This document discusses diabetes healthcare delivery and management. It outlines programs at a university medical group focused on inpatient and outpatient diabetes care, including diabetes educators, order sets, and teams. It also discusses accountable care organizations and their role in managing patient care along the care continuum. Specifically, it details efforts at one organization to improve diabetes management and outcomes for Medicaid patients through initiatives like adding providers, developing quality measures, and restructuring education programs. Results included reduced emergency room visits and hospital days, as well as improved quality metric compliance and A1C levels.

1. Diabetes Healthcare DeliveryA National Tragedy Angelo Sinopoli, MD Chief Medical Officer Chair, Medicine University Medical Group

2. Total Health

3. Percent of Diabetic Medicare Enrollees Receiving Appropriate Management

4. Diabetes Care in South Carolina

5. Inpatient Diabetes Management Two Inpatient Diabetes Educators Insulin order sets IV insulin SQ insulin Pregnancy Insulin pump protocols and standardized order sets Multidisciplinary Diabetes team Hypoglycemia initiative

6. Glucotec

8. The Care Continuum andthe Accountable Care Organization 8 Graphic: Sg2 Accountable Care Organization Value Proposition: The programs, people, protocols, and payment that define care delivery and patient movement along the care continuum

9. Focus on the Medicaid Population in the Medicine Clinic A focus on the big six: Diabetes, CHF, Asthma, COPD, HTN, CAD Initial focus on Diabetes as a pilot Focus on quality measures and utilization Duke Innovation Grant

10. Developed a process for stratifying patients by ER and Hospital utilization Developed an intake process for initiating patients into the “enhanced care” program for buy-in. Working with e-CW to develop CDSS and standard outcomes reporting Duke Innovation Grant

11. Added a Nurse practitioner to the clinic for monitoring and increased access for this patient population Added a Care Manager for coordination of care and Care Coordination Developed an Emergency Room Care Management role Worked to change the culture of the clinic Duke Innovation Grant

12. Restructured the Outpatient Diabetes Self Management Program and connected it to the clinic population Changed the hours of education to make it more patient friendly Streamlined the referral process Implemented central scheduling Refined the billing processes Reorienting around primary care practitioners Duke Innovation Grant

13. Developed Clinical Advisory Teams (CAT) to develop and agree upon standard quality measures by which we would be measured PQRI measures were used as baseline measures but allowed for a higher standard of performance Also supports “meaningful use” across the system These were developed for Diabetes, CHF, HTN, COPD, and Asthma Duke Innovation Grant

14. Physician Quality Reporting System (PQRS – was formerly PQRI)GHS Diabetes Quality Measuresapproved by Clinical Advisory Team in 09

15. Diabetes Quality Measures HgbA1C Measurement and Control LDL Measurement and Control BP Measurement and Control BMI Measurement and Plan Annual Urine (protein) exam Annual Foot Exam Annual Dilated eye exam/Retinopathy Severity

16. Diabetes Quality Measures Antithrombotic Therapy Use of ACE/ARB Therapy Tobacco Use While influenza and pneumococcal immunizations are expected to be addressed for this patient population, GHS will handle them as individual quality measures for all patients according to protocols

17. No such thing as a simple diabetic All have one or more significant co-morbidities such as CHF, CAD, COPD or HTN Duke Innovation GrantChallenges

18. No telephone Poor living conditions Ongoing Medicaid eligibility changes Transportation No car Have to get a ride to the clinic or even to the bus stop Long bus ride with multiple stops Easier to call an ambulance or wait until someone is off from work to take them to the ER Duke Innovation GrantChallenges

19. Defined utilization as being for ALL diagnoses, related and non-related to study conditions Did not exclude outliers Duke Innovation GrantResults

20. Emergency Room visits down 26% Hospital days down 55% Initial PQRI compliance increased by 70% A significant improvement of HgA1c was noted Duke Innovation GrantResults

21. Duke Innovation GrantPhase Two Add additional eligible Medicaid patients Add unfunded population Connect to AccessHealth SC Grant

22. Use the infrastructure and knowledge developed around the Duke Grant to expand to other populations Develop a Diabetes Toolkit Further engage Primary Care around Diabetes Develop IT systems around identifying and tracking patients with particular diseases Obtain front-end disease registry Diabetes Care

23. Questions?