Lenora Lorenzo, DNP, FNP, CDE, FAANP Lisa Tokuda Pharm D, CDE

Faculty

Lenora Lorenzo, DNP, FNP, CDE, FAANP Primary Care Provider, Post Traumatic Stress Disorder Rehabilitation Program, VA Pacific Islands Health Care System (PIHCS) Past Team Leader Chronic Disease Management for Diabetes VAPIHCS Director Region 9 American Academy of NPs Adjunct Faculty University of Hawaii

Lisa Tokuda Pharm D, CDE Clinical Pharmacist for VA Primary Care Patient Aligned Care Team (PACT) PIHCS Principle Investigator (PI): Video SMA to improve DM Care and Group Intervention for DM in Honolulu and American Samoa.

Dr. Lorenzo and Dr. Tokuda declare that in the past 12 months they have nothing to disclose.

Dr. Tokuda PI” & Dr. Lorenzo Co- Investigator are the providers of VIDEO-CONFERENCE SHARED MEDICAL APPOINTMENTS IMPROVES RURAL DIABETES CARE"

Identify key components and elements for successful implementation of Shared Medical Appointments

Discuss strategies and models for patient activation and self management skill building

Discuss steps to Implementation of SMA

“One's destination is never a place, but a new way of seeing things.”

Henry Miller

Uninformed, Passive Patient

Unprepared Provider Practice

Frustrating ineffective interactions

The Usual Way Patient not engaged in own chronic condition/care

Brief, unplanned provider visit, no team

Providers trained to deliver knowledge and be directive with patients

Patients stuck in habits or confrontational modes

Time pressures of patient visits

Limited payment for patient counseling

Is it a provider problem? A patient problem?

Sometimes Sometimes

ALWAYS A system problem?

By 2020, 1 of every 2 Americans could have Diabetes or Prediabetes

United Health Center for Health Reform & Modernization. (2010). The United States of diabetes. Retrieved from http://www.unitedhealthgroup.com/hrm/unh_workingpaper5.pdf

A multi-disciplinary multi-expertise team of providers sees a group of patients (7-12) in a 1.5 to 2 hour visit.

The interactive visit incorporates education as well as clinical management & medication adjustment. Masleyet al. Family Practice Management, June 2000, Vol. 7, No. 6, p33-7

Informed, Activated

Group

Productive Interactions

Prepared, Proactive

Practice Team

Chronic Care Model

Decision Support

Clinical Information

system

Self Management

Support

Community Support

Shared Medical

Appointment

Type 2 Diabetes & A1C>8 With comorbidities -

Hypertension & hyperlipidemia

Non compliance or disengagement

Interest & ability to attend & participate in SMA

Registry and referrals Enrollment strategy: ◦ scheduled/letters & Reminder Calls

Medication prescriber (MD, NP, PharmD);

Diabetes expertise (MD, NP, RN, CDE, nutritionist)

Motivational interviewer (NP, PharmD, psychologist, nurse, social worker)

Health Coach (medical assistant, research assistant, receptionist, peer specialist)

•main responsibility for running the group session • core expertise that is needed is motivational

interviewing skills, which includes techniques to create a patient-centered discussion

Moderator

•MD, NP, RN with MD support, pharmacists • personalized medication review, titration as needed

and written plan based on the process and intermediate outcome measures.

Prescribing Provider

•MD, NP, RN , pharmacists or dietician • content expert; Nutrition, activity, blood glucose

monitoring, self management

Diabetes Expert

•medical assistant, research assistant, receptionist, peer specialist •They serve as peer support and motivator. They recruit, call or send reminders and help to engage patient in program. They may be less intimating to pateints and thus garner more personal information or barriers to DSM

Health Coach]

Team Members ~Roles and Core Expertise

Shared Medical Appointments are a shift in health care delivery method

The default is often to lecture to

patients & see them every 3 months. http://www.groupvisits.com/25-key-first-steps.php

Logistics

Number Pts Invited ◦ 7-10

How many show? ◦ 5-8

Family members invited? ◦ Yes

Confidentiality/Rules! ◦ Each SMA in Introduction

Space requirements? ◦ Large conference type room

SMA Needs? ◦ Diabetes education tools ◦ BP, wt and lab work

Length of session? ◦ 90 – 120 minutes

Structure of sessions

Introduction and information education sharing: ◦ 45 minutes

Group discussion: ◦ integrated 20 minutes

Medical appointment session/medication titration ◦ 45 minutes ◦ May be individual or in groups

Identify & contact patients & family members (significant others)

Establish an agenda for DSMT sessions

Develop or obtain tools for DSMT

Select guidelines & decision support

Develop a documentation template

Team collaborates ◦ challenges, solutions

& plan for ongoing implementation

A: A1C TARGET: <7 ◦ premeal blood glucose target of 80–130 mg/dL, rather

than 70–130 mg/dL, to better reflect new data comparing actual average glucose levels with A1C targets.

BP: <=140/90 ◦ Goal for diastolic blood pressure changed from 80 to

90 mm Hg for most people with DM & HTN. C: Cholesterol <100 ◦ treatment initiation (and initial statin dose) is now;

driven primarily by risk status rather than LDL cholesterol level.

◦Introduction pathophys, ABC’s of Diabetes Includes discussion of feelings and depression ◦Blood Glucose Monitoring Basics & role of diet medications Includes BP cuff & Step tracter monitoring & use ◦Basic of diet nutrition & advance nutrition & labels ◦Short & long term complications & monitoring as well as prevention Includes Review of ABC’s , Urine for Micro albumin, foot exams

Provide education & nformation Intensive skills training (disease specific) Encouraging healthy behavior change Teach patients problem-solving skills Assisting patients with psychosocial issues and the

emotional impact of having a chronic condition Provide ongoing and regular follow-up Engaging patients as active participants in their care

Family & Friends

People Like Me

Communication

Team Care

Follow up

Community, including Workplace

Health Education

Self Management and Self Management Support Supporting Patients Where They Are

Health System

Repetition & Repetition & Repetition

Learn Less More Not More Less Listen with a Positive Mindset

Practice makes Perfect

Billing

Documentatiom Components

Evaluation & Management ◦ Run as a series of 1

pt -1 provider visit w/ observers

Group Diabetes Visits ◦ DSMT claim (G0108,

G0109, S9140, S9141, S9145, S9455, S9460, and S9465)

DSMT content SOAP ◦ ABC’s ◦ Lab results ◦ Action plans ◦ Follow up next visit (close the loop).

The SMA is a voluntary Practice Management Tool

Run as a Series of 1 provider-1 Pt Encounters with Observers

Addresses Each Pt’s Unique Medical Needs Individually

Complete Exams & F/U (medical care from start to finish)

Level of Care Delivered & Documented ◦ Documentation must support E&M code

No current E&M codes ◦ Not fully resolved—adjust to any future changes in rules

Benefits for Patients

Improved clinical outcome measures of A1C, BP decreased ER visits & hospitalizations

Perceived value of frequent visits

Camaraderie and high group (peer support):

With improved self management skills patients gain a sense of control and usually experience improved health.

High patient satisfaction

Benefits for Staff

Supportive environment with high staff satisfaction High quality care is delivered in SMAs using group discussion, motivation & DM management. Thus patients become better at self management, which can decrease HC utilization.

Strong sense of teamwork and spread of provider expertise amongst each other

Overcomes Some Rural Barriers

Improved clinical outcome measures of A1C, BP & decreased ER visits & hospitalizations

Group/Shared Appointments for Peer Support Team Based Care DSMT Motivational Interviewing Action Plans Conversation Map Patient Choice Therapeutic Options Cultural sensitivity Patient Tools: Diabetes handouts, BMI Calculator, Exercise Guide & Step tracker, Blood Glucose Meter, BP Monitor.

A patient-centered, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence

Emerged in addictions field in ‘80s Effective across cultural boundaries Transcends traditional patient education Over 300 clinical trials

AuthoritAriAn

Directive confrontAtionAl

EmpathEtic Collaborative

Evocative Goal-Oriented

Supporting Autonomy

Action Plan = Agreement

Before trying to make an agreement: How important is the change to the person making it?

How confident does the person feel about the change?

You can’t make someone do something he does not want to do!

Action Plan Intervention Don’t Tell Patients What To Do

Negotiate What Changes To Focus On

Blending Your Expertise and Patients’ Desires

Focus on 1 or 2 Concrete Actions to start Not attitudes, numbers, or actions to stop Not “lose 5 pounds in 2 weeks”

Instead…"Walk briskly 20 minutes 3x/week, Monday, Wednesday & Friday after lunch”

Sample Action Plan My Action Plan Date_______ 1 _____(Name)_______________ and ___(my clinician)______________ have agreed to improve my health, I will:

Here is what I can do: _______________________________________ How much? _________ When?____________ How Often?___________ This is how sure I am that I will be able to do this (circle a number) Not sure Very sure 1 2 3 4 5 6 7 8 9 10

___Work on something bothering me

___Improve my food choices

___Stay more physically active

___Reduce my stress

___Take my medications

___Cut down on smoking

“Video Conference Shared Medical Appointments

Improves Rural Diabetes

CONTROL GROUP

N=69 (no SMA)

Diagnosis of DM & A1c >7

Selected from electronic patient records

Collected data at baseline and 4-8 months

Endpoints

HbA1c, BP, lipids

INTERVENTION GROUP

N=31 (SMA 6 grps of 4-6 veterans)

Diagnosis of DM &A1c >7%

Weekly SMA visits (Weeks 1-4) Self-management education, Medication management, Patient assessment of care,

Focus groups

Monthly SMA Visits

(month 3 & month 5)

Endpoints

HbA1c, BP, lipids

7.0

7.5

8.0

8.5

9.0

9.5

Control Group Intervention Group

HbA

1c L

evel

s (%

)

Baseline5 month

HbA1c levels were measured in the Control Group (N=69) and the Intervention-SMA Diabetes Education Group (N=31). Values represent the mean ± SE, *P=0.03.

31 patients received SMA & charts of 69 controls were abstracted for a total of 100 patients in the study. Mean age was 61 ±8.4, and 93% (93 of 100) were males. 61percent of patients had 6-15 years duration for diabetes & 13% (13 of 100) of patients had diabetes for greater than 15 years.

Over the 5 month period, the intervention SMA group showed a significant decline in A1c vs. the control group.

Within the SMA group, a remarkable decrease in A1c levels at the 5 month period among those age 65 & greater was observed. Similarly, a significant decrease in A1c levels was noted in the SMA group by the end of the study (5 mo.) that had diabetes for greater than 10 years vs. those with less than 10 years.

No significant changes over time in blood pressure or lipid levels were found between the SMA versus the control group.

Interestingly, the SMA group showed a significant reduction in incident rates for phone visits, unscheduled visits , ER visits, & hospitalizations compared to controls.

Engage & partner with patients in chronic illness care- they are in charge!

Provide ongoing DSMT & support to build skills.

Use motivational interviewing skills & concrete tools like action plans - they can work.

Build primary practice teams that can support patients in self management- you cannot do this alone for a full panel of patients.

SMA’s is a new practice model that can enhance diabetes care& outcomes as well as increase efficiency & decrease costs.

Bronson D., Maxwell R. (2004). Shared medical appointments: increasing patient access without increasing physician hours. Cleveland Clinic Journal Medicine, 71(5), 367-377.

Cohen LB, Taveira TH, Khatana SA, Dooley AG, Pirraglia PA, Wu WC. Pharmacist-led shared medical appointments for multiple cardiovascular risk reduction in patients with type 2 diabetes. Diabetes Educ 2011;37:801-12.

Edelman et al. Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Annals of internal medicine 2010;152:689-96.

Edelman D, Gierish JM, McDuffie JR, Oddone E, Willliams JW. Shared medical appointments for patients with diabetes mellitus: a systematic review. J Intern Med, 2015 Jan;30(1):99-106. doi: 10.1007/s11606-014-2978-7.

Kirsh S, Watts S, Pascuzzi K, O'Day ME, Davidson D, Strauss G, Kern EO, Aron DC. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Quality & safety in health care 2007;16:349-53.

Palaniappan L., Muzaffar A., Wang E., Wong E., Orchard T. (2011). Shared medical appointments: promoting weight loss in a clinical setting. Journal of the American Board of Family Medicine, 24(3), 326-328.

Sikon A., Bronson D. (2010). Shared medical appointments: challenges and opportunities. Annals of Int. Med., 152(11), 745-746.

Sikon, A & Bronson, D . June 2010 . Shared Medical Appointments: Challenges and Opportunities Annals of Int. Med., vol 152, no. 11

Taveira T, Friedmann P, Cohen L, Dooley A, Khatana S, Pirraglia P, Wu W. Pharmacistled Group Medical Appointment Model in Type 2 Diabetes. The Diabetes Educator 2010;36:109-17.

5. Taveira TH, Dooley AG, Cohen LB, Khatana SA, Wu WC. Pharmacist-led group medical appointments for the management of type 2 diabetes with comorbid depression in older adults. The Annals of pharmacotherapy 2011;45:1346-55.

Wall-Haas C., Kulbok P., Kirchgessner J. (2012). Shared medical appointments: facilitating care for children with asthma and their caregivers. Journal of Pediatric Health Care, 26(1), 37-44.

References