Diabetes Self-Management Education/Training via Telehealth Sarah P. Smith, MAT, RD, LD, CDE Palmetto Care Connections November 16, 2016

Atlantic Quality Innovation Network (AQIN) The federally funded Medicare Quality Innovation Network – Quality Improvement Organization (QIN-QIO) for New York State, the District of Columbia, and South Carolina. Partners - The Carolinas Center for Medical Excellence in South Carolina, IPRO in New York, and Delmarva Foundation in the District of Columbia. One of 14 QIN-QIOs operating across the U.S.

Atlantic Quality Innovation Network (AQIN) Works toward better care, healthier people and communities, and smarter spending Catalyzes change through a data-driven approach to improving healthcare quality. Collaborates with providers, practitioners and stakeholders at the community level to share knowledge, spread best practices and improve care coordination. Promotes a patient-centered model of care, in which healthcare services are tailored to meet the needs of patients.

What is Diabetes Self-Management Education/Training (DSME/T)? •Diabetes self-management education and training (DSME/T) is a collaborative process through which people with diabetes gain the knowledge and skills needed to modify their behavior and successfully self-manage the disease and its related conditions. •This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.

Desired Outcomes of DSME/T: The overall objectives of DSME are to support the following in order to improve clinical outcomes, health status, and quality of life: - Informed decision-making - Self-care behaviors - Problem-solving and active collaboration with the health care team Facilitating positive self-care behaviors directed at successful diabetes self-management was formally adopted as a desired outcome of DSME/T in 2002. Facilitating positive self-care behaviors directed at successful diabetes self-management was formally adopted as a desired outcome of DSME/T in 2002.

7 Specific Self-Care Behaviors Developed by the American Association of Diabetes Educators, known collectively as the AADE7™, have been defined to guide the process of DSME/T and help patients achieve behavior change. Healthy eating Being active Monitoring Taking medication Problem solving Healthy coping Reducing risks

National Standards for DSME/T Five guiding principles 1.Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term. 2.DSME/T has evolved from primarily didactic presentations to more theoretically based empowerment models. 3.There is no one "best” education program or approach; however, programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes. Studies show that culturally and age-appropriate programs improve outcomes and that group education is effective. 4.Ongoing support is critical to sustain progress made by participants during the DSME program. 5.Behavioral goal-setting is an effective strategy to support self- management behaviors.

DSME/T Accreditation and Recognition In 1997, the federal Balanced Budget Act passed, permitting the U.S. Health Care Finance Administration (HCFA)— now called the Centers for Medicare and Medicaid Services (CMS)— to provide expanded coverage for DSME/T. Two certifying organizations: American Diabetes Association - Recognition American Association of Diabetes Educators – Accreditation Terminology differs but the programs’ content and concepts are all based on the National Standards for Diabetes Self-management Education and Support

Providers of DSME/T Team Approach: Registered Nurse Registered Dietitian Registered Pharmacist Requires 2 of the 3 to comprise the team. Exceptions are allowed in rural settings. Other health care professionals may be added to the team to enhance the educational experience.

Reimbursement of DSME/T When a program receives recognition or accreditation, they are able to be reimbursed by: Medicare Medicaid in SC (and 45 other states) Many private Insurers Restrictions apply to certain health care organizations for Medicare reimbursement.

Barriers/Obstacles to providing DSME/T Lack of qualified educators in rural areas Costs incurred vs low reimbursement amount Reporting requirements Institutional support Restrictions on number of hours covered Transportation Low referral rate from healthcare providers .

What to do??? Bright Idea!

Let’s do this via Telehealth!

Things we knew: Transportation and staff time costs were increasing There were limited diabetes educators available Rural areas had needs for education We could provide this education CMS was reimbursing for DSME/T provided by accredited or recognized programs for Telehealth We were targeting Medicare beneficiaries with diabetes and prediabetes

Formed partnerships with: The Carolinas Center for Medical Excellence (CCME) Palmetto Care Connections (PCC) Low Country Area Health Education Center (LCAHEC) Low Country Health Care Systems, Inc. (LCHCS)

First Steps Where education would be provided Approval from distance site organization Compatibility of equipment Responsibilities of all partners Logistics of plan

Proposal to CMS Equipment to be used Who could be the instructor Curriculum to be used Ability to communicate during classes Originating site Distance site(s) Evaluation of format and learning outcomes Impact on contract performance

Results of pilot Attendance Graduates Comparison of pre- and post-tests 1. General diabetes knowledge 2. Comfort living with diabetes Lifestyle behaviors 1. Fruit and vegetable intake daily 2. Exercising > 30 minutes daily 3. Checking BG daily 4. Medication Adherence 5. Daily foot checks

Evaluation and Customer Satisfaction Evaluation Results on format Customer Satisfaction with format

Provided results of pilot to CMS Report to CMS Provided results of pilot to CMS

Where we are today - CMS applauded our initiative to pilot telehealth Continue with expanded pilot to provide additional data Contact period is 50% completed CCME to apply for a Special Innovation Project

References AADE Guidelines for the Practice of Diabetes Self-Management Education and Training (DSME/T). American Association of Diabetes Educators, Chicago, Illinois. Revised November 2010. Haas et al. National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2012 Nov;35 (11):2393-401. Mensing C. Comparing the processes: accreditation and recognition. Diabetes Educ. 2010 Mar- Apr;36(2):219-43. See also Overview Comparison of National Accreditation. Powell MP, Glover SH, Probst JC, Laditka SB. Barriers associated with the delivery of Medicare-reimbursed diabetes self-management education. Diabetes Educ. 2005 Nov-Dec;31(6):890-9. US Department of Health and Human Services. Expanded coverage for diabetes outpatient self- management (final rule). Program memorandum B-01-40. 2001

Questions? This material was prepared by the Atlantic Quality Innovation Network (AQIN), the Medicare Quality Innovation Network – Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.11SOW-AQINSC-TSK

For more information Sarah P. Smith, MAT, RD, LD, CDE Quality Specialist, CDE (80) 767-2590 or (803) 212-7569 ssmith@thecarolinascenter.org IPRO CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.atlanticquality.org This material was prepared by the Atlantic Quality Innovation Network (AQIN), the Medicare Quality Innovation Network – Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.11SOW-AQINSC-TSK