Collaborative Diabetes Care


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Patients with diabetes get the best care with a collaborative team approach. Optometry and ophthalmology can improve our diabetes visits and improve care as well even though we are only a small part of the diabetes healthcare team.

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  • Ahh...Arizona. Golf! Sun!
  • Tohono o'odham have highest prevalence of DM of any population in the world.
  • 20,000 population on reservation
  • Diabetes is a big problem
  • Key here is interdisciplinary team
    Management is the key in team issues, evidence, quality and informatics
    Not really medical!
  • Across the parking lot!
  • Across the parking lot.
  • At kp, the org just bought retinal cameras...without talking to ophthalmology or optometry!
  • I had a patient that said that his eyes were the most important thing in his body healthwise...
    I said what if your heart stopped...would you need your eyes then? He got it!
    Many PCPs just want the dilated exam and that's it due to quality measurement systems (more on this later)
  • NCQA non profit org that develops this
    Many KP former leadership
  • Don't forget that the patient's PCP may not be a physician. And that's ok.
  • Overweight adult: Body Mass Index ≥25 kg/m2 (≥23 if Asian American or ≥26 if Pacific Islander) with one or more of the following:
    • Family history: have a first-degree relative with diabetes
    • Race/Ethnicity: African American, Hispanic/Latino, American Indian and Alaska Native, or Asian American and Pacific Islander
    • History of gestational diabetes or gave birth to a baby weighing > 9 lbs
    • Hypertension: blood pressure >140/90
    • Abnormal lipid levels: HDL cholesterol level <35mg/dl; triglyceride level >250 mg/dl
    • IGT or IFG: on previous testing
    • Signs of insulin resistance: such as acanthosis nigricans or polycystic ovarian syndrome (PCOS)
    • History of vascular disease: diagnosed by physical exam and testing
    • Inactive lifestyle: being physically active less than three times a week
    In the absence of the above risk factors, people age 45 and older are considered at risk and should be tested.
    National Diabetes Education Program
  • Can we play a larger role in early detection?
    Fasting plasma glucose...
  • Can we really make it simpler and more understandable?
  • Is this an indication that our system has failed them?
    Is this disease different for this group?
    Or is this being culturally insensitive to help with adherence?
    EVIDENCE BASED?????????????
  • =not just for optometry
  • Collaborative Diabetes Care

    1. 1. Collaborative Diabetes CareCollaborative Diabetes Care Mark G. Mitchell, OD, MBAMark G. Mitchell, OD, MBA Reno, NevadaReno, Nevada
    2. 2. What my patients think of...What my patients think of... ==
    3. 3. What I think of...What I think of...
    4. 4. We need to change ourWe need to change our diabetes visits to workdiabetes visits to work better as part of the teambetter as part of the team
    5. 5. It's really important to system ● Costs ● Benefits of early intervention ● It's an epidemic
    6. 6. 8.5% World 10.9% US >50% Tohono O'odham Int Diabetes Federation 2013; Tohono O'odham Community Action Prevalence
    7. 7. Demographics African AmericanAfrican American Native AmericanNative American Hisp/LatinoHisp/Latino 0%0% 5%5% 10%10% 15%15% 20%20% 25%25% 30%30% ArizonaArizona USUS
    8. 8. 10% of spending 10% of patients
    9. 9. QUALITY CAREQUALITY CARE “All health professionals should be educated to deliver client-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.” Institute of Medicine, Health Professions Education: A Bridge to Quality (2003).
    10. 10. Sounds like Midwestern... “All health professions schools have an obligation to educate future practitioners who are prepared both to assess and to meet the health needs of the public. This obligation entails…fostering greater inter- professional teamwork and collaboration.” Macy Foundation, “Revisiting the Medical School Education Mission at a time of Expansion, 2009
    11. 11. DiabetesDiabetes A great chance to collaborate and foster interdependence.
    12. 12. Oh...Oh... And improve patient care.
    13. 13. Working togetherWorking together Collaborative – includes concepts of shared responsibilities, shared decision-making, shared values, shared planning and intervention, and sharing of professional perspectives Interdependent - mutual dependence rather than autonomous – arises out of common desire to address patient’s needs • D'Amour, D., M. Ferrada-Videla, et al. (2005). "The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks." Journal of Interprofessional Care Supplement 1: 116-131.
    14. 14. Why don't they care?
    15. 15. Why don't they care? ● PCPs are trying to prevent: ● MI, CVA, amputation, vision loss, etc ● They are trying to follow current evidence-based guidelines for – BP – Foot screening – Eye screening – Cholesterol – Education – And, it goes on and on
    16. 16. Why don't they care? They're concerned with far more than the eye...
    17. 17. 2013 US Costs2013 US Costs US Primary Eyecare US Diabetes 0 50 100 150 200 250 Billions Sources: Ken Research, American Diabetes Association
    18. 18. 2013 US Costs2013 US Costs US Primary Eyecare US Healthcare 0 500 1000 1500 2000 2500 3000 Billions Sources: Ken Research, American Diabetes Association
    19. 19. 2013 US Costs2013 US Costs US Primary Eyecare US Healthcare 0 500 1000 1500 2000 2500 3000 Billions Sources: Ken Research, American Diabetes Association 1%1%
    20. 20. We think of... They think of...
    21. 21. HEDIS ● Healthcare Effectiveness Data and Information Set ● NCQA ● Measure performance of health plans to allow comparisons
    22. 22. HEDIS 2014 Out of 85 HEDIS measures Only 2 eye measures DM exams that's part of the Comprehensive DM Care measure The other is glaucoma screening in older adults
    23. 23. What they really want from us? IS IT TIME FORIS IT TIME FOR LASER?LASER?
    24. 24. This isn't particularly collaborative. We're small potatoes.
    25. 25. The Usual PCP Report Do they have any DM findings? What else have you done? Do they need any tx? When do they need to come back?
    26. 26. Who's the PCP? MD DO NP PA Front desk staff?
    27. 27. Benefits of Medicine Collaboration ● Interprofessional relations ● Valuable contribution of optometry students ● (we can't bill Medicare for their services anyway, why not put them in medicine clinic?) ● Oh, and the patients will benefit too ● Save a visit ● Get better care
    28. 28. Midwestern could be there... ● Collaboration ● Optometry-Osteopathy ● A New Two O's
    29. 29. Diabetes care is comanagement We are held to a medical standard Same as ophthalmology We need to do more.
    30. 30. Diabetes ● The standard of care is medical and involves: ● state of the art examination ● coordinated comanagement with physicians ● continuous patient education ● timely referral when complications occur.
    31. 31. ● The timeliness of a referral is important, especially for patients with good vision and significant retinopathy. Failure to make a timely referral can result in litigation
    32. 32. The Diabetes Eye Visit ● a thorough history must be taken ● the examination should include: ● measurement of visual acuity ● refraction (as indicated) ● tonometry and slit lamp evaluation ● Dilated ophthalmoscopy and fundus biomicroscopy
    33. 33. ● Ophthalmologists are sued by patients with diabetes more frequently than any other type of physician. ● Because loss of vision from diabetes is often preventable if timely diagnosis and treatment are provided, failure to refer appropriately can result in significant awards for damages.
    34. 34. Maybe if we help the PCP?Maybe if we help the PCP? Maybe then they'll love us...Maybe then they'll love us...
    35. 35. What more could we do? ● Make the dilated eye exam more like their own office visit ● BP, ask about compliance, any difficulties ● Review medications ● Go over self measurement logs...MDs don't have time – And, reimbursement doesn't help ● Educate ● Order screening blood tests for at risk patients
    36. 36. Get a blood test... If at risk for diabetes or pre diabetes
    37. 37. Or... ● Have diabetes eye evaluations as part of a team effort with ● Medicine ● Podiatry ● Education/Adherence ● Blood draw
    38. 38. What more could we do? Educate
    39. 39. ● Optometrists should educate patients with diabetes concerning the risk of ocular complication and the need for periodic examination. ● Patients with retinopathy should be placed on a reasonable recall schedule or, if appropriate, referred to a physician. ● Recall schedules are based on the level of retinopathy observed.
    40. 40. ADHERENCE! 75% of patients don't take their medications as prescribed! And, we're the ones who get sued?!
    41. 41. Source: M. Sokol et al., "Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost," Journal of Medical Care, 2005. Return on Investment from Improved Medication Adherence: Diabetes $1 more spent on diabetes medicines = $7.10 less spent on other services AverageAnnualSpending RelatedtoDiabetes Adherence (%)
    42. 42. NONADHERENCE! –Increases deaths, hospitalizations, and emergency room visits –Increases overall health care costs –Diabetes specific medications are not the only important thing Patients, health care providers, and health care systems all play a role in creating the quality and outcome gap between current reality and optimal diabetes management. Clinical Diabetes 2008;26:1 17-19.
    43. 43. Diabetes is a common and very costly chronic disease. There is broad-based agreement on how to manage diabetes, yet less than 40% of adults with diabetes achieve guideline-recommended levels of medical care. Commonwealth Fund.
    44. 44. Change the exam a little ● Improve intraprofessional relations ● Improve referrals to optometry ● Improve patient care
    45. 45. The New Diabetes Eye Visit ● Vision, dilated exam, of course ● Add blood pressure ● More complete history ● Medication ● Adherence/compliance ● Any issues ● Education ● Your choice on how extensive
    46. 46. The New Diabetes Eye Visit ● And, send a report ● Send it right away...yes, right after or during visit ● Consider other team members that might need it – PCP, of course – Podiatry – Endocrine – Dental – Wound care – Even, the patient! ● MAKE SURE PATIENT IS IN THE LOOP
    47. 47. I can't do it! ● We have to...we're held to a medical standard ● It doesn't take much time (and, you can train your staff) ● Standards for BP, glucose, a1c easy to learn ● Patients accept this readily (they expect it!) ● OK, so maybe education is hard, but we can get better
    48. 48. The Business CaseThe Business Case
    49. 49. While there are questionable economic benefits for a health plan, there are real economic beneifts for private practitioners and other providers. Increased referrals Better interactions with PCPs Increased recall effectiveness More network opportunities
    50. 50. Faculty Development Commitment to the value of IPE and IP collaborative practice Knowledge of scope of practice of the professions Effective teamwork skills Teaching and managing large classes Interactive learning Small–group facilitating
    51. 51. What's best for the patient?What's best for the patient? Working as part of the team.Working as part of the team.