2. Nina Watson MSN, RN, CDE Diabetes Outreach Team Diabetes Center of Excellence Wilford Hall Ambulatory Surgical Center Joint Base-Lackland, TX Ellen Cobb BSN, RN, CDE Diabetes Education Coordinator Diabetes Center of Excellence Wilford Hall Ambulatory Surgical Center Joint Base-Lackland, TX Doris Acuna BSN, RN Disease Management 359 th Medical Group Joint Base-Randolph, TX

3. Disclosure to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: Presenter: Nina Watson, MSN, Rn, CDE – No COI/Financial Relationship to disclose Presenter: Ellen Cobb, BSN, RN, CDE – No COI/Financial Relationship to disclose Presenter: Doris Acuna, BSN, RN – No COI/Financial Relationship to disclose “The views expressed are those of the presenter(s) and do not reflect the official views or policy of the Department of Defense or its Components.” Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration.

4. Diabetes Self-Management Education via Telemedicine in the Air Force

5. Learning Objectives Describe the role/value of DSME via telehealth modalities Describe the telehealth technology available within the Air Force Describe the DSME via VTC/MIST initiative Discuss the limitations and strengths of the program identified during the pilot program Discuss the feasibility of expanding the program to the AFMS and DoD

6. Diabetes Education in the Air Force >50,000 people with diabetes in the AF healthcare system –9 endocrinologists –~10 CDEs in dedicated positions Bulk of diabetes care by Primary Care –Varying levels of expertise/interest –Inconsistent levels of care/education

7. Diabetes Education in the Air Force Air Force Medical Operations Agency (AFMOA) conducted enterprise wide AFSO21 (Air Force Smart Operations for the 21 st Century) on diabetes care and education –Diabetes care non-standardized and fragmented –Diabetes Center of Excellence (DCOE) tasked with addressing/standardizing care and education

8. Diabetes Education in the Air Force Initial solutions targeted providers –Diabetes Central on AF Knowledge Exchange –Diabetes Champion Course –Diabetes ECHO (providers) –Diabetes Webinars (nursing and support staff)

9. Diabetes Education in the Air Force Targeting patients –American Diabetes Association (ADA) recommends all patients with new diagnosis or without prior education should attend DSME –Not available at all Military Treatment Facilities (MTFs) –Not always available in the network for referrals

10. Diabetes Education in the Air Force Current options –Patients deferred to network –Disease Managers provide diabetes education –Clinic staff provides abbreviated, non-standardized education associated with office visit –Certified educator provides complete education (limited access)

11. Diabetes Education in the Air Force Questioned if possible to provide DSME via telehealth to MTFs throughout AF using in- place technology and resources. –Certified Program and CDEs at DCOE –Disease Managers at each MTF –Current telecommunication technologies

12. DSME via Telehealth An interactive real time telecommunications system is required. The patient and provider must be able to see and hear each other.* Patient must be present and participate in the telecommunication.

13. Services Covered DSME: Add GT modifier to HCPCS G0108 and G0109 MNT: Add GT modifier to HCPCS 97802, 97803, 97804, G0270

14. Originating Site Location of the patient during the DSME Does not have to be ADA/AADE recognized and may bill for third party insurance –Can charge billing fee per participant using HCPCS code of Q3014 (January 2013, $24.43)

15. Distant Site Location of the educator during the DSME encounter Distant site has to be ADA/AADE recognized –DCOE DSME recognized by American Diabetes Association since 2007 –Reimbursement same as if provided in person

16. Telemedicine success for DSME Diabetes education via telemedicine and in person was equally effective in improving glycemic control, and both methods were well accepted by patients. Diabetes- related stress reduction was observed in both groups. Izquierdo, Knudson, Meyer, Kearns, Ploutz-Snyder, & Weinstock (2003) Multi component telehealth strategies effectively utilized to conduct remote DSME to rural, underserved, and clinically diverse primary care setting. Davis, Hitch, Salaam, Herman, Zimmer-Galler, & Mayer-Davis (2010)

17. Telemedicine success for DSME Pilot study suggests DSME-T may offer opportunities for DSME among rural residents with diabetes. Balamurugan, Hall-Barrow, Blevins, Brech, Phillips, Holley, & Bittle (2009) Literature review (852 publications) suggests that both teleconsultation and videoconferencing are practical, cost-effective, and reliable ways of delivering a worthwhile health care service to people with diabetes. Verhoeven, van Gemert-Pijnen, Dijkstra, Nijland, Seydel, & Steehouder (2007)

18. Telemedicine success for DSME Outcomes from the diabetes disease management program increased the number of diabetics who brought blood glucose under control. Dimmick, Burgiss, Robbins, Black, Jarnagin, & Anders (2003) Literature review (58 publications) supports DSME-T as a useful, appropriate, and acceptable to patients and providers. Fitzner & Moss (2013)

19. Available AF Technology Video Tele-Conference (VTC) –Not available at all MTFs Skype and other web-based conference software not an option Medical Interagency Satellite Training Program – MIST

20. VA-DoD MIST Program Air Technology Network (ATN) is located at Wright-Patterson AFB, Ohio Mission is to promote, manage and deliver instructional broadcasting for DoD distance learning programs and other interactive television (ITV) users

21. VA-DoD MIST Program ITV –One-way video & two-way audio –Via satellite

22. VA-DoD MIST Program Variety of Instructional Methods –HD video & high-end graphics –Live, interactive learning exercises –Student interaction with the experts—standardized instruction –Student to student interaction—enhanced in a classroom setting through audio-conferencing

23. VA-DoD MIST Program Inexpensive course development Inexpensive delivery for medium-to-large audiences Inexpensive downlink equipment ITV integrates well with online media

24. VA-DoD MIST Program

25. DSME via Telehealth Initiative Proposed that the DCOE could provide DSME via telehealth to MTFs throughout AF using in- place technology and resources. –Certified Program and CDEs at DCOE –Disease Managers at each MTF –Current telecommunication technologies

26. Disease Managers Six essential components 1)Population Identification 2)Evidence-based clinical practice guidelines to reduce practice variation and improve care* 3)Collaborative practice models* 4)Patient self-management education** 5)Process and outcome measurement, evaluation, and management* 6)Feedback and reporting to stakeholders.

27. Disease Managers Partnered with Randolph AFB Disease Management Team

28. Current Technology MIST classrooms available MIST studio to be installed Interim VTC –Poor quality of picture –Location

29. DSME via Telehealth Initiative Phase 1 –September 2015 partnered with Randolph –October 2015 “dry run” –January 2016 went live –June 2016 collect 6 month data

30. Program Development Curriculum review Assessments Documentation Training for Disease Managers Marketing

31. Curriculum Review Review/update lectures –Standardize curriculum (PowerPoint slides) –Assessments and data collection Knowledge Attitude Behavior –SMART goals

32. Curriculum Class 1: 1 st Tuesday of each month, 0830-1130 CST –Initial assessments –Overview of Diabetes –Nutrition, part 1: Healthy Eating Class 2: 2 nd Tuesday of each month, 0900-1130 CST –Exercise –Hypoglycemia –Nutrition, part 2: Choosing a Diet

33. Curriculum Class 3: 3 rd Tuesday of each month, 0900-1130 CST –Psychosocial Considerations (behavioral change) –Setting SMART Goals –Complications of Diabetes Class 4: 4 th Tuesday of each month, 0900-1130 CST –Medications and how they work in the body –Nutrition part 3: Special Situations Meal preparation; eating out Sick days

34. Assessments Class 1 Class 2 Class 3 Class 4 6 months Initial (demographics; social & lifestyle; basic health history) X Knowledge Test (True/False) XX Diabetes-related Distress Scale (DDS-17) XXX Self-report behaviors XXX Patient Satisfaction Survey XXXX Provider Satisfaction Surveys XXXX

35. Documentation Electronic Health Record: AHLTA (Armed Forces Health Longitudinal Technology Applicaton) “Notewriter”: locally developed excel-based database that once data is entered –Generates a note that is copied/pasted into AHLTA –Collects/stores data for future use –Storage meets HIPPA requirements

36. Documentation Facilitated documentation Facilitated data collection –Demographic data for recognition –Knowledge, attitude and behavioral data For pilot project For recognition

37. Training for Disease Managers Binders –Copies of PowerPoints/handouts –Assessments and data collection –SMART goals –Patient and provider evaluations Documentation –Notewriter/AHLTA –Database Provider Satisfaction surveys collected after each class

38. Challenges at Distant Site Getting faculty buy-in Scheduling classes –VTC room—location, conflicts –Coordination with Randolph for attendance Comfort in front of camera –Remembering to look at camera –Soliciting input from distant audience

39. Challenges at Distant Site Broadcasting issues –VTC to satellite link, technical issues Power outages High circuit volume, audio and visual loss Overhead mikes—difficulty hearing speaker, picks up background noise –Time lag for 2-way conversation (3-6 seconds)

40. MIST Studio Anticipated installation June 2016 –Costs—minimal due to grant funding implementation of MIST throughout DoD –Facility challenges Moving to new facility Modifications to classroom Telephone/Internet/power requirements Coordination through committees

41. Challenges at Originating Site Soliciting support –Leadership/Clinic staff –Disease Managers –Patients Venue/MIST classroom –Location in conference room upstairs –Shared conference room –Support from Education and Training

42. Challenges at Originating Site Program development –Training for the Disease Managers –Trial run October 2015 –Binders and Materials Recruiting patients –Provider briefings –Referral process –Scheduling

43. Challenges at Originating Site Broadcast issues –Location of TV within conference room –Quality of picture, especially when using whiteboard –Loss of audio or video –Microphone issues –Changes in equipment/lack of technical support

44. Challenges at Originating Site Check-in, Scheduling and Documenting –Computer unavailable in room –Delayed documentation –Procured laptops: facilitated check- in/scheduling/documentation Documentation to Notewriter –Familiarization –Data collection

45. Provider Experience—Means Overall satisfaction was high: 5.06 on 6pt scale All 17 responses stated they would organize another class in this format

46. Provider Issues—Means Some issues with audio/video reported from 6 Feb and 23 Feb classes. Four reports of difficulties in setting up technology early in the process. They are now resolved.

47. Patient Survey Summary All remote participants reported feeling comfortable taking the classes 98.6% of all participants understood the information High overall satisfaction with DSME classes –96.6% for WHASC –96.8% for RAFB

48. Patient Experience: No Significant Differences

49. Patient Experience: Significant Differences

50. Patient Knowledge Summary of Differences in Knowledge from Baseline to Completion Overall (WHASC & RAFB) p value BaselineCompletion Activity1.77 (.56)1.89 (.31) 0.18 Reduce Risk**2.53 (1.14)3.19 (.74) <0.001 Healthy eating*2.98 (1.34)3.38 (1.03) 0.045 Foundational**1.53 (1.06)2.36 (.79) <0.001 Bg Monitoring**1.66 (.96)2.06 (.53) 0.006 Medication**3.51 (1.74)5.23 (.98) <0.001 Overall**13.36 (5.03)17.23 (2.43) <0.001 *p<0.05; ** p<0.01

51. Summary of Differences in DDS-17 from Baseline to Completion Overall (WHASC & RAFB)p value BaselineCompletion DDS Total1.75 (.69)1.81 (.76)0.55 Emotional1.87 (.90)2.01 (.90)0.37 Physician-related1.40 (.77)1.56 (.96)0.35 Regimen-related2.11 (1.23)1.98 (1.03)0.39 Interpersonal1.41 (.70)1.55 (.87)0.17 *p<0.05; ** p<0.01

52. Phase 2 Summer 2016 –Expand to 5 MTFs Goals: –Refine Disease Manager training program –To identify and solve technical issues –Resolve documentation issues Challenges: –Staffing

53. Future Proof of effectiveness –Generate staffing to provide the program –Become the standard of care in the AFMS –Potential to expand DoD where recognized DSME programs are not available

54. Special Acknowledgments DCOE Dr. Tom Sauerwein Jana Wardian, Ph.D. Connie Morrow, MAEd-AET Loralyn Beck, RD Cindy Western Diana Holub Monika Valentin Kim Bullock, BSN, RN Diana Garza Stanley Kuzbinski 59 th Medical Center Joshua Guerrero Garland Kinard DSME Faculty Maj. Jeffery Colburn Jennifer Honig, RD, CDE Haley Herbst, RD Capt. Michael Glotfelter Ann Hryshko-Mullen, Ph.D. MIST Alex Autry Joe Kustra Clay Middlebrook Randolph AFB Joyce Mason Jennifer Wetzel Lt. Col. Weidman Lt. Col. Winters Deborah McNear-Watkins Jennifer Wilheim Lt Col Francis Carandang

55. References Balamurugan, A., Hall-Barrow, J., Blevins, M. A., Brech, D., Phillips, M., Holley, E., & Bittle, K. (2009). A Pilot Study of Diabetes Education via Telemedicine in a Rural Underserved Community—Opportunities and Challenges A Continuous Quality Improvement Process. The Diabetes Educator, 35(1), 147-154. Davis, R. M., Hitch, A. D., Salaam, M. M., Herman, W. H., Zimmer-Galler, I. E., & Mayer-Davis, E. J. (2010). TeleHealth improves diabetes self-management in an underserved community diabetes TeleCare. Diabetes Care, 33(8), 1712-1717. Dimmick, S. L., Burgiss, S. G., Robbins, S., Black, D., Jarnagin, B., & Anders, M. (2003). Outcomes of an integrated telehealth network demonstration project. Telemedicine Journal and e-health, 9(1), 13-23. Fitzner, K., & Moss, G. (2013). Telehealth—an effective delivery method for diabetes self-management education?. Population health management, 16(3), 169-177. Izquierdo, R. E., Knudson, P. E., Meyer, S., Kearns, J., Ploutz-Snyder, R., & Weinstock, R. S. (2003). A comparison of diabetes education administered through telemedicine versus in person. Diabetes care, 26(4), 1002-1007. Verhoeven, F., van Gemert-Pijnen, L., Dijkstra, K., Nijland, N., Seydel, E., & Steehouder, M. (2007). The contribution of teleconsultation and videoconferencing to diabetes care: a systematic literature review. Journal of Medical Internet Research, 9(5), e37.

56. Thank you! Questions?