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.

1. Collaborative Diabetes CareCollaborative Diabetes Care
Mark G. Mitchell, OD, MBAMark G. Mitchell, OD, MBA
Reno, NevadaReno, Nevada

2. What my patients think of...What my patients think of...
==

3. What I think of...What I think of...

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. It's really important to system
● Costs
● Benefits of early intervention
● It's an epidemic

6. 8.5%
World
10.9%
US
>50%
Tohono O'odham
Int Diabetes Federation 2013; Tohono O'odham Community Action
Prevalence

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. 10% of spending
10% of patients

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. 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. DiabetesDiabetes
A great chance to collaborate and
foster interdependence.

12. Oh...Oh...
And improve patient care.

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.

15. Why don't they care?

16. 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

17. Why don't they care?
They're concerned with far more than the eye...

18. 2013 US Costs2013 US Costs
US Primary Eyecare US Diabetes
0
50
100
150
200
250
Billions
Sources: Ken Research, American Diabetes Association

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

20. 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%

21. We think of... They think of...

22. HEDIS
● Healthcare Effectiveness Data and Information Set
● NCQA
● Measure performance of health plans to allow
comparisons

23. 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

24. What they really want from us?
IS IT TIME FORIS IT TIME FOR
LASER?LASER?

25. This isn't particularly
collaborative.
We're small potatoes.

26. 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?

27. Who's the PCP?
MD
DO
NP
PA
Front desk staff?

29. 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

30. Midwestern could be there...
● Collaboration
● Optometry-Osteopathy
● A New Two O's

31. Diabetes care is comanagement
We are held to a medical standard
Same as ophthalmology
We need to do more.

32. 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.

33. ● 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

34. 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

35. ● 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.

36. Maybe if we help the PCP?Maybe if we help the PCP?
Maybe then they'll love us...Maybe then they'll love us...

37. 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

38. Get a blood test...
If at risk for diabetes or pre diabetes

40. Or...
● Have diabetes eye evaluations as part of a
team effort with
● Medicine
● Podiatry
● Education/Adherence
● Blood draw

41. What more could we do?
Educate

42. ● 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.

43. ADHERENCE!
75% of patients don't take their medications as
prescribed!
And, we're the ones who get sued?!

44. 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 (%)

45. 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.

46. 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.

49. Change the exam a little
● Improve intraprofessional relations
● Improve referrals to optometry
● Improve patient care

50. 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

51. 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

52. 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

53. The Business CaseThe Business Case

54. 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

55. 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

56. What's best for the patient?What's best for the patient?
Working as part of the team.Working as part of the team.