Results of a Peer Mentoring Intervention in Older Patients with Diabetes: The Care Companion Program Deborah Graham, MSPH AAFP National Research Network Cynthia Henderson, RN, CCM WellMed Medical Management

Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

Objectives On completion of this session, the participants: Will have learned about the implementation and effects of a peer-to-peer mentoring program taking place in a large medical organization for older patients with diabetes. Should be able to list several survey and screening tools that can be used in practice to help measure the psychological and sociological effects of peer mentoring and support group activities. Should be able to recognize how peer-to-peer mentoring might affect their own patient outcomes.

Agenda Practice overview Care Companion Program implementation Survey and Screening Tools Evaluation Methods and Outcomes

Program Overview WellMed Medical Management and the Care Companion Program

WellMed Organizational Overview Dr. George M. Rapier III founded WellMed in San Antonio, TX in 1990 as a single primary care practice Dr. Rapier grew WellMed into a diversified healthcare company to serve Medicare-eligible Seniors: Primary Care Clinics Medical Management Services UM, Case Management, Disease Management Transportation Services

Organizational Overview 56 primary care clinics (in-house lab, x-ray, pharmacy) with more than 100 physicians in Texas and Florida

Organizational Overview Specialize in Medicare-eligible Seniors – responsible for 87,000 lives Manage Full-Risk Capitated Insurance Contracts Primary Care Centric Medical Group (Family Practice, Internal Medicine + added Podiatry, Dermatology, Cardiology, Oncology, Pain Medicine) Contract for all Medical Services (Specialty, Hospital, Ancillary, Hospice) Fully functional primary care centric, patient centered medical home (PCMH) functioning as an accountable care organization (ACO)

WELLMED CARE MODEL ACCESS TO CARE & INFO Health care for all After-hours access coverage Accessible patient & lab info PRACTICE-BASED SERVICES Comprehensive care for both acute & chronic conditions Prevention screening & services Ancillary diagnostic services CARE MANAGEMENT Wellness promotion Disease prevention Patient engagement and education CARE COORDINATION Collaborative relationships–ER, Hospital care & Specialist care Care Transition PRACTICE MANAGEMENT Disciplined financial management Cost-Benefit decision-making Facilities management HEALTH INFO TECHNOLOGY Electronic medical record Electronic orders & reporting Evidence-based decision support QUALITY & SAFETY Evidence-based best practices Medication management Quality improvement PRACTICE-BASED CARE TEAM Provider leadership Effective communication Patient participation Source: TransforMED.com

Peers for Progress Grant AAFP NRN was one of 14 grantees in 6 continents to evaluate the contribution of peer support in diabetes and to provide a model for peer support programs around the world Partners –WellMed –Latino Health Access (Orange County, CA) –Modeling Dr. America Bracho’s Carpeta Roja Program in our Senior population Supported by the AAFP Foundation and the Eli Lilly and Company Foundation Inc.

Peers for Progress Grant Program Purpose Empower patients to become “managers of their own health and health care” Group dynamic develops during Diabetes 101 classes Volunteers who have diabetes provide support to patient partners through mentoring activities

Implementation Implemented at 15 clinics 18 month staggered recruitment period, September 2009 through February 2011 Three intervention components: Diabetes 101 courses – led by nurse educator Small group mentoring – co-led by nurse educator and peer mentor One-to-one mentoring – peer mentor and mentee Peers program was re-named WellMed Care Companion Program after 1 st year

Diabetes 101 Courses 8 week Diabetes 101 courses conducted by diabetes educators Patients attended Diabetes 101 classes at their home clinic Referred by provider, health coach or self-referral Diagnosis of diabetes No diagnosis of cognitive impairment

Diabetes 101 Curriculum Developed as a combination of LHA’s Carpeta Roja curriculum and the WellMed Disease Management curriculum for diabetes –Week 1 – What is Diabetes and Stages of Change –Week 2 – Blood Glucose Monitoring –Week 3 – Healthy Eating –Week 4 – Meal Planning –Week 5 – Medication –Week 6 – Get Up and Move – Physical Activity –Week 7 – Diabetes Complications –Week 8 – Coping and Living With Diabetes

Mentor and Mentee Identification Potential Mentors were identified in Diabetes 101, invited to attend additional training Remainder of participants identified as Mentees and invited to be paired with a Mentor

Mentor/Mentee Interaction Ongoing monthly support meetings Mentors must have at least 4 contact hours per month Encounters between Mentor and Mentee are documented and tracked, as well as Mentor contacts with community and family members Encounters focus on healthy eating, monitoring, reducing risk factors, problem solving, physical activity, goal setting, emotional support, encouragement and motivation

Survey and Screening Tools

Data Collection Intervention patients completed surveys at –Baseline –8 weeks –6 months post intervention Baseline and 8 weeks collected during Diabetes 101 classes 6 month post survey collected by mail or phone

Patient Socio Metric Data Summary of Diabetic Self-Care Activities (SDSCA) Behavioral Risk Factor Surveillance System (BRFSS) Morisky Scale for medication adherence EQ5-D, basic knowledge related to diabetes and quality of life

Patient Clinical Metric Data Diabetes Distress Scale (DDS-2 and 17) Depression Screen (PHQ-2 and 9) HgbA1c LDL Blood pressure Weight

Evaluation

Implementation Results Numbers at a glance Implemented at 15 clinics 9,297 Patients with Diabetes 485 enrolled in D completed D101 (attended at least 6 out of 8 sessions) 116 Mentees (program goal = 200) 53 Mentors (program goal = 50)

Demographics of Participants who Completed D101 AgeRace/Ethnicity <65 years14.9% Black8.2% years43.0% Hispanic43.7% years36.1% White40.2% 85+ years6.0% Other2.5% Gender Unknown4.4% Female62.3% Male37.7%

Demographics of Participants who Completed D101 EducationAnnual Household Income 1-6 years6.3% <$10, % 7-11 years18.0% $10,000-$24, % years56.0% $25,000-$74,9997.3% 16+ years14.6% $75, % Unknown5.1% Unknown29.1% Marital Status Single8.9% Married53.2% Div/Widow33.9% Unknown3.8%

Analytic Methods Mixed methods, non-randomized comparison group design Usual care comparison group of patients with diabetes identified from EHR Usual care at high level –quarterly visit with health coach and physician –Instruction on diet and self-management –Clinical and social metrics from EHR Propensity scores used to compare intervention and usual care (matched for gender, age, disease severity)

Result Highlights A1C values decreased more steadily in Peers patients than control patients Statistically significant changes in Diabetes self- management behaviors including monitoring blood glucose Healthy eating and physical activity improved in Peers patients from pre- to 6-month follow-up. Statistically significant reductions in level of emotional distress related to their Diabetes from pre- to 6-month follow-up in Peers patients

A few of our Mentors

For more information…… Deborah Graham, MSPH AAFP National Research Network Cynthia Henderson, RN, CCM WellMed Medical Management