Camden Coalition of Healthcare Providers: Integrated Diabetes Care Program

Camden Coalition of Healthcare Providers: Integrated Diabetes Care Program PROJECT OVERVIEW The Camden Coalition of Healthcare Providers (The Coalition) aimed to improve the quality, capacity, and accessibility of healthcare for vulnerable populations in Camden, New Jersey. The Coalition established the Camden Citywide Diabetes Collaborative (CCDC) to improve diabetes care at the patient, practice, and community levels, and the Integrated Diabetes Care Program (IDCP) to provide coordinated diabetes care for patients with the highest healthcare utilization. Using a team of nurses, Community Health Workers (CHW), practice coaches, and other specialists, the Coalition sought to strengthen diabetes care directly through care management for the most complex patients, in primary care offices, and in classes for diabetes selfmanagement. CONTEXT AND PARTNERS Camden, New Jersey is located in Camden County across the Delaware River from Philadelphia. Ninety-five percent of Camden residents are minorities; 49.9% are African American, and 42.1% are Hispanic. Urban decay and poverty are the two central features of this area with 35% of families living below the poverty line, as compared to 9.6% in the U.S. and 13.2% in the state of New Jersey. Further, only 59.4% of Camden residents have completed high school. In addition to unemployment, poverty, and low education rates, Camden residents experience high prevalence of diabetes and diabetic complications. Patients with diabetes in Camden are twice as likely to visit the emergency department and 2.5 times more likely to be admitted to the hospital, compared to patients without diabetes. In addition, program participants experience social co-morbidities such as lack of social support (37.6%), mobility barriers (73%), and homelessness (3%). Further, program participants suffer high rates of co-morbid health conditions such as hypertension (91%), depression (55%), asthma (43%), and arthritis (36%). In an effort to address disparities related to diabetes, the Coalition addressed three goals: 1) Enhance the capacity of primary care provider practices to provide evidence-based diabetes care; 2) Improve access to diabetes self-management activities for Camden residents citywide; and 3) Empower Camden residents with diabetes to reach optimal diabetes control through innovative care management strategies. Staff at the Coalition believe that if they could provide the small percentage of super-users those who have multiple inpatient admissions related to diabetes as well as behavioral health issues and social barriers to health with better, more coordinated care that addressed the underlying barriers to diabetes care; and through effective care management increase their quality of life and decrease healthcare costs. To address the needs of super-users after care management ended and the needs of other diabetics who did not meet that criteria, the Coalition established health system transformation components within 12 local primary care sites. Examples of practice transformations include: 1) Healthcare provider and clinical diabetes education staff; 2) Improved linkages between endocrinology and primary care providers; 3) Multi-site community and practice-based diabetes education in English and Spanish offered to any Camden resident; 4) expanded inter- 1

professional collaboration for diabetes educators and advocates in Camden through the CCDC; and data sharing to better identify and coordinate care for diabetics. The Coalition engaged more than 27 partners to implement the Camden Coalition s Integrated Diabetes Care Program. The partners included: Camden hospitals o Cooper University Hospital o Our Lady of Lourdes Hospital o Virtua Hospital Two Federally Qualified Health Centers (FQHC) 12 primary care practices Social service agencies (Center for Family Services; Cathedral Kitchen; Joseph's House; AARP) Behavioral health agencies (Integrated Oaks; Rutgers Behavioral Health Services) ASSESSMENT AND PLANNING An assessment completed by the Centers for Disease Control and Prevention: National Diabetes Surveillance System revealed that the financial burden from diabetes patients living in Camden is high. Analysis of claims data from the three local hospitals, identified 6,711 patients living with diabetes in Camden accounting for 23,997 hospital and emergency department visits from 2002 to 2008, making the total charges $854,534,656. Equally important, the assessment revealed that the annual hospital and emergency department visits by diabetes patients increased from 3,122 in 2003 to 5,052 in 2008, an increase of 61.8%. This assessment phase underscored the need for addressing diabetes in Camden. In addition, a planning phase was used to design the diabetes intervention. The Coalition used the Chronic Care Model as a framework for action. This model combined a patient-centered health delivery approach with selfmanagement support, shared-decision making, community engagement, clinical system transformation, and organizational support. There were five phases for the intervention planning and implementation. First, the Coalition hired staff, planned the intervention, and prepared PCP offices and stakeholders for the Camden Citywide Diabetes Collaborative. Second, staff were trained, support groups were recruited, and exercise classes and food availability programs were prepared. Third, program activities were expanded within geospatial hotspots of greatest need within Camden. Fourth, program activities were continued, data were collected, and key learnings were disseminated. Fifth, data analysis was conducted and intervention findings were disseminated. INTERVENTION COMPONENTS The Integrated Diabetes Care Program included three intervention sections: a) enhanced diabetes care in primary care practice offices; 2) incorporate diabetes self-management strategies; and 3) enhance behavioral health support and community engagement through care management. The intervention was delivered by the Registered Nurse Clinical Coordinators (RNCC), Community Health Workers (CHW), and Licensed Practical Nurses (LPN), and Licensed Social Workers (LSW), and AmeriCorps volunteer health coaches), see mode of delivery in Table 1. 2

Table 1 below summarizes the Integrated Diabetes Care Program components, specific elements, and mode of delivery. INTERVENTION COMPONENTS Diabetes Self- Management Education Support for Managing Diabetes and Distress Enhanced Access/Linkage to Care SPECIFIC ELEMENTS (what was done) English and Spanish 4 part DSME class held in geographically accessible locations (e.g., community centers, churches, residential apartment buildings, primary care locations, etc.) Classes utilize a conversation map incorporating AADE7 self-care behaviors After DSME class patients interested join Healing SPIRIT and Circles of Peace programs offered in the community includes training in selfmassage and group massage Home-visits to reinforce education, help develop and set goals, and coach self-advocacy using motivational interviewing and goal setting to address the patient s needs Patients who have been admitted to the hospital are scheduled an appointment with their PCP within 7 days of discharge Patients identified through hospital utilization or the diabetes registry are enrolled in community care management services Improve Quality of Care Development of insulin titration protocols to improve clinical practices within Camden clinics. Monthly meetings with PCP Advanced access scheduling with one practice visit Deliberate on the data collection, process, and implementation strategy to reduce waiting times for appointments to under 3 days Working to get a citywide library of education materials that can be used by any primary care office across the city Community Creating referral loops with nutrition, exercise, Organization, and mental wellness programs Mobilization, and CDE meetings to discuss barriers and Advocacy opportunities in increasing practices 7 Day Pledge all primary care providers and their staff sign a pledge to try and see all hospitalized patients with 7 days of discharge Health System and Health Information Exchange (HIE) gets feeds Community from all three hospitals and few regional Transformation hospital networks and provides access to providers across the community on admissions, labs, and discharge reports HIE daily feeds provide real-time lists of primary care office patients who have been seen in the ED or inpatient setting the previous day allowing MODE OF DELIVERY (by whom and how) Diabetes Educators (English and Spanish) CHW Health Coaches Healing SPIRIT licensed massage therapists Sister Lucy and Fiona Hesketh Circles of Peace RN Eileen Donnelly-Coyle Home-visits LPNs and AmeriCorps Health coaches. IDC outreach team led by a nurse care coordinator 2 bilingual LPNs 3 AmeriCorps health coaches 1 CHW Program manager and nurse care coordinator meet with practice administrators and providers to discuss ongoing issues CHW Program manager and nurse care coordinator meet with practice administrators and providers to discuss ongoing issues Providers Camden Coalition for Healthcare Providers Hospitals 3

practices to target their outreach and be responsive to patient needs Diabetes Registries stores records of all diabetic patients and all of their A1c and it allow providers to segment their population, and target outreach STORY OF COMMUNITY TRANSFORMATION Redesigning Primary Care Delivery in Camden: Virtua Family Health Center A partnership between the Camden Coalition of Healthcare Providers (Coalition) and Virtua Family Health Center began informally over five years ago as a gathering of family practice doctors in the area sharing ideas on improving care in Camden. As the Coalition grew, it formalized this partnership with Virtua to redesign primary care practice. Initially, Virtua saw the Coalition as an outside resource providing support on tough to treat patients with diabetes or super-users, but through sustained collaboration efforts, the Coalition and Virtua have cultivated a partnership to transform how care is delivered at Virtua and in Camden. The Camden Coalition of Healthcare Providers embedded staff in the Virtua practice who used modeling, dialog, and coaching to: 1) streamline practice workflows, 2) incorporate the use of data for targeted treatment, 3) panelize patients, 4) implement group visits, and 5) shed light on the need for adaptive primary care for complex patients. Reflecting on the embedded staff, Dr. Bhalodia the Medical Director at Virtua stated, I ve learned a lot from the Coalition and the teams, the health coaches and nurses, on helping the patient understand their diseases and ways to coach them to empower them to learn their disease more [it s about] learning ways to help patients learn and manage their conditions better. The breakthroughs and success stories that Virtua Family Health Center patients have experienced has helped to solidify practice transformations and encourage further innovation, especially for those thought to never reduce their A1C or stay out of the emergency room. Partnering and practice redesign, however, have not always been easy, it requires persistence and commitment by both organizations. Despite the challenges Dr. Bhalodia, described the partnership as a no brainer that will improve his patients quality of life. Going forward the Coalition CHP will continue to work with Virtua to re-define the traditional staffing roles of nurses, medical assistants, health coaches, community health workers and social workers to create more efficient and effective primary care. STORY OF PERSONAL TRANSFORMATION John is a 44-year old man who had a difficult life. A former pro wrestler and without family or social support, he became homeless. John began to use drugs and even attempted suicide. He survived the suicide attempt but suffered seizures, anxiety, and depression. To make matters more challenging, John suffers from diabetes and is insulin dependent, has hypertension, and conditions were worsened by poor medication adherence. In one year, he had seven inpatient admissions and seven emergency department visits, making him both clinically and socially complex. Through his medical records, the Camden team was able to connect with John and link him to the needed resources. The team first accompanied him and provided him with transportation services to therapy, the PCP, and to social services. With the help of the team, he was able to stay at a shelter and eventually get his own 4

apartment. At the same time, he worked on managing his diabetes through medication adherence and lifestyle change programs. One-year post the intervention, John had two inpatient admissions, and only one emergency department visit. John noted, At first I was reluctant, but the communication and the relationship with the team is wonderful and very supportive. They are always in touch with me and assist me in meeting my goals. For example, guiding me to my new apartment and MICA program. I feel security with the team. I was not just left, put out in the middle of nowhere. They actually did what they said they were going to do and that made all the difference. EVALUATION RESULTS AND FINDINGS Data on Project Implementation Figure 1 displays the cumulative number of services provided by Camden Coalition of Healthcare Providers as part of the diabetes program. Services provided include DSME classes, home visits, medication reconciliation, case management services, linkages to community resources, and scheduling appointments. The results show steady implementation of program components from project onset (9/2011) to completion (6/2016). [Note: In a cumulative graph, each new activity is added to all prior activities. The steeper the line, the higher the rate of services that were provided]. Following the planning period (9/2011 to 1/2012), there was a marked increase in services provided. In May 2014, a third class, resulting in two English-speaking classes, one Spanish speaking class, and an increase in total services provided. 5

Figure 1: Services Provided Over Time Combined the two intervention teams to create the Clinical Redesign Team Data on Additional Outcomes For the medically and socially complex diabetes patients, the Coalition aims to reduce avoidable emergency department visits and hospital admissions through improved care management and coordination. From October of 2012 through December of 2015, the program has enrolled 295 patients. On average, patients had just under eight (7.8) chronic conditions, including diabetes. The most common conditions were hypertension (91%), hyperlipidemia (62%) and depression (55%). These patients also had social complexities: 73% had a mobility barrier, 38% lacked social support, 26% had a language barrier, and 3% were homeless. The intervention is high-touch and prioritizes in-person encounters at locations that patient feels safe and comfortable in. On average, 94 hours are spent on the patient in this time, with 83% of these hours spent in person. An average of 26.6 hours is spent with the patient in their home. Process metrics for the program include: Promptness of an initial home visits, with a target of 3 days (Figure 2) Promptness of primary care follow-up, with a target of 7 days (Figure 3) 6

Occurrence of medication reconciliation (Figure 4) Reduction of unhealthy days (Figure 5) Figure 2: Home Visits Completed Initial Home Visits Completed Percent of Patients Enrolled Who Had a Home Visit and A Home Visit within 3 Days of Hospital Discharge [Prior to Graduation] 120% 100% 80% 60% 40% 20% 91% 55% 96% 92% 46% 46% 86% 59% 96% 93% 50% 48% 82% 24% 73% 96% 95% 95% 35% 36% 38% 41% 92% 94% 17% 41% 0% 2012, Q4 2013, Q1 2013, Q2 2013, Q3 2013, Q4 2014, Q1 2014, Q2 2014, Q3 2014, Q4 2015, Q1 2015, Q2 2015, Q3 2015, Q4 Home Visits Completed 3 Day 7

Figure 3: Primary Care Visits Completed 120% Initial Primary Care Provider (PCP) Visits Percent of Patients Enrolled Who Had a PCP Visit and Percent of Patience Who Had a PCP Visit Within Seven Days [Prior to Graduation] 100% 80% 82% 88% 73% 91% 88% 93% 79% 73% 96% 95% 86% 83% 94% 60% 40% 20% 18% 19% 38% 27% 42% 41% 35% 24% 20% 48% 50% 17% 59% 0% 2012, Q4 2013, Q1 2013, Q2 2013, Q3 2013, Q4 2014, Q1 2014, Q2 2014, Q3 2014, Q4 2015, Q1 2015, Q2 2015, Q3 2015, Q4 7 Day PCP Visits 8

Figure 4: Medication Reconciliation Completed 100% Medication Reconcilliaiton (Med Rec) Percent of Patients Enrolled Who Had Medication Reconcillation Completed Prior to Graduation 90% 80% 91% 92% 8 86% 96% 86% 82% 92% 86% 86% 83% 76% 70% 69% 60% 50% 2012, Q4 2013, Q1 2013, Q2 2013, Q3 2013, Q4 2014, Q1 2014, Q2 2014, Q3 2014, Q4 2015, Q1 2015, Q2 2015, Q3 2015, Q4 % Med Rec 9

Figure 5: Reduction in Unhealthy Days To assess impact, MIT is currently conducting a randomized controlled trial (RCT). This process is necessary to rule out regression to the mean, and other threats to internal validity. During the RCT, a pre-post intervention admission rate will be monitored. Six months after enrollment, the Coalition observed a 49.1% reduction in the number of inpatient admissions when compared to the 6 months prior to enrollment in the intervention. Using an average in-patient stay cost of $5,159, derived from hospital claims data, this translates into a total savings of about $1,367,135 over the life of the program. Additional outcome proxies include a reduction in self-reported unhealthy days. At baseline, on average, enrolled patients with diabetes report feeling physically or mentally unhealthy to the extent that their activities were disrupted for 25 of the last 30 days. At 30, 60, and 180 days after enrollment, we are observing reductions in the number of self-reported unhealthy days, compared to baseline (Figure 5). The average number of unhealthy days reduced by 5.293 days at 30-day follow-up, 6.64 at the 60-day follow-up, and 6.839 at 180 day follow up.] All current indicators, both quantitative and qualitative, point to the program helping to reduce readmissions and improve patient health and health perceptions. However, these are not statistically validated and most robust analysis is required. 10

WHAT WE ARE LEARNING Camden Coalition staff identified restraining and facilitating factors for implementing the Integrated Diabetes Care Program. Restraining factors that made the program more difficult to implement included: Overcoming barriers to access such as bi-directional stigma between patients and healthcare providers, scheduling, availability of services in Camden (e.g., housing, mental health, transportation, and insurance). Working within and changing existing systems poses a challenge as the Clinical Redesign staff push providers to think and practice outside their traditional training and experience. Scaling the intervention poses a challenge around translating the complexity of this intervention into standardized workflows, while still maintaining flexibility for customized care to address the unique context and challenges faced by each patient. Maintaining perseverance poses a challenge for both staff and patients, especially when they are faced with failure in the short-term. Changing health systems, particularly when faced with roadblocks. Facilitating factors that made the program easier to implement included: Developing and implementing a patient-centered model of care proved successful in allowing providers to spend dedicated time with patients to understand their unique needs and address challenges through a coordinated team by meeting patients where they are. Providers are changing the culture of their practice, restructuring their workflows, and changing how they understand and interact with patients, and transforming the way they provide care. Building and maintaining a supportive, innovative culture is cultivated through practices of open dialogue, celebrating successes (no matter how small), continuous evaluation and correction, and exposure to ideas outside the organization. This collaborative culture shows great success in staff retention. MOVING FORWARD AND PLANS FOR SUSTAINABILITY The Camden Coalition of Healthcare Providers aims to sustain the Integrated Diabetes Care Program components and specific elements through various tactics of sustainability. Table 2 below outlines tactics for sustaining the intervention. TACTICS OF SUSTAINABILITY Share positions and resources with organizations that have similar goals Become a line item in an existing budget of another organization SPECIFIC EXAMPLES The Coalition currently uses staff resources across multiple primary care practices to address care coordination, quality improvement and patient engagement initiatives that are collaboratively agreed upon. Through the above tactic, we hope to build appropriate systems in place that would allow the practices to absorb the costs of these efforts and continue them by using existing practice staff resources. 11

Incorporate the initiative s activities or services into another organization with a similar mission Apply for grants Tap into available personnel resources Solicit in-kind support Pursue third-party funding Develop a fee-for-service structure Acquire public funding Establish a donor or membership base Through our Cross Site Learning program, we have engaged with 11 sites across the country as they implement initiatives to decrease healthcare costs and improve outcomes adapting the care coordination model used at the Coalition in their respective communities. The Coalition is actively applying for grants that would continue its efforts and support its infrastructure. The Coalition taps into available personnel resources within the organization as well as the community to help provide wrap around care for patients, and has been an extremely useful method to maintain consistent and ongoing communication with fellow staff and community members. In-kind support is solicited around technical assistance, data, evaluation, and performance improvement in our programming. This has proved to be very helpful as we strive to build an evidence base for this work. The Coalition recently signed an agreement with United Healthcare, a Medicaid Managed Care Organization, to provide care coordination services to their members. We are working with multiple practices across Camden to launch these efforts. Having third party funding is one of the main ways to achieve sustainability for the work. The Coalition is actively pursuing contracts with other Managed Care Organizations as well. As part of the Coalition s Cross Site Learning Program, the initial group of sites that received technical assistance were a part of a grant funded program. As that program is ending, the Coalition has launched technical assistance partners through a fee-forservice structure with 3 sites across the country, and plans to use this tactic as a method to achieving sustainability. The Coalition currently has a grant from Centers for Medicare and Medicaid Innovations (CMMI) and actively pursues public funding when aligned with project efforts. The Coalition currently has a large membership base that receives ongoing communications and progress. Turning this into a donor base has not been explored at this stage but the Coalition will look into it for the future. PROJECT PUBLICATIONS AND MATERIALS Project Publications: Kaufman, S., Ali, N., DeFiglio, V., Craig, K., Brenner, J. (2014). Early efforts to target and enroll high-risk diabetic patients into urban community-based programs. Health Promotion Practice, 15, 62S-70S. doi: 10.1177/1524839914535776 12

List of project materials (e.g., curricula, printed materials, etc.) Diabetes Self-Management Education curriculum is attached here as Appendix A. PROJECT CONTACT INFORMATION Stefan Lynch, RN Director, Clinical Redesign Camden Coalition of Healthcare Providers slynch@camdenhealth.org 856-365-9510 ext. 2018 EVALUATION CONTACT INFORMATION This case study was prepared by the Work Group for Community Health and Development team (Ithar Hassaballa, Charles E. Sepers, Jr., & Jerry Schultz) at the University of Kansas http://communityhealth.ku.edu, in collaboration with the Camden Coalition for Healthcare Providers, and as part of the evaluation of the BMS Foundation s Together on Diabetes initiative. Charles E Sepers, Jr, Evaluation Project Coordinator Work Group for Community Health and Development, University of Kansas Email: csepers@ku.edu Phone: 785-864-0533 Jerry Schultz, Co-Director Work Group for Community Health and Development, University of Kansas Email: jschultz@ku.edu Phone: 785-864-0533 13

Appendix A: DSME Class Outline The Diabetes Weigh is an 8-hour Diabetes Self-Management Education program that meets guidelines established by The American Diabetes Association. Goal: Patients will develop the skill to know their blood glucose response to food, medication, and exercise. With this skill, patients will be empowered to make lifestyle changes to improve their diabetes care. Bring Meds to first visit Class 1 Individual Assessment Medication Reconciliation, Personal goals, Financial, Insurance and Food insecurity, readiness, literacy, depression screening, Explore Problems or issues Message: You can delay or even prevent complications. Diabetes is a life-long condition and changes over time. Class Description Introduction Introduction: Name and when did you find out you had diabetes? Explain the difference between Type 1and Type 2 Diabetes. Explain the Causes and signs of diabetes. Introduction to Care Plan. Articulate Blood Glucose Goals. Knows own A1c, goal A1c Patient can fill out Care plan. Experiences the hope of DCCT and UKPDS Describe complications of diabetes and explains how to reduce risks. Verbalizes how avoid complications of diabetes. Who is at risk for hypoglycemia? Recognizes and demonstrates treatment of hypoglycemia. Verbalizes ABC s to reduce the risk of heart disease. States own A1c, Blood pressure, Cholesterol LDL. Will discuss with primary if at risk for Sleep Apnea. Will discuss with primary if at risk for depression. Knows Tests and Check-ups for good diabetes care. Verbalizes Healthy Plate Verbalizes connection between weight loss and blood glucose. Verbalizes and demonstrates how to select No Sugary Drinks Homework: Try to eat The Healthy Plate Way Bring in Meter 14

BHAVIOR CHANGE: NO SUGARY DRINKS, THE HEALTHY PLATE Brings Meter and Food logs Class 2 Individual Assessment Examine meter, Review Healthy plate log, Review Message, F/u on previous visit assessment Message: The only way your doctor can help manage diabetes is by seeing your blood glucose logs. Review use of meter. Recognizes the connection between day-to-day BG and A1c Names the times to check BG. States fasting and after meal blood glucose for a person without diabetes. Verbalizes the target BG for before meals, two hours after meals, and before bed. Review Hypoglycemia. Review physiology of blood glucose regulation Can state some of the metabolic problems associated with Type 2 Diabetes. Verbalizes three things that affect BG Use American Academy of Family Physician book to review food. Verbalizes and demonstrates how to select healthy starch foods: whole grain, low fat and the right portion size. Homework: Practice Pattern Management record keeping. Discover food choices that lower and or raise blood glucose. BEHAVIOR CHANGE: RECORDS BG AND FOOD FOR PATTERN MANAGEMENT. Bring Pattern Management Logs Class 3 Individual Assessment Review BG logs, Review knowledge of A1c, Review message, F/u previous assessment Message: You will need several medications to manage your diabetes. You need to be a detective and learn if food, activity or medicine is affecting your diabetes Use Conversation map cards and BG logs to determine blood glucose response to food using pattern management. Hypoglycemia treatment. 15

Brainstorm possible explanations for highs or lows in BG logs. Review medication types States the need for multiple medications in the management of Type 2 diabetes. Demonstration how to select healthy meats using food labels and food samples. BEHAVIOR CHANGE: PERSONAL MEDICATION GOAL Class 4 Individual Assessment Review Message, Review knowledge of hypoglycemia treatment (if applicable), review taking medication, demonstrate pill box. Address sustainability. Message: You are in charge of your diabetes--forming a team: you and your doctor- when to call goals your responsibilities, your doctor s job. Know the test needed for good diabetes care. Practices healthy foot care. Verbalizes need for foot exam, eye exam, influenza vaccination, and pneumovax. Discusses blood pressure and cholesterol goals. Examines types of exercise in their own life. Discovers blood glucose response to exercise. Treatment for hypoglycemia States Sick Day Guidelines. Have a sick day plan to prevent hospitalizations. When to call your doctor. Demonstrates selecting healthy fruits, vegetables and milk using labels and food samples. BEHAVIOR CHANGE: PERSONAL AADE 7 GOALS. Conversation Map Support Group will continue this work. If BG is high, we recommend coming back to this class at least two more times or Conversation Map. Revised 2012 16