PATHS: Providing Access to Healthy Solutions An Analysis of Opportunities to Enhance Type 2 Diabetes Prevention and Management Maggie Morgan and Sarah Downer The Center for Health Law and Policy Innovation Harvard Law School May 30, 2014

PATHS Structural Analysis Food Physical Activity Disease Prevention Access Quality Disease Management

TYPE 2 DIABETES: PREVENTION

Economic Access to Healthy Food Nutrition and Cooking Education Geographic Access to Healthy Food Early Childhood, School Food, and Wellness Programs Physical Activity/ Built Environment Diabetes Type 2 Prevention Themes

Ease of application Improved online services EBT at farmers markets Participation (SNAP) Invest in interagency pilot programs Scale up successful programs Interagency Collaboration SNAP and WIC

Healthy Food Retailers New Food Retailers Grants and loans to incentivize in low-access areas Zoning policies Existing Food Retailers Tax Incentives for offering healthy food Farmers Markets Development in new areas EBT acceptance Transportation Invest in sidewalks and public transportation Leverage existing transportation

Results from Study Committee on Food Desert Zones Snap Ed Implementation Local Government Action School Gardens School Breakfast Further study

Complete Streets vs. Transportation Funding Health Impact Assessments Sidewalk RequirementsData Collection Built Environment Community Awareness and Physical Activity Information

Early Childhood Interventions Best practices Home visiting programs Revise Star Rated License System Financial Incentives for Centers that Excel

Direct Certification School Breakfast Community Eligibility Technical Assistance Summer Feeding Programs School Food

Wellness Policy Implementation Shared Use Agreements Tax Credits for Workplace Wellness Programs Wellness

TYPE 2 DIABETES: MANAGEMENT

Goal: Whole-Person Patient Centered Diabetes Management Primary Care Specialty Care Lifestyle Modification and Management Services Community Resources

Access to Key Services Managing Health Disparities Access to Providers Healthcare Delivery System Whole- Person Diabetes Care Teams Type 2 Diabetes Management Themes

Expanding Access to Key Services Diabetes Equipment & Supplies Innovative Use of Health Technology Diabetes Self- Management Programs Behavioral Health Services Diabetes Prevention Program

5-7% weight loss 150 min/week physical activity 58% Reduction in Diabetes

NC Recommendations: Diabetes Prevention Programs Medicaid reimbursement Increase state funds for targeted, evidence- based prevention efforts Extend postpartum Medicaid benefits beyond 60 days Increase support for clinical practices through funding for AHEC, Office of Rural Health, etc

Durable Medical Equipment, Supplies and Insulin Cost-Sharing; Quantity Limits; Brand Changes Need to Test Frequently

NC Recommendations: DME and Insulin Provide assistance to help patients with copays and coinsurance to access insulin Lower costs of testing supplies for patients who follow best- practices approaches to diabetes management Expand access to health insurance for low- income people

Need for Statewide and Local Coordination Billing and Reimbursement Challenges NC Successes in DSME, DSMP and MNT Continuing Barriers to Access Diabetes Self-Management Programs

NC Recommendations: Diabetes Self- Management Education and Support Establish statewide Diabetes Self- Management Task Force Recognize “gold seal” diabetes education programs Develop strong DSME care teams Offer reimbursement for clinical practices

Behavioral Health Services and Diabetes Management Three Highlights 1.Poor behavioral health lowers patient’s ability to provide effective self-care 2.Integrating behavioral care into patient’s primary care improves health outcomes 3.Two barriers to integration: Shortage of behavioral health providers Lack of coordination between primary care and behavioral health care systems

NC Recommendations: Behavioral Services (1) Expand the use of telepsychiatry (2) Implement Pay-for- Performance incentives to improve provider coordination (3) Incentivize behavioral health providers to join the state’s Health Information Exchange (4) Better incorporate behavioral health education into diabetes care

Health Information Exchange Technical Assistance to Clinical Practices Telemedicine Opportunities Geographical Mapping-Durham Diabetes Coalition Project Innovative Use of Health Information Technology

Increasing Access to Providers In-state physician recruitment and retention Recruitment of minority providers Incentives for primary care providers Nursing/nurse practitioner shortages Enrollment and Recruitment of Providers Opportunities for valuable providers such as pharmacists to serve on diabetes care teams Role of community health workers Promoting comprehensive health care teams Geographic and racial disparities Transportation Promise of Telemedicine Focus on undeserved areas and areas with high health disparities

NC Recommendations: Retention and Recruitment Expand current residency programs and create new ones Target in-state residents for medical school and residency programs Expand the number of Primary Care NPs within the state Maintain increased Medicaid reimbursement rates Encourage recruitment of minorities into medical and nursing schools

NC Recommendations: Promoting Comprehensive Healthcare Teams Support Medication Therapy Management Programs Further Embed Clinical Pharmacists into NC Medicaid Incorporate Pharmacists into NC’s Medicaid Chronic Health Homes PHARMACISTS Increase Financing of CHW Programs Gather Data on CHW Certification Programs COMMUNITY HEALTH WORKERS

NC Recommendations: Reduce Health Disparities Expand the use of promising telemedicine programs Promote successful loan repayment/incentive programs Explore transportation challenges and opportunities

Opportunities for Provider Coordination Increased Health Outcomes?? Medicaid Health Homes through CCNC; Patient- Centered Medical Homes Shift towards shared savings and bundled payments may help diabetes prevention and management Financial Incentives for Providers Coordinated Care Models for People with Diabetes Health Information Technology Accountable Care Organizations Healthcare Delivery System

QUESTIONS?