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Diabetes Care Challenges Offer Hospitals Strategic Opportunities

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   February 19, 2014

Diabetes is a potentially significant area for other hospital service lines, such as cardiovascular or oncology programs. So hospitals are teaming up with insurers, tapping into technology, and intensifying follow-up care for diabetic patients.

This article appears in the January/February 2014 issue of HealthLeaders magazine.

In 1999, Saint Mary's Hospital in Grand Rapids, Mich., opened a diabetes center. Little did hospital officials know then, but they were ahead of their time and today are confronting a disease that affects about 8.3% of the U.S. population.

Other healthcare leaders are responding, too, devoting resources to help overcome a disease that some view as rampant or out of control. To try to stem the increasing incidence, education programs are booming. Electronic medical records are in demand. Physician groups and hospitals are using apps to engage in patients in the moment. Physicians and pharmacists are teaming up to ensure patients know about their medications.

In 2011, Saint Mary's Health Care was renamed Mercy Health Saint Mary's, as part of Saint Mary's in Grand Rapids and Mercy Health Partners in Muskegon. The regional system includes five hospital campuses with 800 total beds. It is part of Trinity Health, the national Catholic hospital system based in Livonia, Mich.

Mercy Health Saint Mary's original diabetes center merged with Thyroid Specialists of West Michigan to become what it is today, Mercy Health Physician Partners Diabetes & Endocrine Center in Grand Rapids. The organization's diabetic care framework is much more sophisticated today, as a multidisciplinary team evaluates patients and coordinates care for a growing patient population.

"Diabetes is a dynamic disease that is always changing, and we look to be on the cutting edge," says Mary Harnish, RN, clinical nurse leader who oversees the inpatient diabetes program at Mercy Health Saint Mary's, which in 2011 received inpatient diabetes certification from The Joint Commission.

"We expect to see increases across the nation, not only because of an increase of obesity but also because we are doing a better job of catching diabetes. Primary care physicians are doing a good job of screening," Harnish says. "People are coming to the hospital who may not have a primary care doctor, and those who are seeking care are so sick they are coming to the emergency room. That's always a challenge and shows how important it is to have early detection by primary care doctors."

Diabetes requires continuing medical care, plus ongoing patient self-management and education to prevent acute and long-term complications. Some patients "have a passion about taking care of themselves, while other are less attentive to the self-care of their disease," says Harnish.

For hospitals, focusing on diabetes is a potentially significant area for other service lines, such as cardiovascular or oncology programs. Hospitals are launching specific diabetes-focused efforts and teaming up with other facilities and insurers, initiating education programs, tapping into technology, and intensifying follow-up care.

The diabetes patients are at higher risk than other patients for complications, falls, and longer lengths of stay, which can have economic implications. Starting in fiscal year 2015, hospitals that have high healthcare-acquired complication rates will see their Medicare payments cut 1%. Hospitals targeted for such cuts would be in the top quarter for the rate of hospital-acquired conditions, such as infections or falls, as compared to the national average, according to the Association of American Medical Colleges.

Deebeanne M. Tavani, DO, chief of the division of endocrinology at Main Line Health System, which serves Philadelphia and several suburbs, keeps tabs of the numbers. "Another 12 million people actually walk the streets of America meeting the criteria of diabetes and don't even know it," says Tavani. About one in 10 have diabetes now, she says. Main Line Health includes 331-bed Lankenau Medical Center, 319-bed Bryn Mawr Hospital, 231-bed Paoli Hospital, and 204-bed Riddle Hospital.

When diabetes strikes during childhood, it is often assumed to be type 1 or juvenile-onset diabetes, but children are now being diagnosed with type 2 diabetes, formerly known as adult-onset.

Main Line Health has a diabetes process improvement team centered at Lankenau. The group includes endocrinologists, nutritionists, certified diabetes educators, nurse managers, and pharmacists. This team reviews order sets and disseminates guidelines to other campuses. It is important to evaluate prediabetes conditions, especially because of growing obesity rates in the country, and the team works on that, says Tavani.

Prediabetes is a condition in which blood sugar levels are higher than normal but not high enough to be considered type 2 diabetes.

Janet Wendle, RN, BSN, CDE, director of Main Line's education program, says she and other educators focus on encouraging patients to make lifestyle changes and keep up with their medications. The Centers for Disease Control and Prevention monitors records of obesity rates, and the states with the highest obesity rates also have the highest rates of diabetes, says Wendle.

Another factor in the increase of diabetic patients is because, in part, "this is a social issue, too. Patients are losing jobs and have no healthcare," says Tavani. "We are seeing an indigent population, and they repeatedly come to the hospital every couple of months. They run out of their diabetes medicine. We don't know if this is going to change," she says.

Main Line Health has a diabetes management program that includes individual consultations with a diabetes nurse specialist or diabetes dietician specialist, a 10-hour course in diabetes management, plus support groups and other resources.

At educational meetings with people with diabetes, Wendle says, "We talk about prediabetes, and when I ask them, 'How many of you have prediabetes?' usually more than half the hands go up." She warns them that they need to make changes, but understands that, for many, to make "behavioral changes, it's really tough."

Physician referrals for education are especially important. In a recent review of the system's program, of 100 people who were asked how they found out about the Main Line program, Wendle says 95 found out about it from primary care physicians.

Often, diabetes patients have comorbidities. Diabetes as a principal or secondary diagnosis can increase patient lengths of stay, which can decrease hospital revenue.

Success key No. 1: Multidisciplinary teams

As Mercy Saint Mary's Hospital developed its diabetes program, one of the first things officials did was to target efforts at admissions for those who knew they had diabetes and those who didn't.

The effort is a focus of Mercy Saint Mary's multidisciplinary diabetes operations team, the overriding team that focuses on inpatient and outpatient care. There are other teams that focus on diabetes as part of the hospital system, too, says Harnish.

Physicians, nurses, dieticians, and social workers comprise the operations team, which works with primary care physicians. "We invited the primary care physicians to come on the team so we're all talking the same language to the patient," says Harnish, the clinical nurse leader who oversees the inpatient diabetes program.

Mercy Saint Mary's also assembled a glycemic control team that works with other physicians in various service lines, such as cardiology and oncology, to coordinate care with respect to national protocols. The team includes specialists such as neurologists and vascular, cardiothoracic, gastrointestinal, and bariatric surgeons. The diabetes operations team handles blood sugar management protocols and education for patients.

"We work on diabetes or prediabetes throughout our healthcare system in a coordinated manner and ask 'How can we fill in any gaps we may have found?' " Harnish says. "A primary care physician may not know what to do further, having done all he or she can to help patients deal with their diabetes. They need to see a specialist."

To address such cases, the hospital works with healthcare coaches in primary care offices "to keep people on task to make sure they are following through with diet and exercise goals and to help keep them motivated," Harnish says. They particularly monitor those with prediabetes and in follow-up care make clear to patients: "You are heading toward diabetes. You're in the prediabetes stage."

Mercy Saint Mary's team focus also has steered the hospital toward continual innovations in diabetes care, she says. Several years ago the hospital improved physician protocols for diabetes control by implementing a basal-bolus regimen for glycemic control.

The hospital found the treatment better than what it had been using, a sliding-scale regular insulin practice. Some studies have shown the basal-bolus regimen has resulted in less treatment failure. The hospital uses electronic medical records to monitor blood glucose readings directly from meters for bedside testing, Harnish says, "which was a huge improvement" in patient care.

Success key No. 2: Partnerships with pharmacists

In Ohio and elsewhere around the country, physicians and pharmacists are simultaneously seeing diabetic inpatients to improve care. Both can answer the patients' questions, and the dual effort "allows a more comprehensive understanding of diabetes by the patient and more patient-specific therapy changes," says Stuart J. Beatty, PharmD, BCPS, CDE, assistant professor of clinical pharmacy at the Ohio State University College of Pharmacy.

The coordination continues after the patient visit: A note is shared electronically with the primary care physician, which improves efficiency during the next office visit, says Michael S. Langan, MD, FACP, director of the primary care track, at OSU CarePoint East, an outpatient clinic in Columbus that is part of the 976-licensed-bed Ohio State University Wexner Medical Center. The note can lead to improved clinical care because the primary care physician can follow up on any acute issues regarding diabetes, he says.

"Additionally, the pharmacists often call the patients in between office visits to check in on diabetes treatment adjustments and/or goals. The calls are documented within the EMR and shared with the primary care team," Beatty says. "Changes made at diabetes clinics are communicated with the community pharmacy through either a telephone call or through electronic prescribing, as appropriate."

OSU CarePoint East uses a patient-centered medical home model and includes attending physicians, resident physicians, pharmacy faculty, pharmacy residents, nurse practitioners, registered nurses, medical assistants, and social workers in the same office. CarePoint is a community outreach location of Ohio State University Wexner Medical Center. Each CarePoint location provides routine and specialty care, such as diabetes, cardiology, orthopedics, radiology, and primary care. The same EMR that is used at the medical center is used at this and other outpatient facilities so that information from both inpatient and outpatient procedures is included in the documentation, says Beatty.

"If we have a patient who has been hospitalized at OSU, we can look through the hospital-stay labs, procedures, medication changes, and documentation very easily because we are in the same EMR," says Langan.

The OSU College of Pharmacy has been involved in a program known as Project IMPACT: Diabetes, which includes clinicians and about 2,000 patients in 25 communities across the country focusing on improving the health of patients who are diabetic. According to six months of data collected from the program in 2012, there was a 0.7-point reduction in A1C levels, from 9.0% to 8.3%, and a reduction in LDL cholesterol from 99.5 mg/dL to 92.2 mg/dL.

Pharmacists collaborate and refer patients to other healthcare providers to ensure that patients receive comprehensive care, says Benjamin Bluml, senior vice president for research and innovation at the American Pharmacists Association Foundation, who designed and is leading Project IMPACT: Diabetes.

"A lot of people are challenged in their lives and may not be coming to appointments," Bluml says. "We've heard amazing stories: Patients have really gotten their diabetes under control and are trying to do the right thing with food choices; they are also making sure they are taking their medications. It's an inspiring thing that you are helping people in some portion of their lives through a team-based process."

The care features one-on-one patient consultations, group educational classes, grocery food tours in conjunction with certain markets, and exercise programs. Some of the patients also receive discounted or free healthy lunches at employer worksites and discounted copayments for medication and supplies.

Despite the promising results, a significant problem is the lack of reimbursements.

"We feel very strongly that our model works and have data to show that patients are healthier once enrolled in our program," Beatty says. "Unfortunately, there is not a reimbursement structure available to pay pharmacists to provide these services alone or any additional reimbursement from a standard office visit with a physician by having a team of healthcare professionals involved.

"This makes it very difficult to hire healthcare providers, such as pharmacists, even though it has been shown that patients are healthier when providers are working together as a team to care for the patient. This has been a limitation to expansion of our model to more patients with diabetes or other disease states," he adds.

Success key No. 3: Overcoming nonadherence

Providers are working to overcome a significant obstacle to improving the condition of diabetic patients: nonadherence to medication prescriptions.

"Nonadherence is probably the most common barrier we observe that leads to poorly controlled diabetes," Beatty says.

The Ohio State University Medical Center was involved in a study presented during the American Diabetes Association scientific sessions in 2013 that showed disease education programs can have a positive impact on hospitalizations. Sara J. Healy, MD, a soon-to-be endocrinology fellow at the medical center, presented data on patients hospitalized from 2008, with a discharge diagnosis of diabetes and glycated hemoglobin (HbA1c) levels greater than 9%. There was a 30-day analysis of 2,265 patients and a 180-day analysis of 2,069 patients. According to the study, readmission rates were 5 percentage points lower for those who received the education (11%), than those who didn't (16%).

Wendle, head of Main Line Health's education program, says medication adherence is an important concern. Years ago, she says, physicians would tell patients they had a slight case of diabetes or were borderline: "That means nothing. The statement now is prediabetes. I had a woman who came into the program, and she had taken it four years ago and had fallen off the wagon and came back. Some prediabetics have warning signs, while there others who don't have any symptoms and become complacent."

The availability and convenience of some smartphone apps allows patients to "have information at their fingertips when they are going to a restaurant and have a GPS for walking. These can be extraordinary motivators to see cause and effect," she says.

One patient came in for education counseling because she heard Tom Hanks announced he had type 2 diabetes, Wendle says, noting "whatever it takes."

As Beatty sees it, there are ways hospitals and physicians can overcome barriers that keep patients from controlling their diabetes, such as areas involving cost, motivation, diet, nutrition, and follow-up care.

Cost: If patients believe they have problems meeting expenses associated with improving care, they can work closely with the OSUWMC Department of Pharmacy medication assistance program technicians and pharmacists, who will help patients with the paperwork for the program at no cost. "This has a significant impact on patient access to treatment, in particular insulin and supplies," which can cost as much as $300 per month for patients, Beatty says.

Motivation: It's not easy to get patients to make lifestyle changes, such as increasing physical activity—what Beatty calls a "limiting step." To help, OSU provides patients with pedometers and instructs them on how to track their daily steps. "This gives us and the patient an objective number of how active the patient is and allows us to make measurable goals to improve activity," she says. "This also helps patients to see that when we discuss physical activity, any activity is good; it doesn't have to be lifting weights or jogging 3 miles a day."

Diet and nutrition: OSU educates patients about basic nutrients, especially carbohydrates. Diet and nutrition are among the "hardest components to overcome" for patients trying to control their diabetes. Among other things, the team teaches portion control and how to make healthier choices in meals, and provides cookbooks designed for diabetes patients.

Follow-up care: Proper follow-up is among the measures physicians and hospitals can take that have the "biggest impact on adherence," Beatty says. "In the office, many patients commit to making a change, but once they are home, it is easy to say, 'I'll start my exercise tomorrow.' " At OSU, the physician office contacts patients between visits and "holds them accountable to making a lifestyle change," Beatty says. "A call coming from a physician's office carries a lot of weight to patients in showing that we care and we want to help them get better. There are some patients we call every week to keep them on the path toward better health."

Success key No. 4: Text reminders

For many people, getting text messages consistently from someone may be annoying. But Sanjay Arora, MD, of the Keck School of Medicine at the University of Southern California in Los Angeles, found something else among diabetic patients treated in emergency departments. Not only did the patients like receiving the daily text messages he and his team sent as reminders to improve their control of diabetes and medication adherence but the patients also did a better job of improving their health.

Arora is an emergency department physician at the 600-bed Los Angeles County Hospital of the University of Southern California Medical Center. Patients overwhelmingly liked the messages, in part because they felt the physicians cared about them, Arora says.

The messages were simple and to the point: "Having diabetes can lead to a heart attack or stroke—but it doesn't have to" and "Eat more fruits, vegetables, beans, and whole grains, and less salt and fat."

The patients who received text messages for six months improved enough to reduce their dependence on the emergency department in their care for diabetes, Arora says. He and colleagues wrote about their findings in the Annals of Emergency Medicine. The study was dubbed "TExT-MED."

Text messaging is effective, low-cost, and widely available for patients who often see themselves as having no other source of medical care than the ED, he says.

The study focused on adult patients with poorly controlled diabetes who visited an urban, public emergency department. They received two daily text messages for 6 months. For patients who received text messages, blood glucose levels decreased by 1.05%, compared with a decrease of 0.60% in the control group. Self-reported medication adherence improved from 4.5 to 5.4 on an 8-point scale, compared with a net decrease of 0.1 points in the control group.

"The study population has very little access to regular primary care and very limited time, and they weren't getting the education they needed or the personalized level of care," he says.

The proportion of patients who visited the emergency department over the 6-month period was lower among the text-messaging group, 35.9%, than in the control group, 51.6%.

Arora says if someone sent him a text message two or three times a day, "I would think, 'Enough.' " But the patients felt different. To them, it "wasn't annoying; it felt like the first time a doctor really cared for them. That was the most surprising for me."

Reprint HLR0214-9

This article appears in the January/February 2014 issue of HealthLeaders magazine.


Joe Cantlupe is a senior editor with HealthLeaders Media Online.

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