1. Virtually Possible: The Use of Technology in the Treatment Of Diabetes Cheryl B. Masters, PhD, Jerry Nymberg, MD, Mark Robinson, MD, Andrea Cochran, PhD, Wes Teeter, MA, LPC Cabarrus Family Medicine Carolinas Healthcare System Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session #B5b Saturday, October 12, 2013

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Study Summary Study question: Will video-enhanced home monitoring devices increase patient access (and improve outcomes) to a diabetes care team embedded in a patient centered medical home? Study population: Total enrollment of 119 poorly-controlled diabetic patients (HbA1c > 9%) Study sites: CFM-Kannapolis, CFM-Concord Study duration: 3 month intervention and 3 month follow-up Diabetes Care Team: care manager, nutritionist, clinical psychologist, and clinical pharmacist

4. Baseline Data ConcordKannapolis 2012 DataConcordKannapolis Number of Active Patients13, 1059, 579 Office Visits35, 08327, 347 MD’s (n)95 ACP’s (n)22 Residents (n)66 NCQA PCMH Level33 Total Diabetics (n)1069908 % of A1c > 911.1 %

5. FREQUENTLY CITED BARRIERS TO GLYCEMIC CONTROL Transportation Financial resources Mood disorders Limited knowledge about diabetes Gatchel & Dordt (2003) Clinical Health Psychology and Primary Care

6. Objectives Participants will identify the relationship between mood, stress and diabetes. Participants will describe the prominent psychosocial obstacles to diabetes management. Participants will identify the advantages of virtual services as a platform for diabetes management.

7. Patients Randomized to Three Groups Group 1Group 2Group 3 Usual care from PCP No cost to access diabetes care team No care manager Usual care from PCP Care manager No cost access diabetes care team Care manager coordination of diabetes care team services Usual care from PCP Care manager Virtual access to diabetes care team using video- enhanced home monitoring devices Face Time via iPad Honeywell home monitor transmissions of glucose, BP and weight

8. Baseline Demographics Group 1Group 2Group 3 N413940 Age (mean)48.650.951.6 Female %59%67%45% Race: White African American Latino 28 12 1 25 14 0 31 9 0

9. Group 1Group 2Group 3 A1c11.210.911.3 SD for A1c1.61.31.9 Glucose (Office)246270231 Weight (male)255234221 Weight (female)221203213 Total Cholesterol190202175 Triglycerides271258226 Baseline Glycemic Control Mean by Group

10. DID VIRTUAL TECHNOLOGY IMPROVE ACCESS?

11. CHANGES IN ACCESS TO THE TEAM Patients Seen Before the Study Patients Seen During the Study At least one visit to nutritionist 47 81 At least one visit to pharmacist 23 77 At least on visit to behaviorist 2 56

12. Number of Visits with ALL DCT Disciplines by 3 Months DisciplineGroup 1Group 2Group 3 Pharm, Nutr, and Behav521 21 * CM, Pharm, Nutr, Behav2817 CM, Pharm, and Nutr71220 * Main study outcome Note: 100% saw their PCP at study entry

13. Visits by Discipline After 3 Months (FT is the number of FaceTime Visits) (41 FT) (52 FT) (46 FT) (12 FT)

14. DID TECHNOLOGY IMPROVE GLYCEMIC CONTROL?

15. IMPROVEMENTS IN GLYCEMIC CONTROL

16. WAS DEPRESSION OR STRESS RELATED TO DIABETES?

17. WHAT PERCENTAGE OF PATIENTS SCREENED POSITIVE FOR DEPRESSION? 35%32%

18. DID PHQ-9 SCORES IMPROVE WITH TREATMENT?

19. TOP 10 STRESSORS ( HOLMES & RAHE) 1. Christmas 2. Personal injury/illness 3. Change in financial state 4. Change in eating habits 5. Change in health of family member 6. Death of close family member 7. Sexual difficulties 8. Change in social activities 9. Change in sleeping habits 10. Death of close friend

20. HOLMES & RAYE BY GROUP Holmes & Raye Group 1 Group 2 Group 3 Total Score Mean (standard deviation) 89.46 (95.38) 123.69 (134.70) 102.70 (96.96) Score <150 Score 150-299 Score 299+ *Slight risk of illness *Mod risk of illness *Significant risk of illness or change in health

21. STRESS, DEPRESSION AND HBA1C VariablesGroup 1Group2Group3 Holmes Raye and Initial HbA1c0.10 (0.52) -0.10 (0.54) 0.01 (0.91) Holmes Raye and Initial PHQ-9-0.23 (0.16) -0.03 (0.86) -0.17 (0.29) Spearman Correlations (P-values in parentheses)All ns

22. COPING STYLE AND HBA1C Group 1 Group2 Group3 Coping Style 1=active 2=mixed 3=passive Kruskal-Wallis 1.86 (0.26) 2.302.03 Coping Style and Initial HbA1c -0.51 (0.06) 0.11 (0.59) 0.46 (0.01) Spearman Corr.All ns

23. iPad Satisfaction: Group 3 (n=33)

24. SATISFACTION WITH TECHNOLOGY

25. Honeywell Satisfaction: Group 3 (n=38)

26. Diabetes Care Team Satisfaction with iPad 2

27. Diabetes Care Team Satisfaction with Honeywell Home Monitor

28. SUCCESSFUL OUTCOMES All three groups had increased access to care provided by the Diabetes Care Team (DCT). If you make visits to DCT free, provide free test strips, and free labs, patients will come! Test strips cost $310/patient, Labs cost $563/patient All three groups improved mean A1c at 3 months. The team process works! The relationship between Diabetes and Depression is bidirectional. Uncontrolled diabetics should be screened with the PHQ-9.

29. ADVANTAGES AND DISADVANTAGES OF VIRTUAL SERVICES All patients eventually were able to operate the technology Ideal for medication reconciliation, seeing how people really people really eat on a daily basis and what their real life stressors are. Ideal for patients with transportation issues and limited mobility. Only lost 1 iPad to a car crash, one was stolen but returned. There were some technical issues: Ringer is too low Lose visit preparation and “specialness” of a visit Patients don’t know iPAD visit etiquette Calls get dropped; often had to pre-call anyway Need to set limits/controls on MiFi’s. Limits on FaceTime as an immediate “on call” device to practice

30. THE END

31. Any Questions??

32. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!