analysis of a claims database with over 4 million commercial health plan members: • Identify the prevalence of diabetes within the population; • Identification of algorithms to identify diabetes education within claims; • Identify the incidence of diabetes education claims. • Assess impact of Diabetes education on claims cost and adherence to recommended care (e.g., HEDIS measures) through development of an appropriate comparison group. Source: Solucia Consulting Interim Report for AADE, Aug 2008

12. Description of People who Obtain DSME/T Source: Solucia Consulting Interim Report for AADE, Aug 2008

13. Comparison of Clinical and Financial Metrics PMPM = per member per month Source: Solucia Consulting Interim Report for AADE, Aug 2008

14. Cost Comparison According to Whether the Physician Practice is a High, Middle or Low User of DSME/T Represents Risk adjusted data for commercially insured population Source: Solucia Consulting Interim Report for AADE, Aug 2008

15. Quality of Care Comparison Source: Solucia Consulting Interim Report for AADE, Aug 2008

16. Value of the Diabetes Educator: Summary of Findings • People with diabetes education: • Save money and have better outcomes. • Are more likely to adhere to recommendations for screening/HEDIS measures. • Are younger, more likely to be female, located in more affluent areas, have lower clinical risk, higher adherence to diabetes care recommendations and lower average costs. • Physicians and patients exhibit high variation in their use of diabetes education.

17. Physician and Educator Collaboration Yields Positive Results • People with diabetes treated by high users of diabetes education have lower average cost. • Differences in average costs are entirely driven by reduced inpatient costs. • Outpatient and pharmacy costs are slightly higher. • In conclusion, diabetes educators collaboration with physician practices results in improved quality and reducing costs for those with diabetes.

18. It Takes a Village Community for Successful Collaboration • Informed, proactive patients, • Healthcare system, • Health care providers (including diabetes educators), • Local businesses, agencies, and clubs, • State and county programs, • Schools, and • Faith-based organizations.

19. Delivery Models in the Community • Three Unique Models for Diabetes Education • Independent • MD office based (Primary Care Model) • Institution based • To support these, AADE has: • Designed a process for each • Developed tools • AADE7 System • Reimbursement Guides • Free on-demand webinar • Entrepreneurial tool kit

20. AADE Independent Diabetes Education Model • The Model involves a licensed health professional and a promotora/community health worker (under the direction of a diabetes educator) for delivery of the intervention. • AADE7 serve as the foundation of the curriculum. • Involves a practitioner with a provider number (e.g., nurse practitioner, registered dietitian).

21. Demonstrate the Value of DE in Practice • Advance therapy • Track and improve outcomes • Improve reimbursement • Insurer incentives • Ensure client satisfaction

22. Enhancing the Program Model • Change the philosophy • Position the program so as to get the best ROI • Clinic/ Physician office • “ Go after the business” • One stop shopping for consumers • Creative reimbursement models

23. Goal Setting Topics Healthy eating Being active Monitoring Taking medication Problem solving Healthy coping Reducing risks AADE 7 Self-Care Behaviors™ Goal Sheet is part of the AADE 7 IMPACT™ product

24. Behavior Change Strategy • Patient makes the choice • Specify the problem • Identify successes • Set SMART goals • Identify the barriers • Agree in writing • Track the outcomes • Plan for relapse prevention

25. Setting Behavior Change Goals • First page when entering IMPACT • Prompt to create site upon first visit • AADE News

26. Case Study Olga L 45 y.o. Type 2 Dm I year ago bg random 286 a1c 11.8% BMI 32 Cholesterol 209 LDL 154 HDL 37 TG 280 BP 130/90 On metformin 500mg QD. Was on Byetta but has not taken it in the past 6 months. Taking Alli at this time Pt is single with two young adult children, she lives alone. Works 7- 5 pm as a manager of a warehouse. No exercise, enjoys eating but tries to cut back. Drinks daily 2-3 glasses of wine . No smoking Met with a diabetes educator once a year ago, owns a meter but has not tested in over 6 months.

27. Questions • Challenges this pt faces in her diabetes management • What would be your plan regarding her diabetes self management   • What would you do today  • If referring to a diabetes educator what would you expect • If not referring what is your plan for self management  • When do you bring her back • F/u plan

28. Assessment Food preference Portion size Knowledge of how food affect metabolic control Who shops and prepares meals Financial resources Religious and cultural preferences Intervention Individualized meal plan Food diaries Count carbs Menus Patient Goals Following a schedule Following meal plan Types of foods Overeating Outcomes Weight loss Weight management Healthier food choices Blood glucose control Healthy Eating

29. Portion Sizes Are Increasing Calorie changes of single serving foods (1955 to 2001) • McDonalds Fries • from 2.3 to 6.9 oz • 200 to 610 calories • Coca-Cola • from 6.5 oz to 20 oz • 86 to 230 calories • Snickers • from 1.1 oz to 3.7 oz • 130 to 505 calories • “Snacks” increased from 416 to 1,345 calories 600 500 400 300 1955 200 2001 100 0 fries McD's Snickers Coca-Cola Nutrition Action Healthletter 2001

30. Assessment Type of activity Duration Frequency Comorbidites Interventions Set an exercise plan Patient Goals Initiate Maintain Increase Outcomes Improved health Weight Being Active

31. 1200 1000 800 600 400 200 Energy Expenditure of Physical Activity All out competitive sports Running 10 mph Energy Expenditure (kcal/h) Running 6 mph Climbing stairs Sexual intercourse Gardening Walking 4 mph Bicycling Walking 2 mph Chewing gum (11 kcal/h) Adapted from: Alpers. Undergraduate Teaching Project. Nutrition: energy and protein. American Gastroenterological Association, 1978.

32. Assessment Scan markers that act as indicators in the overall control of diabetes A1C BG Blood Pressure Lipids BMI Depression state Renal function Complications Interventions Schedule for testing Alerts for Cues Patient Goals Make appointments and plans for testing Understand what the values stand for Outcomes Pt is using tests to monitor the overall state of diabetes control Monitoring

33. Assessment Adherence to medication plan Meds schedule Misses doses Refill Rx Understands actions Plans for secondary effects Cost Interventions Addressing the issues Patient Goals Increase or maintain adherence to medication plan Outcomes Improved diabetes control Taking Medications

34. Assessment Skill to deal with “emerging issues” Interventions Develop strategies to overcome obstacles Utilizes resources Patient Goals Able to problem solve Outcomes Hypoglycemia Hyperglycemia Problem Solving

35. Assessment Health Literacy Healthcare system Adherence to treatment plans Interventions Address the issues Patient Goals Reduction is risky behaviors Outcomes Microvascular Macrovascular Reducing Risks

36. Assessment Healthy eating Being active Taking medications Monitoring Risk reduction Interventions Use of Resources Addressing specific issues Patient Goals Adopting Outcomes Making diabetes a part of their lives! Health Coping

37. Goal Setting Topics Healthy eating Being active Monitoring Taking medication Problem solving Healthy coping Reducing risks AADE 7 Self-Care Behaviors™ Goal Sheet is part of the AADE 7 IMPACT™ product

38. Driving the Practice • National Standards for DSMT • Scope and Standards of Practice for Diabetes Educators • Practice Guidelines for Diabetes Education • Competencies for Diabetes Educatoes • Accreditation Standards

39. How to establish a diabetes program • Volume • Diabetes days • Group visits • Reimbursement and coding

40. Planning Group Medical Visits • GMV in response to: • Increasing prevalence of chronic diseases • Aging population with complex needs • Need to include family members is DM • MD visit 10-15 min • Healthcare cost

41. Planning Medical Group Visits • Issues to consider • Condition to address • Pts to invite • Frequency of visits • 1:1 follow up problems identified

42. GMV • Yearly annual visit • 2 hours - 20 pts • If Dm out of control 6-8 wks • Create individualized flow sheets • Education materials • Reading lists • Filed trip • Invited speaker

43. GMV • Potential: • Greater access to pts • A more holistic approach • Increase time with MD • Attention to psychosocial issues • It is voluntary, interactive, efficient, tram based and fun

44. GMV • Pts reported: • Improved trust • Better coordination • Better community orientation • More culturally competent care

45. Working with a diabetes educator • Finding an educator • Establishing a referral process • Communication with the educator

46. Learn more atwww.diabeteseducator.org/accreditationContact us at:DEAP@aadenet.org

47. Questions?