CDC’s 6|18 Initiative: Physician Role Preventive Medicine 2017 May 24, 2017 Office of Health Systems Collaboration Office of the Associate Director for Policy Victoria C. Costales, MD, MPH Director, Center for Prevention & Lifestyle Management Associate Program Director, Internal Medicine/Preventive Medicine Residency Program Griffin Hospital, Derby, CT

Increasing Provider Engagement Identify possible facilitators to provider engagement: Possible roles for payers and providers? Hear from you Explore opportunities to increase provider utilization of 6|18 interventions in practice settings

vv Intervention Payer Role Provider Role Improve access and adherence to asthma and blood pressure medications Formulary changes, pricing strategies, co-location of asthma medications and devices Use standardized treatment protocols, e.g. for hypertension treatment, asthma management, and tobacco cessation Expand access to evidence-based tobacco cessation treatments, promote utilization of covered tobacco treatment Identify tobacco users, cover all cessation treatment and counseling Screen, refer tobacco users to cessation services Promote a team-based approach to hypertension control (e.g. physician, pharmacist, lay health worker, and patient teams) Increase use of teams through payment incentives or use global payment to teams that include pharmacists Consider workflow redesign, use Medication Therapy Management Programs multiple chronic conditions, including hypertension Provide access to self-measured blood pressure monitoring Reimburse for ambulatory cuff and time to train in use Prescribe cuff, provide training, consider workflow redesign vv Recommend select 1-2 two intervention topics to highlight on this slide. Talking points: The 6|18 interventions have possible roles that payers and providers could play. For example: Improving access and adherence to asthma and blood pressure medications: a payer could support this intervention by working with their pharmacy benefit manager to select less costly but equally effective medications. In terms of improving asthma medication adherence, a payer could structure their medication benefits plan to permit asthma medications and spacers/nebulizers to be dispensed from the same location. Providers can improve medication adherence by following standardized treatment protocols so that current evidence-based medication regimens can be followed Tobacco: Payers can promote access of tobacco benefits by identifying tobacco users and providing that user data to providers. Providers and their staff can promote access to tobacco cessation by screening for tobacco use at every visit and referring those who are willing to quit to tobacco cessation services Team based hypertension: Payers can make the formation of teams possible by increasing global payments or administrative payments to providers to allow for staff to practice at the top of their license and for the time to interact as a team. Providers can look for ways to redesign their office workflows to allow other members of the team to interact with the patient so that the physician’s time can be more focused on more time-intensive patients. SMBP: payers can pay for the cost of a bp cuff for home based measurements and pay for the physician’s time to interpret home-based readings; providers can then prescribe the bp cuffs

Intervention Payer Role Provider Role Promote 2007 NAEPP guidelines for evidence-based asthma medical management Include guidelines as part of clinical practice guidelines; incentivize use Follow 2007 NAEPP guidelines as an asthma standard of care Expand access to home visits by licensed lay health workers to improve self-management education/reduce home triggers Reimburse for asthma self-management education, home assessment, and lay health worker time Refer patients for asthma self-management and home assessment for asthma triggers Reimburse providers for the full range of contraceptive services Reimburse providers for full suite of contraceptive services; unbundle the device’s payment from the post-partum payment Receive education and training in use of contraceptive devices and contraceptive counseling Expand access to the National Diabetes Prevention Program (NDPP) Pay for CDC-certified DPP provider programs Screen for diabetes and pre-diabetes, refer to CDC-certified DPP programs once identified Recommend highlighting 1 of the asthma topics Asthma: Payers can specifically call out the 2007 NAEPP guidelines as the preferred content for asthma clinical practice guidelines. BCBS TX for example, provides direct links to the NAEPP guidelines for their providers. Providers in turn can create asthma action plans for all their patients and use the medication workflows indicated in the guidelines Asthma home visits: Payers can pay for nurses, respiratory therapists, asthma educators to provide asthma self management education to those patients with asthma symptoms not controlled by the first lines of NAEPP therapy; they can also pay for home visits for those who need additional support. Providers can identify those patients who have had multiple ED visits as candidates for possible home visit support Contraceptive services – payers can reimburse providers for their time to provide counseling for the full suite of contraceptive services. They can also pay for the LARC devices as they are often more expensive than the cost of the global pregnancy-post partum care bundle package. Providers can support this area by receiving training in LARC use and be willing to provide that service when indicated or requested DPP: Payers can pay for CDC certified DPP programs as outlets for identified pre-diabetic patients; providers can support diabetes prevention by recognizing that pre-diabetes is a serious and real concern, by identifying patients with elevated A1c and/or overweight/obesity as potential pre-diabetic candidates, and then referring them to CDC certified DPP programs

Perceived barriers to Physician/Provider Engagement in Diabetes Prevention Insufficient time to educate patients on diet and lifestyle1 Cost/lack of insurance coverage for patient education1 Difficulty in the process of referring patients to available programs2 1 Mainous AG, et al. JABFM November–December 2016 Vol. 29 No. 6:663-671. doi:10.3122/jabfm.2016.02.150252 2 Chambers EC, et al. Increasing Referrals to a YMCA-Based Diabetes Prevention Program: Effects of Electronic Referral System Modification and Provider Education in Federally Qualified Health Centers. Prev Chronic Dis 2015;12:150294. DOI: http://dx.doi.org/10.5888/pcd12.150294

Practice Example: Efforts to Increase Provider Engagement: EHR Modification and New Referral Process For ease of referral: DPP included in patient referrals section Fax sent to the Griffin Hospital CDC-recognized DPP Diabetes Educator contacts the patient

Efforts to Increase Provider Engagement: Provider Education Clinic Providers (Attending Physicians and APRNs) and Staff Referral Seminar All-staff meeting Resident Physicians Noon conference Health and Community Resource Fair All providers Reference Sheet/Guide for referrals to Lifestyle Change Programs (emailed) Results: 10/2016-4/2017: 23 referrals (3 from the HCR fair)

Efforts to Increase Provider Engagement: Increasing Referrals to DPP (Resources) (1) American Medical Association. Prevent Diabetes Toolkit. Retrieved from: https://preventdiabetesstat.org/toolkit.html (2) Centers for Disease Control and Prevention. (2016 September). Approaches to Promoting Referrals to Diabetes Self-management education and CDC-recognized prevention program sites. Retrieved from https://www.cdc.gov/diabetes/pdfs/programs/stateandlocal/emerging_practices-promoting_referrals.pdf (3) Chambers EC, et al. Increasing Referrals to a YMCA-Based Diabetes Prevention Program: Effects of Electronic Referral System Modification and Provider Education in Federally Qualified Health Centers. Prev Chronic Dis 2015;12:150294. DOI: http://dx.doi.org/10.5888/pcd12.150294

Increasing Provider Engagement Questions from you?