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Diabetic Education and Case Management

State: TX Type: Promising Practice Year: 2020

Denton County faces unique challenges with the population growth the county is experiencing. Less than 5 years ago Denton County was one of the top five fastest growing counties in the United States. Infrastructure such as grocery stores, sidewalks, and public parks that encourage healthy behaviors and decrease incidence of chronic disease are falling short.

In Texas, diabetes is an epidemic affecting 14.2% of the adult population, compared to 9.4% in the USA. As such, Texas is second only to California in the amount of money spent on diabetes. Diabetes and prediabetes cost an estimated $23.7 billion in Texas annually.

Funding for diagnosis, treatment delivery, and ongoing management of diabetic patients across the USA remains an ongoing challenge. The Waiver 1115 or the Delivery System Reform Incentive Payment (DSRIP) program allowed DCPH to secure funding to reach more diabetic patients with the goal of reducing their HbA1c to save long-term costs and improve quality of life. The Waiver 1115 in collaboration with Texas Medicaid, HHSC and CMS supplied $25 billion in funding to Texas with 10% dedicated to Public Health, to assist those low income uninsured residents. 99% of the DSRIP participants are Hispanic or Latino and 59% have less than a high school education.  To participate in the program required a cost investment by DCPH and to document improved outcome though required goals and metric established by HHSC and CMS.

The big question was how to empower an underserved population of diabetic patient, improve outcomes and lower costs in a public health setting?

Three goal were established:

  1. Provide culturally and linguistically appropriate diabetes self-management group and individual education opportunities, and lower their HbA1c by 2.5%


  2. Provide diabetic patients a reduction in  multiple visits, onsite HbA1c testing results, coaching, and culturally appropriate diabetes self-management education materials


  3. Recoup investment paid into the DSRIP Program, and earn additional state funding for expansion by demonstrating improved HbA1c results and outcomes.


POC cycle of care allows us to ensure the client is administered the most robust services and treatment planning in one visit. This diminishes social determinants of health by reducing barriers such as transportation to multiple visits, patients having to request time off for numerous appointments, loss of family earnings, and complication cost avoidance. This tool really assists us in promoting health equity in our community. Currently each new diabetic patient is administered in one visit using the POC cycle of care testing, their HBA1c, Retinal scan, and Foot exam. Beginning in September the POC cycle of care testing will include testing for Micro-Albumin, and a Lipid panel? This will complete the three annual exams recommended by the ADA in one visit if results are normal.



The POC cycle of care is a streamlined approach to treatment planning for staff and the patient. All staff members can be involved with direct patient care. Case managers, CHW's and nurses all participate with in the cycle of care. When assessing the client value, POC testing has improved patient outcomes. The per test cost savings of $1.85 was achieved compared to sending out a venous blood sample for HbA1c analysis. Additionally, the patient no-show rate for appointments has been reduced by at least 50%, to approxemently 12% improving the efficiency of the office and further lowering costs.

The POC cycle of care has assisted DCPH in achieving the required DSRIP goals and metrics allowing funding to continue for 7 years? Today 76.43% of the diabetic patient have reduced their HBA1c to below 9%., and 44% 44% of patients with diabetes have a hemoglobin HBA1c below the ADA recommended 7.0%.

The POC cycle of care has played such an important role in the success of the Delivery System Reform Incentive Payment program which is changing and saving lives. By providing teaching moments with rapid results the POC cycle of care empowers the individuals to take control of their disease, while reducing the cost of complications. The DCPH model could be replicated throughout public health organizations, to reduce the cost of uncompensated care and improve the lives of their citizens. Additionally, the use of community health workers in such programs creates employment for unlicensed health care professionals.

Empowering a low-income population of diabetic patients with onsite HbA1c testing results, coaching, and culturally appropriate diabetes self-management education materials improve outcomes and lower costs in a public health setting. A cornerstone of the program was the implementation of point-of-care testing, or lab tests performed at or near the patient and at the site where care or treatment is provided. Through the use of point-of-care instruments from National vendors, we were able to test patient hemoglobin A1c (HbA1c) levels to check how well their diabetes was being controlled and monitor for early kidney disease—and importantly—review the results with our patients, provide culturally and linguistically appropriate diabetes education, and discuss any impact on their treatment plan—all in the same visit. 

This was incredibly important for our patients, most of whom live below the Federal poverty line and who have limited access to healthcare. By eliminating the need for multiple doctor visits, we were able to promote health equity in our community by reducing common barriers to care and compliance, such as transportation challenges, the need to take several days off from work, and fear of loss of wages.     


In addition to point-of-care testing, patients also received retinal scanning and met with nurses trained to perform foot exams and assist in wound care, all during the same visit.  By involving all staff—case managers, community health workers and nurses—in direct patient care we strengthened the bond of trust between our staff and the community we serve, which is a critical component for ensuring optimal patient outcomes.




The Denton County Public Health (DCPH) Diabetes Education and Case Management (DECM) program provides a multifaceted approach to the diagnosis, treatment, and ongoing management of diabetes. Funded through the Texas Delivery System Reform Incentive Payment (DSRIP) plan, the DECM Program has demonstrated improved quality of life and long-term cost savings through program interventions.

Health economic models have shown that, for a population of 400 patients, the improvement of 1.0% HbA1c results can lead to multiple complication episodes avoidance, which would result in over $500,000 in savings for the healthcare system.

To heighten quality of life for patients living with diabetes and reduce healthcare costs associated with unmanaged diabetes, DCPH DECM established measurable program objectives, including:

> 44% of patients with diabetes who had hemoglobin A1c below 9.0%

> 52% of patients with diabetes whose most recent blood pressure level is below 140/90 mm Hg

.> 44% of patients with diabetes who had a retinal or dilated eye exam by an eye care professional or a negative retinal exam in the previous 12 months

Increase number of patients with diabetes who receive a visual and sensory foot exam with mono filament and a pulse exam in the previous 12 months

Increase number of patients receiving self-management education

Increase healthcare cost expenditures saved through care management

Based on the results iterated, data suggests the multifaceted case management model implemented is effective in reduction of cohort hemoglobin A1c, resulting in cost aversion for common complications of uncontrolled diabetes. Metrics indicate prioritization of individualized curriculum and care plans, through the lens of culturally and linguistically appropriate services, is effective in improving quality of life and reducing markers of uncontrolled diabetes.

DCPH aims to continue furthering impact through implementation of a synchronized video notification and compliance monitoring system. Utilization of this system will further self-management practices through encouraging accountability to medication management and treatment plan adherence.

Health Care Costs Aviided by Lowering Cohort A1c

Scenario

Total

Follow-Up Cost

$ 507,600

HbA1c Test Cost

$ (152,280)

Complication Cost

$422,911.82

Total Savings

$ 778,231.82

When assessing the client value, POC testing has improved patient outcomes. The per test cost savings of $1.85 was achieved compared to sending out a venous blood sample for HbA1c analysis. Additionally, the patient no-show rate for appointments has been reduced by at least 50%, to approxemently 12% improving the efficiency of the office and further lowering costs.




Objectives:

Examines the positive outcomes of a redesign in the Diabetes Education and Care Management (DECM) program at Denton County Public Health, (DCPH) a participant in Texas' Delivery System Reform Incentive Payment (DSRIP) plan. Group education in Denton is presented every Thursday night at the DCHD conference room with diabetic meal served. Group education is presented every Tuesday night in Lewisville with a diabetic meal served. All group education is presented in Spanish, and individual education is presented in English or Spanish. The curriculum presented is in collaboration with Texas AM AgriLife Extension, and is called, Si, Yo Puedo Controlar Mi Diabetes! This program targets Spanish speaking low literate Hispanic/Latinos with type 1 or 2 diabetes. Sí, Yo Puedo is recognized by the USDA National Institute of Food and Agriculture (NIFA) as an exemplary community health program. Through community collaboration, DCPH exemplifies one of AgriLife partnerships to serve the Hispanic/Latinos population with diabetes. The data provided by AgriLife continues to show additional improvement in Diabetic knowledge”, Diabetes self-care”, Increase in confidence in self-care”, and How is your health most of the time?” DEPH is one of the few, or only DSRIP project to have ongoing documentation of sustainable success from an outside agency or university, not associated with DSRIP. New data that is being processes through the UNT Health Science Center that shows that there is no significant deviation in education being presented in English or Spanish, or received by male and female. In other words the education is benefiting both male and female, in either Spanish or English with positive results. To date the DECM program has made incredible progress. These accomplishments have been achieved through the dedication of the case manages, and the ability to treat, educate and support the patient at their provider visits.

The POC cycle of care has assisted DCPH in achieving the required DSRIP goals and metrics allowing funding to continue for 7 years? Today 76.43% of the diabetic patient have reduced their HBA1c to below 9%., and 44% 44% of patients with diabetes have a hemoglobin HBA1c below the ADA recommended 7.0%.

The POC cycle of care has played such an important role in the success of the Delivery System Reform Incentive Payment program which is changing and saving lives. By providing teaching moments with rapid results the POC cycle of care empowers the individuals to take control of their disease, while reducing the cost of complications. The DCPH model could be replicated throughout public health organizations, to reduce the cost of uncompensated care and improve the lives of their citizens. Additionally, the use of community health workers in such programs creates employment for unlicensed health care professionals.


You must accept the patient for who they are, where they are in the season of life, and respect their cultural beliefs. By acknowledging their cultural believes, and their season of life, you gain insight, and trust. This may be the first time any health care professional has communicated with them in their native language. As the bond of trust is being formed, the provider, and clinic staff must always respect the individual as a fellow human being, not as a low income, uninsured non-compliant freeloader.

Over the last 3 years we have seen a series of changes in our program. It has opened our eyes to see that we lack the ability to understand the world as our patients do. Example, at a patient visit the provider was discussing the patients eating habits, and was somewhat stern manner. The patient broke down and begin to cry, say I can only eat what I have”. I live in a house with 5 families, in one bedroom with my family of 7. We are not allowed to use the refrigerator, or cook. Most all of our food is canned. The provider and nurse begin to cry. This patient had be administered the Personal Needs Assessment, but was not honest due to being concerned about legal status.  Food stamps where in progress from the assessment for the children, but not approved as yet. The social worker was called to the visit and begin assisting with housing, food stamps and Medicaid for the children and any other needs.

The number one lesson learned is you need to speak the language, due to the loss of emotion, and miscommunication during translation. Continue to ask questions and interview your patients more than once. Involve the family, for support, and to determine if the entire situation is being discussed. Meet them at their level, and always show compassion and concern. You never know in this economy when you could be in the same situation.

The Costs and Savings analysis indicated a loss/ benefit from the initiative being examined. Meaning that there was a loss experienced due DCPH have no additional revenue stream from Medicaid or MOC's. The target population at DCPU are 100% uninsured low income. All Medicaid patients are navigated out to a medical home in the community.

The cost analysis does not take in to consideration the cost reduction in diabetic complications or reduction in hospital cost. With the Point of Care Testing and reduction in the DSRIP patients HBA1c hundreds of thousands of dollars have been saved. With the use of the Siemens International Healthineers Diabetic Management tool it is estimated that the current cohort of diabetic patient at DCPH have saved approximently $778,231.82 in complication cost. Not only has a dollar valued reduction,  but an increase in quality of life with a reduction in loss of eye sight, loss of Kidney function, and loss of limb.

As the safety net for the uninsured of Denton County the lack of Medicaid revenue has an impact on the cost analysis. Medicaid patients are navigated to a medical home in community to help sustain medical care and a relationship with the Medicaid provider. With the vast number of uninsured in Texas, DCPH will have a continuous flow of patients that will need assistance.

The relationship with any of the MCO's is non-excising. They have no desire to be involved with the DSRIP projects, or even discuss a relationship. For Public Health there is no reason the MCO would be interested as there is no way to make the patient paying members. Many would not qualify for Medicaid due to legal status or how to navigate the system. DCPH has for the last 3 years been try unsuccessfully to reach an agreement with Amerigroup. Offer a bundle measurement that would allow the member to remain with their current PCP and all Point of Care testing would be sent to their PCP reducing time and cost for Amerigroup. This would reduce the cost of office visits, missed work, and multiple visits by the patients. DCPH will continue to pursue the MCO agreement.

The patient has also lead to an impact on the cost analysis. Dealing with a population that has had little or no access to healthcare for most of the life span causes many problems. Low education and understanding of medical care and basic terminology can cause confusion. DCPH Diabetic Education and Case Management program (DECM) eliminated many problems. Each case manage is required to attend the appointment with the patient and do teach back after the provider leaves the room. This has eliminated confusion on how the patient interprets the provider's instructions. Even with this method of communication, the patient still has problems understanding the scope of diabetes and the complications. This problem can lead to medication errors, diet misconception on the part of the patient, even with hours of instruction. This lack of health literacy will take many years to overcome, and even with weekly group education will most likely remain a problem.



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