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1 Diabetes Care for High Risk Populations: Lessons from a Community Based Program.

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Presentation on theme: "1 Diabetes Care for High Risk Populations: Lessons from a Community Based Program."— Presentation transcript:

1 1 Diabetes Care for High Risk Populations: Lessons from a Community Based Program

2 2 Software Screen

3 3 Today’s Speakers Marie Laboissonniere RN Med CDOE CVDOE and Susanne Campbell RN MS St Joseph Center for Health and Human Services Providence, RI

4 4 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.

5 5 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

6 6 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

7 7 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)

8 8 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

9 9 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

10 10 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

11 11 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

12 12 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

13 13 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

14 14 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

15 15 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

16 16 Strategies/Patient Resource Information For information on Pharmacy Assistance software (Systemetics) contact 888-593-1085 or For patients with insurance and high co pays, call Patient Advocate Foundation Co-Pay Release at 1-866-512- 3861 (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 ; For Roche products: visit; and go to patient assistance

17 17 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

18 18 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

19 19 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

20 20 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

21 21 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

22 22 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

23 23 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

24 24 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

25 25 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

26 26 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

27 27 Questions / Discussion ?

28 28 Have additional questions? Please contact us at

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