M. Dianne Brown, MS, RDN, LD, CDE OU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center Cynthia Scheideman-Miller, MHSA Heartland Telehealth Resource Center Oklahoma Telemedicine Conference 2014: Telehealth Transition October 16, 2014

1. Accessing Diabetes
Education Through
Telehealth
M. Dianne Brown, MS, RDN, LD, CDE
OU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center
Cynthia Scheideman-Miller, MHSA
Heartland Telehealth Resource Center
Oklahoma Telemedicine Conference 2014
October 16, 2014

2. Objectives:
1. Discus the benefits of a diabetes telehealth program for
patients and how it can be partnered with provider
education to improve diabetes management
2. List processes involved when selecting a diabetes
telehealth program for your patients
3. Outline key components of a diabetes telehealth
program including patient and provider site
requirements.

3. Why Diabetes
Tele-education?

4. 2011 2013
Prevalence* of Self-Reported Obesity Among U.S. Adults, by State, BRFSS
State PrevalenceConfidence Interval
Oklahoma 32.5 (31.2, 33.9)

5. 26
million
Americans
have
diabetes
7th
leading
cause of
death in
the U.S.
79 million
Americans have
pre-diabetes
Diabetes by the
Numbers

6. The research shows:
People with Diabetes
• Don’t follow through
on referral
• Are emotional /
shocked at diagnosis
• End up relying on
family / friends
• Believe they know
enough / can handle it
on their own
Providers
• Know importance of
DE, but don’t
necessarily prescribe
– or don’t prescribe
definitively enough
• Sometimes forget to
follow up with patients
to encourage
attendance

7. Diabetes Education Patient Benefits
Studies have shown people who receive diabetes education
Use primary
care /
prevention
services
Take
medications as
prescribed
Control glucose,
blood pressure,
LDL cholesterol
Have lower
health costs

8. Diabetes Education Process
Year 1
Patient
Diagnosed
with Diabetes
PCP refers
patient for DE
Patient
assessed by
CDE
*DSMT Class
(10 hours)
**MNT
3 hours (by RD)
Year 2
2 hour Refresher
Classes
*DSMT - 2 hours &
**MNT -2 hours (by RD)
*Diabetes Self-Management Training
(DSMT)
**Medical Nutrition Therapy (MNT)

9. Prevalence of Diabetes
(2011 Overall)
N/A
2.25% or Less
2.26% - 3.35%
3.36% - 5.04%
5.05% - 6.74%
6.75% - 8.44%
8.45% - 10.14%
10.15% - 11.84%
11.85% - 14.00%
14.01% or Greater
Where most Certified Diabetes Educators (CDEs)
Live in Oklahoma

10. Recognized or Accredited Diabetes
Education Programs in Oklahoma
34- Recognized by the
American Diabetes
Association (ADA)
17- Accredited by American
Association of Diabetes
Educators (AADE)

11. Telehealth benefit # 1
Provides access- multiple sites may
be used
 patients
 other health care providers
Telehealth benefit #2
Saves money
 patient & CDE saves “gas” money
 remote site “borrows” CDE
 informed patients reduce hospital admission

12. Telehealth benefit #3
Saves time
 patients & CDE do not lose
time with travel and information
is delivered in “real time”
 CDE can see more patients, reducing service
wait time for patients
Telehealth benefit #4
 Helps to address cultural diversity which
contributes to challenges of education, patient
compliance, and cooperation with treatment
regimens
 Increased ability for participation with diabetes
care team

13. Telehealth Concern #1
Budget Considerations
 technology set up on remote
 and originating sites
Telehealth Concern #2
Time needed for set up
 Training Staff
 Patient teaching tools and resources at remote
Telehealth Concern # 3
 Services are only reimbursable by Medicare if the
services were provided to a Medicare or Medicaid
beneficiary at an acceptable originating site.

14. Selecting a Diabetes
Tele-education Program

15. Define what you want vs need
 ADA program for Medicare reimbursement
 Champions
 Technology – fits in your needs and budget
 A program that is right for your organization
and population served
 Sales pitches can be misleading

16. Selecting a program
 Is this a program you want as a partner in
patient care or contract with for total delivery?
 Do they follow the same State laws, Hospital
by-laws as on-site programs are required to
supply?
 What are their references?
 Are the providers (distant site) in Oklahoma?

17. Double Check the Contract
 What if expectations aren’t met?
 Who is responsible for what?
 What staff will be needed at the originating site
before, during, after the classes?
 Who gets the data?
 Who tracks patient satisfaction?
 Is there training for staff at the patient site?
 No-Show policy
 Telehealth Consent Form – who is responsible to
get this signed prior to services?

18. Developing a Diabetes
Tele-Education Program

19. Early Development
Champion Support
 Administration
 Providers
 Originating Site
 Distant site
Delivery Model
 Multiple sites or single site
 Contract vs direct billing
 Individual sessions conducted remotely or on-site

20. Early Development, con.
Program Components
Understand current process flow
and staffing:
 Multiple sites or single
 Optimal number and arrangement
 Mandatory documentation – define the who, where,
how
Resources
 Consider health literacy & culture
 What resources go with the patient or stay

21. Budget
 Budget
 Start up costs
 Equipment
 Broadband
 Marketing
 Staff time
 Contract development
 Liaisons
 Staff prep for sessions
 Consultants

22. Technology
Software
 Reliable
 Image quality
 ASC X12 encryption standard
 Compatible with other software
 Linkage of older to newer technology
 Split screen capable
 Transmission requirements

23. Technology
Distant (Provider) End
 Computer
 High-definition camera
 Monitors – single will work, dual is better
 Speaker/microphone
 Projector
 Software – some have split screen capabilities
 Desktop – Self-contained
 High quality image
 Split screen capabilities
 Frees up computer for EHR

24. Technology
Originating (Patient) Site
 Patient Cart
 High-quality image
 Can be wheeled to patient bedside
 Multi-purpose
 Issue: mobility vs larger monitor
 Wall-mounted Monitors
 High quality image
 Split screen capabilities
 The closer to “real” size, the better

25. Reimbursement:
Medicare
• ADA approved program
• Service must be real time
using interactive
audio/video
• Eligible originating (patient)
site – rural HPSA – online
tool to determine eligibility
• Codes:
• 99201 GT modifier
• HCPCS codes G0108 &
G0109
Medicaid
• ADA approved program
• Service must be real time
using interactive
audio/video
• Eligible originating (patient)
site
• Codes: 99201, 97802-
97803 GT modifier
• Must be delivered using
appropriate equipment and
meet HIPAA, privacy &
security requirements

26. Reimbursement (con.):
Medicare
• Eligible originating site
• Office of physician/practitioner
• Hospital
• CAH
• RHC
• FQHC
• Eligible provider
• Registered Dietitian
• Advanced Registered Nurse
Practitioners
• Nutrition professional
• Clinical Social Worker
Medicaid
• Eligible originating site
• Office of physician/practitioner
• Hospital
• CAH
• RHC
• FQHC
• School
• I/T/U
• Eligible Provider
• Registered Dietitian
• Advance Registered Nurse
Practitioners

27. Handouts such as: My Carbohydrate
Guide
Food Models

28. Organize the
classroom
-Pens, highlighters,
sharpies
-Ketone chart and
strips
-Glucose wands
-Food models
-Sample of fast
acting glucose
-Etc.

29. Diabetes Education
Tele-health Patient
Take Home Resources
• Have topics organized by title and number
the file (or computer files)
• Have reference list to find resource topics
quickly.

30. Final Development
Staff training
 User training
 Cheat Sheet
 Troubleshooting Guide
 Help Desk
 Contingency Plan
 Helpdesk visit
 3rd level vendor support
Patient recruitment
 Marketing material
 tele-health brochure
 internal web page
 Clinician invitation
 Patient Mailing
 Telehealth Patient Consent Form

31. Diabetes Tele-education Pilot
 Instructors
 Dietitian at one rural location, nurse specialist
at the other
 Diabetes tele-education delivered at a lower cost
 LOS shorter for those who attended class –
reduced hospital costs
 Pre- and Post-tests comparable to on-site classes
 High patient and provider satisfaction
 Rapport between class attendees unforeseen plus

32. Telemedicine Patient Satisfaction Survey
Question Score_________
How comfortable did you feel? 4.2 ± 1.2 (19)
(0, very comfortable; 5 very comfortable)
How convenient was the encounter? 4.4± 1.0 (19)
(0, not at all convenient ; 5 very convenient)
Was the lack of physical contact acceptable? 4.3 ± 1.3 (19)
(0, not acceptable; 5 very acceptable)
Concerns about privacy? 1.1± 1.7 (19)
(0, no concerns; 5 very concerned)
Overall satisfaction? 4.3± 1.3 (19)
(0, not at all satisfied; 5 very satisfied)
Would you do it again? (yes/no) 16/3
Diabetes Care, Vol. 26, No 4, April 2003

33. Quality Checks: Metrics
Utilization Satisfaction Sustainability Outcomes
By location patient financial health
By service provider support care plan
By provider staff champions no-show
Rynn Geier, MBA, RD, LD, CDE presented at AADE annual meeting Aug 6-9 2014

34. Summary:
 Establish goals for a telemedicine program
 Gain champion support
 Develop a budget
 Choose a vendor
 Take time for clinical training and well-planned
program deployment
 Develop strategies for program “buy –in”
 Build into your program
 Measure your outcomes: metrics

35. Don’t Forget Diabetes Education
for Providers
Providers have the same information as their
patients
 Increases provider’s confidence that they have
the latest diabetes information
 Reinforcement – patient’s hear the same message
 Providers have a contact/mentor
“Prior to the study it was almost impossible for this type of
patient to get the consultation and specialized care that is not
accessible in a small rural community.” Rural Home Health
Administrator

36. Who knows what future
telehealth will look like?