1. Transforming Diabetes Care

2. Transforming Diabetes Care Program Content
Product training to enhance care
Applying the Chronic Care Model to diabetes care
Reimbursement through improved coding
New standards, guidelines and decision points in therapy
Changing behaviors in healthcare
SPEAKERS NOTES:
These are the topics that were covered at the Johnson and Johnson Diabetes Institute class that I attended.
How to use several different products and software and, more importantly, how to use the information they provide
How to apply the Chronic Care Model in diabetes care
Reimbursement and coding of diabetes services
How to help people with diabetes change behavior.
My goal is to briefly cover some of the topics we discussed in the course and then have a discussion about how our practice might benefit from this information.
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3. Transforming Diabetes Care How adults learn…
What I hear,
I forget;
What I see,
I remember;
but what I do,
I understand.”
~ Confucius, 451 B.C
Problem solving,
role playing,
case studies,
myths and truths,
downloading,
testing, injecting,
“pumping”
The course stressed how adults learn and the emphasis on adult learning continued throughout the program to not only discuss but to model adult learning techniques by using problem solving, role playing, case studies, myths and truths, “hands-on” practice with computer software and with blood glucose monitors and insulin pumps.
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4. What proportion of people with diabetes have…
Controlled BP (<130/80mmHg)
LDL at the goal level (<100 mg/dl)
A1C at the goal level (<7%)
What proportion have met all three?
The first challenge they gave us was to come up with that percent of people with were meeting each goal then what percent were meeting all three goals.
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5. What proportion of people with diabetes have…
Controlled BP (<130/80mmHg) %
LDL at the goal level (<100 mg/dl) 36%
A1C at the goal level (<7%) %
What proportion have met all three?
7.3%
Sayday, et al JAMA 2004; 291:335
This publication is from the National Health and Nutrition Examination Survey
Only 7.3% of those self reporting have met all three.
JJDI has charged the graduates with becoming the 7% solution!
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6. Currently our medical system is set up to deliver acute care
Currently our medical system is set up to deliver acute care. A new model of care that addresses living with chronic diseases is represented here by the Chronic Care Model. It outlines the essential components of a system that encourages high-quality health care and leads to improved outcomes for patients. The components are the Community, the Health System, self-management support, delivery system design, decision support and clinical information systems. I will walk you through each component of this system in a few minutes.
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]
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Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.] 6

7. Looking at Our Practice: Questions we should ask ourselves
What aspects of the model can we adopt?
Which guidelines will we follow?
How do we make sure our coding is correct?
Who in our community do we involve?
Would we benefit from a diabetes registry?
But before I do that we should keep these questions in mind as they are key to our implementing the model
What aspects of the model can we adopt? (can we take small steps to change our practice)
Which guidelines will we follow? (The goals are similar, and we all need to agree on targets)
How do we make sure our coding is correct? (There are many resources in our community we can use)
Who in our community do we involve? (There are many resources in our community we can use)
Would we benefit from a diabetes registry? (We can quickly see what patients need what care)
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8. Joel Henderson and his family
Meet
Joel Henderson and his family
43 yr old obese male
Type 2, HTN, dyslipidemia, sleep apnea
Family hx - heart disease, depression
A1c 8.6%
BP 146/96
Chol 192
We talked about a number of hypothetical patients, I’ll go over this one.
Listed are some of his problems [read them off the slide]
We should talk about how the chronic care model would fit for Joel
Admits his diabetes is not a priority
Busy stressful life
“My wife worries about my diabetes for me”
Understands family history and risks
Adult daughter and granddaughter recently moved back home
“I really don’t know what questions to ask.”

9. © Johnson & Johnson Diabetes Institute, LLC 2009
Chronic Care Model
Pillars of Care
The first pillar of the chronic care model I want us to discuss is Community Resources
Many resources exist to help our patients and I will talk about some of the ones we learned about during the course
Community
Resources
Self-Manage-
ment
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
© Johnson & Johnson Diabetes Institute, LLC 2009

10. Community Resources and Collaborations
Local Malls (for ‘mall walking’)
Public Library
Local Restaurants
Beauty Salons
Barber Shops
Parks & Recreation Dept.
Visiting Nurse Organizations
Literacy Volunteers of America
American Diabetes Association
Local Senior Centers
Local Health Care Providers
Churches
Service Organizations
Housing Authority
Grocery Stores
Schools
Local Worksites
Media
There are many COMMUNITY RESOURSES that can be utilized to support the patient with diabetes.
Connecting people with chronic diseases to a community that supports them is one way to support healthy living.
These are examples of partnerships between a healthcare system and it’s community.
PRESENTER: Pick some of these as examples and tell how they could be used
Which of these do you think we should try?
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11. © Johnson & Johnson Diabetes Institute, LLC 2009
Chronic Care Model
Pillars of Care
SELF MANAGEMENT SUPPORT is an important pillar of the Chronic Care Model since diabetes is primarily a self-managed condition
Diabetes Self Management principles can be taught by Diabetes Educators
Diabetes Self Management education can be done in individual or group settings
Diabetes Education in group settings may be reimbursed, depending on the insurance plan.
Community
Resources
Self-Manage-
ment
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
© Johnson & Johnson Diabetes Institute, LLC 2009

12. Self-Management Support
Joel’s role includes:
Testing his blood glucose
Learning food’s effect on his glucose
Begin exercising regularly
Our role includes:
Assessing his readiness to make these changes
Provide visits and perhaps referrals that support his efforts such as:
Medical Nutrition Therapy
Diabetes Self Management Education
Provide support
Diabetes is a self managed disease.
Let’s discuss Joel’s responsibilities:
Testing his glucose, Learning how certain foods effect his glucose.
Getting regular exercise.
We support his self management efforts by
Listening and understanding his ability to make changes,
Seeing him regularly,
Referring him to diabetes education and nutrition counseling
Diabetes self management really requires a team effort with Joel at the center.
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13. Self-Management Support Medical Nutrition Therapy Referral
Joel and his wife learn:
Relationship between his food
choices and his glucose control
Value of SMBG in helping him
make food choices
Effects of exercise on glucose
control
A MEDICAL NUTRITION THERAPY referral is essential to
understanding the enormous role food plays in blood glucose control.
Joel is encouraged to invite his wife to the appointment because new information is always better retained when two people are listening and learning.
Using his blood glucose testing as a way to learn about food and exercise is key. A food and glucose log will help a lot.
Knowing how much his glucose changes after exercise is also important.
Testing before and after exercise on occasion will show him that exercise helps
control his blood glucose.
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14. Self-Management Support
Changing Behavior
“Joel won’t change his eating habits.”
“Joel isn’t getting enough exercise.”
“I can’t seem to get through to him!”
Our role:
Assess where Joel is on the road to change
Work to motivate him to change behaviors
Tools that can help:
Importance and Confidence Rulers
One of the most difficult parts of Self-Management Support is
BEHAVIOR CHANGE
It is important to assess Joel’s readiness to learn all this new information
about his diabetes care.
At JJDI we learned to use tools such as the Importance and Confidence
Rulers to help him change and adopt new behaviors.
PRESENTER: (Demonstrate the Rulers to your colleagues with some
role playing) .
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15. © Johnson & Johnson Diabetes Institute, LLC 2009
Chronic Care Model
Pillars of Care
DELIVERY SYSTEM DESIGN is a pillar describing the need to change the way the practice is organized and care is delivered.
The goal in changing how the practice is organized or how care is organized is to
make care delivery more efficient
One of the things we learned was to use a registry to pick certain patients and
have them come on the same day
Community
Resources
Self-Manage-
ment
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
© Johnson & Johnson Diabetes Institute, LLC 2009

16. Delivery System Design
Shared Medical Appointments
Benefits of SMA
Improves access to good care
Improves patient satisfaction
Improves patient-provider communication
( NOTE: For those Graduates that attended in 2008 the terminology
of “Group Medical Visit” has been changed in the updated curriculum
to “Shared Medical Appointments”)
One way to provide valuable medical appointments for people with chronic
disease is to offer shared appointments.
We learned that SHARED MEDICAL APPOINTMENTS can:
Help us to deliver care more efficiently
Improve our patients’ satisfaction with our practice
Help us communicate better with patients and give them a chance to ask
questions of us as well as other people with diabetes in their group
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17. Joel might benefit from A Shared Medical Appointment
Sample Agenda
I Introductions
(15 min)
II Self-management education
(30 min)
III Interactive with HCPs
(30-40 min)
IV Q&A on topic
V 1:1 visit time
(30-45 min)
I we look at our patient, Joel, he may benefit from the peer support
that occurs in a shared medical appointment
This is a typical agenda with a sample room layout to help us
understand how visits like this work and are organized
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18. Benefits of Shared Medical Appointments to our practice include:
Fewer ER visits/admissions
Patient retention
Increased satisfaction
Efficiency
Less isolation
The BENEFITS TO OUR PRACTICE include:
Shared Medical appointments decrease ER visits/admissions (studies have
shown decreased ER visits or hospital admissions as a result of this practice
change)
Patient retention (studies show patients who feel less isolated and more a part
of a group are less likely to leave a practice)
Increased satisfaction (much as with retention, patients who feel part of a
group feel more satisfied with their care)
Efficiency (having services provided in a cluster fashion allows more efficiency)
Less isolation (patients and providers learn that they are not alone in having some difficulty
with new diabetes behaviors)
CLEVELAND CLINIC JOURNAL OF MEDICINE, VOLUME 71, NUMBER 5, MAY 2004
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19. © Johnson & Johnson Diabetes Institute, LLC 2009
Chronic Care Model
Pillars of Care
DECISION SUPPORT involves evidence based guidelines,
algorithms and consensus statements from major organizations
Some examples are:
The ADA and European Association for the Study of Diabetes (EASD) together
released a guideline on Medical Management of Hyperglycemia in type 2 diabetes which contains:
An algorithm for overall medication management
A metformin titration algorithm
An insulin initiation and titration algorithm
The ADA provides Clinical Practice Recommendations which are a supplement
to Diabetes Care each January
Both of these resources are on the JJDI Website so that we can use them in
our practice.
Community
Resources
Self-Manage-
ment
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
© Johnson & Johnson Diabetes Institute, LLC 2009

20. Treat to Target A1c BP Chol LDL/HDL TG < 7% 130/80 < 200
ADA
American Diabetes Association
< 7%
130/80
< 200
<100*
>40 men
>50women
<150
AACE
American College of Endocrinology
< 6.5%
ADA and AACE Guidelines are represented on this slide. As you can
See they are the same except the goal A1C
We can decide which we will follow to be consistent with our patients.
* CVD < 70
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21. The Price our Patients pay….
“…a hypothetical patient progressing from nonpharmacologic treatment through sulfonylurea or metformin monotherapy to combination oral agent therapy….would accumulate nearly 5 HbA1c-years of total burden >8.0% and about 10 HbA1c-years of total burden >7.0%. The latter figure exceeds the mean reduction in glycemic burden (9.0 HbA1c-years) achieved over 10 years by the U.K. Prospective Diabetes Study”
The Price our Patients pay….
‘Avoidable Glycemic Burden’
As weeks and months go by and our patients are NOT being treated
to a glucose target, the price they pay is referred to as the “avoidable
glycemic burden”.
If we, as practitioners, treat our patients to target and as AACE recommends
make adjustments every 2-3 months (not 6 – 12 months as is typical) we can
significantly reduce the glycemic burden
in our patients.
We learn that a significant burden of increased cardiovascular risk occurred
when we were not able to get patients to target quickly. *
*[Glycemia Treatment Strategies in the Action to Control
Cardiovascular Risk in Diabetes (ACCORD) Trial}
Brown, J. et al Diabetes Care 2004;27:1539
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Brown, J. et al Diabetes Care 2004;27:1536

22. 2009 ADA/EASD Consensus Algorithm Early Insulinization
This newest algorithm from AMERICAN DIABETES ASSOCIATION
supports the notion that people with diabetes benefit from early insulinization.
In the figure above note the “Less well validated therapies” as described in each of the four boxes in the lower portion of the slide are tier 2 choices. It suggests that moving to other oral agents are second tier therapies to those in Tier 1 and should be implemented secondary to Tier 1 options. (AACE guidelines indicate making adjustments every 2-3 months not 6-12 months as is typical)
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DIABETES CARE, VOLUME 32, NUMBER 1, JANUARY 2009: 200

23. Early Insulinization Barrier Frequent Hypoglycemia Weight gain
Needle phobia
Guilt and failure
Time to titrate
Solution
Analogue insulins
RD consult, metformin
“Adam’s technique”, an insulin injection technique
Explain progressive nature of diabetes
“Do it yourself” algorithms prescribed by the healthcare professional
Insulin given early on with frequent titration helps prevent micro and macrovascular complications.
Both practitioners and our patients have barriers to insulin that need to
be addressed. At JJDI we began this discussion by identifying type 2
diabetes as a progressive disease, in which patients will likely eventually NEED insulin to keep them at target.
As a group we agreed that insulin can be referred to as another “hormone therapy replacement” when our patients describe a fear of insulin that we listen and help them understand.
“Do It Yourself algorithms”:
Starting dose per package insert 10 units
Treat to Target Trial “ ” algorithm
Add 2,4, 6,or 8 units of glargine weekly until mean FBG=100
ATLANTUS Study “3-2-1” algorithm
Add 2 units glargine every 3 days until mean FBG=100
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24. Using evidence based guidelines
As an office,
we need to define
Decision Support resources for us
Using evidence based guidelines
Define targets and algorithms
ADA, AACE, Staged Diabetes Management etc
Regular updates
There are a number of guidelines for diabetes care and we should decide which targets we are shooting for
There are treatment algorithms and we discussed several of them
ADA Medical Management of Hyperglycemia
AACE Roadmap
Staged Diabetes management is an algorithm used on one of our Chronic Care Model cases
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25. A decision point… Joel is now on max doses of metformin and glyburide.
His A1C is 7.0% today.
What is the likelihood that it
will be above 7.0% on his
next visit in 6 months?
Let’s get back to Joel and talk about his glucose targets and the progressive nature of his diabetes
PRESENTER: [read the slide asking the question and get some discussion going}
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26. Duration of control…. (c) Brown JB, et al. Diabetes Care 2004;27:1538
This study from the journal Diabetes Care shows that the likelihood t
hat Joel’s A1c will be OVER 7% is 70% !!!
Diabetes is a progressive disease and we have to continually adjust
therapies to help keep our patients in control.
One of the earliest signs of loss of control is increasing post meal
glucose levels.
His target for after meal glucose should be 140 mg/dL or lover.
Keeping track of them will show changes over time.
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Brown JB, et al. Diabetes Care 2004;27:1538

27. Decision Points involve a number of factors
TARGET
What is the goal you are shooting for?
METHOD
What is your choice of therapy to get there?
TIMING
When do you decide it isn’t working?
How often do you make changes?
DECISION POINTS in therapy involve identifying the target,
agreeing to a method of therapy that will get you there and clearly
understanding when it isn’t working and make changes frequently.
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28. © Johnson & Johnson Diabetes Institute, LLC 2009
Chronic Care Model
Pillars of Care
And the last pillar we discussed was CLINICAL INFORMATION
SYSTEMS
Community
Resources
Self-Manage-
ment
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
© Johnson & Johnson Diabetes Institute, LLC 2009

29. Clinical Information Systems
EMRs
Diabetes Registry
Real time data
Identifies gaps in care
Care reminders and feedback
Individual patient care planning
Proactive population-based care
Clinical information systems are useful in tracking and managing
care of patients with chronic disease.
For instance the use of a registry of our diabetes patients can help us
track who is in need of lab work, announce community programs
(smoking cessation, diabetes days) offer shared medical
appointments etc…
The Registry will help us to make sure our patients get the routine
things done and improve our HEDIS score.
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30. Reimbursement Barrier Solution Identifying all billable moments
Not getting reimbursed for diabetes education
Not paid for preventive counseling -“Diet and Exercise”
Knowing what can be billed on the same day
Cannot bill for MNT + DSMT on same office visit
Solution
Find a coder to identify billable moments
ADA Recognition will open doors
Always get a referral for DSMT and for MNT
Get referrals for additional hours of MNT if requested from the professional for treatment changes
At JJDI we discussed how to obtain appropriate reimbursement for the care we give.
Here are just a few of the barrier and solutions we discussed.
PRESENTER: [Read from the slide, then add in your own Ah-ha moments]
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31. Key Learnings Recognize barriers and provide solutions to:
Treat to target
Early insulinization
Reimbursement
New approaches
Changing behaviors
Assessing readiness
The Key Learnings from the JJDI course were:
A Treat-to-Target approach for Glucose, Lipids and Blood Pressure
Using insulin earlier in therapy to get to goal quicker
Reimbursement is key and knowing how to code services correctly is key to
Reimbursement
Helping people change behavior allows them to take control of their own care
We need to assess their readiness to change
We can help them change using Motivational Interviewing techniques we learned
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32. How will we change our practice?
As a practice, which of these key learnings
should we implement ?
And when do we begin ?
Close with this slide. Try and get ideas and commitments to bring change to your
practice.
Remember….”there is no try, only do!”
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