1 Chronic Disease Duke Family Medicine Woody Warburton, MD Professor and Division Chief Conference on Practice Improvement: Health Information and Patient Education November 10, 2006 Denver, CO

2 Outline 1. The Clinical Practice 2. Chronic Disease Management What are we doing in diabetes? What are we doing in diabetes? Group visits – a 15 month analysis Group visits – a 15 month analysis 3. Diabetes metrics – how are we doing? 4. Obstacles 5. Conclusions & Next Steps

3 Clinical Practice Profile  Family physician faculty (.2→.6 FTE) 14  Physician assistants & nurse practitioner  (.2→.8 FTE) 6  Established patients (3 visits in 3 years) 13,400  Diabetic patients 1,400  Hypertension patients 4,200  Medicare 12%  Medicaid 15%  Managed Care (Duke Select) 42%  Other (Aetna, Cigna, BCBS etc) 31%  Provider office visits/year 38,000

4 Learners & Staff FM Residents FM Residents Medical students/month Medical students/month 2 Pharm D students/mo 2 Pharm D students/mo PA students/mo PA students/mo 5 RN/ 3 LPN/ 10 MA 5 RN/ 3 LPN/ 10 MA 1.2 MSW 1.2 MSW 1 Pharm D 1 Pharm D 0.3 Registered Dietician 0.3 Registered Dietician

5 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes 4. Delivery System Design 5. Decision Support 6. Clinical Information Systems 3. Self- Management Support 2. Health System Resources and Policies 1. Community Health Care Organization Chronic Care Model Source:

6 So What Are We Doing? I. Clinical Information System Registry -CDEMS Registry -CDEMS DM Reminder Tab DM Reminder Tab Transcription Template Transcription Template (Poor Man’s Reminder System)(Poor Man’s Reminder System)

7 Diabetic Template

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10 II. Delivery System Design  Multidisciplinary Team - Weekly  MD  RN  Front desk/Call center  PA  Pharm D  MSWCD  MSW – Medicaid  Case manager – Duke Select (HMO) Work with Community Partners!!!!!

11 Case Management Conferences  MSW / Pharm D/ Clinician (s)  Move to continuity teams  Use registry to define candidates

12 Foot Care  PA Trained at (Diabetic) Wound Clinic & Podiatrist Office  Acquire equipment – nail cutters & dremel  Readily available monofilament for testing  Internal marketing

13 Nutrition  Popular topic with group visits  1 + year battle to get RD onto staff  Billing headaches  Still struggle for patient self management

14 Home Visits  Students / Residents  1° with Medicaid population  Excellent learning  No show problem

15 Diabetic Group Visits

16 Attendance (July ’05 → Sept ’06) 50% arrival rate 50% arrival rate 13.5% cancellation rate 13.5% cancellation rate 34.9% no show rate 34.9% no show rate

17 Participants Clinical Metrics 1 group visit only – 48 participants A1c<7% = 27% (13/48) A1c<7% = 27% (13/48) LDL<100 = 29% (14/48) LDL<100 = 29% (14/48) BP<130/80 = 33% (16/48) BP<130/80 = 33% (16/48) Repeat Group Visits – 25 participants A1c<7% = 48% (12/25) A1c<7% = 48% (12/25) LDL<100 = 56% (14/25) LDL<100 = 56% (14/25) BP<130/80 = 48% (12/25) BP<130/80 = 48% (12/25)

18 Satisfaction Scores Graph

19 Time/Energy Analysis Quality coordinator - 5 hrs/mo Quality coordinator - 5 hrs/mo Call Center reminders - 2 hrs/mo Call Center reminders - 2 hrs/mo Physician Assistants (2) – 4 hrs/mo Physician Assistants (2) – 4 hrs/mo Pharm D – 2 hrs/mo Pharm D – 2 hrs/mo

20 Group Visit: Cost Analysis Cost Per Group Visit Personnel $ 382 Direct cost – Refreshments $ 20 Gift card $ 50 $ 50 TOTAL$452 Revenue Total charges (99213 & 99214) $9,557 Total adjustments (per contracts) <$5,927> Total payments $3,507 $3,507 Average revenue per Group Visit $319

21 Group Visit: Conclusions 1. Group visits meet patient satisfaction & improve care. 2. Patients feel more comfortable with their disease. 3. May need >1 yr to see clinical benefits. 4. Not cost effective with current model. 5. Unclear if this is a “stepping stone” to new chronic disease care. 6. One of many tools to improve chronic disease management.

22 III. Decision Support  DM tab – long time coming!!!  Endocrinologist on DM team – key buy-in

23 IV. Self-Management  Patient Self Management Support  Residents teach faculty about Self Management  Staff (RN, MSW, & Pharm D) provide follow-up support

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25 V. Organization of Health Care  Mission to” improve health of the community”  Focus - 1° on chronic disease – less on preventive & acute care  Department chair & division chief leadership  QI program metrics

26 Quality Measurement Without an EMR  Random sample ~ 100 charts – every months  Resident & student (MS, PA, Pharm D) work force  QI masters trained analyst  HEDIS/State/ACCC/CMS - standard audit

27 Results So Far  HEDIS Metrics  State Metrics  ACCC Metrics  Healthy People (2010)

28 Diabetes A1c Monitoring(I) % Diabetic pts (18-75) w A1c in past yr Family Medicine Division n = 93 Repeat measure: 12/ HEDIS 90th%tile = 92% 3/15/2006

29 Diabetes A1c Monitoring (II) % Diabetic pts (18-75) w 2 A1c in past yr Family Medicine Division 10/1/2016 N = 80 Repeat Measure: 12/06

30 Diabetes A1c Control* % Diabetic pts (18-75) w A1c >9.0 Family Medicine Division *Lower rates are better for this measureRepeat Measure: 12/06 n = HEDIS 90th%tile = 21%

31 Diabetes A1c Control (II) % Diabetic pts (18-75) w A1c< 7.0 Department of Community and Family Medicine 6/06 n = 80 Repeat Measure: 12/07

32 Diabetes Lipid Monitor (I) % Diabetic pts (18-75) w LDL in past 2 years Family Medicine Division 2005 HEDIS 90 th %tile = 95% 10/1/2016 Repeat: 1/2007

33 Diabetes Lipid Monitor (II) % Diabetic pts (18-75) w LDL in the last 12 months Family Medicine Division 10/1/2016 Repeat: 1/2007

34 Diabetes Lipid Control % Diabetic pts (18-75) w LDL < 100 Family Medicine Division n = 93 (random sample) Repeat measure due: 7/ HEDIS 90 th %tile = 48%

35 Diabetes Lipid Control % Diabetic Pts (18-75) w LDL < 130 Family Medicine Division 2005 HEDIS Goal (LDL-C  130) = 76.3% n = 66 (random sample) Repeat measure due:1/07 10/1/2016

36 n = 66 Repeat measure: 1/ HEDIS 90 th %tile = 66% 10/1/20166 Diabetes Eye Exam % Diabetic pts (18-75) w eye exam in past yr Family Medicine Division

37 Diabetes Foot Exam % Diabetic pts w foot exam in past yr Family Medicine Division n = 66 *2010 Healthy People Goal = 75% Repeat Measure: 1/200710/1/2016

38 Diabetes Monofilament Exam % Diabetic pts w exam in past yr Family Medicine Division n = 66 *2010 Healthy People Goal = 75% Repeat Measure: 1/200710/1/2016

39 n = 80 Repeat Measure: 1/07 10/1/2016 Diabetes Aspirin Therapy % Diabetic pts ≥ 40 w daily aspirin prescribed Family Medicine Division

40 Learners Integrated Into Model Clinical Practice Guidelines Clinical Practice Guidelines QI Audit QI Audit Initial meaningful changes in practice to improve care Initial meaningful changes in practice to improve care Attend monthly QI meeting Attend monthly QI meeting Resident taught faculty about self-management Resident taught faculty about self-management

41 Obstacles  No extra $ but department priority  E-browser/data repository is specialty driven & not CDM focused  No true EMR  Faculty -agree on CPG for the practice -group not solo practice faculty believe in & model different behavior -older MD have problems  No shared residency clinical practice data  Nursing – old / new school

42 Obstacles (con’t) Resident issues  CDM not sexy  CDM not easy -- takes time & energy  Not recognize importance of team function & QI work  Rotation schedule – difficult to be part of the development

43 Conclusions & Next Steps  Diabetes is great model to learn elements of CDM  QI metrics feed improvements in Diabetes care  Behavior change is hard – staff & faculty – patients  Focus & spotlight improves care  Hypertension & COPD are next!!!