The Burden of Diabetes

Cost-Effectiveness of Interventions for Preventing & Treating Diabetes Priority Level 1 Glycemic control in people with A1c>9 Blood pressure control in people with BP>160/95 Foot care in people at risk Priority Level 2 Preconception care Lifestyle DM prevention Influenza vaccine Annual eye exam Smoking cessation ACE inhibitors Priority Level 3 Metforming prevention Cholesterol control (>200) Intensive glycemic control in people with A1c>8 Screening for undiagnosed diabetes Annual microalbuminuria screening

Cost-Effecttiveness (QALY US$) of Diabetes Mellitus (DM) Interventions in Latin America & the Caribbean $10,000 DM Screening Cholesterol Control (>200) $5,000 Metformin Prevention Micro Alb Screening Glycemic Control (A1c>8) $0 -$5,000 Smoking Cessation ACE Inhibitors Influenza Vaccine Annual Eye Ex Lifestyle Prevention 0 1 2 3 4 Cost Saving Preconception Care Glycemic Control (A1c>9) Foot Care -$10,000 Feasibility Level BP Control (>160/95) Source: Disease Control Priorities in Developing Countries. Feasibility based on difficulty reaching target population, capacity, medical knowledge needed, capital required and social acceptability

Chronic Care Model HEALTH SYSTEM COMMUNITY Healthcare Organizations Resources & Policies Self- Management Delivery System Design Decision Clinical Information System Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Healthcare Organizations Visibly support improvement in chronic illness care at all levels of the organization Provide incentives to encourage better chronic illness care Facilitate care coordination throughout the organization

Six Focal Areas Community Resources & Policies Form partnerships with community organizations to support and develop interventions that fill gaps in needed services Encourage patients to participate in effective community programs Advocate for policies to promote health, prevent disease and improve patient care

Six Focal Areas Self-Management Emphasize the patient s central role in managing his/her health Use effective self-management support strategies that include goal setting, action planning and problem-solving Organize internal and community resources to provide ongoing self-management support to patients

Six Focal Areas Decision Embed evidence-based guidelines into daily clinical practice Share evidence-based guidelines and information with patients to encourage their participation Integrate specialist expertise and primary care

Chronic Care Model HEALTH SYSTEM COMMUNITY Health Care Organizations Resources & Policies Self- Management Delivery System Design Decision Clinical Information System Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Delivery System Design Define roles and distribute tasks among team members Use planned interactions to support evidencebased care Ensure regular follow-up by the care team Give care that patients understand and that fits with their cultural background

Six Focal Areas Clinical Information Systems Provide timely reminders for providers and patients Identify subpopulations for proactive care Facilitate individual care planning Share information with patients and providers to coordinate care Monitor performance of practice team and care system

Breakthrough Series for the Improvement of Chronic Care (6 13 months timeframe) Select Topic (develop mission) Participants Prework Planning Group Develop Framework & Changes LS 1 A P S D A LS 2 P S D A LS 3 S P D FINAL E-mail Visits Assessments Telephone Monthly Team Reports

Also known as: The PDSA Cycle Four Steps: Plan, lan, Do, Study, tudy, Act Shewhart Cycle Deming Cycle Learning and Improvement Cycle Act Study Plan Do

Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Study Plan Do

S D Repeated Use of the Cycle D S DATAP A A P S D Changes That Result in Improvement A P Hunches Theories Ideas A P S D

VIDA Project VIDA was a one-year intervention project focused on quality of diabetes care improvement in the state of Veracruz, Mexico. The intervention used the Chronic Care Model* and the Breakthrough Methodology* to promote collaboration between primary care teams to identify gaps in the provided care and find solutions.

Priority-setting: Diabetes Care Model Organization of diabetes care Community linkages Self management support: Establish: patient goals, dm education program, groups Delivery system design: Reference system, specialist care Decision support: Monthly meeting to ensure use of guidelines Clinical information system QUALIDIAB Informed activated patient Productive interaction Prepared productive team Better health for people with diabetes

The intervention plan included: A structured diabetes education program In-service training on diabetes management and foot care Innovative reference system with specialist visit Monitoring system (QUALIDIAB) Strengthen the Grupos de Ayuda Mutua (diabetic clubs) and the promotoras work In addition, primary-care centers were able to implement other strategies to respond to specific needs

Change Package Act Heath Team Integration Plan Educational Program Diabetes care improvement Patient : Grupos de Ayuda Mutua Glycemic Control Study Complications Prevention Do

Patient with good control (A1c< 7%) before and after the intervention among cases and controls 45% 40% 40% 35% 30% 25% 27% 24% 28% 20% 15% 10% 5% 0% Before (p 0.208) After(p 0.024) Cases (<0.00) Controls (0.276)

Foot Exam Reported Eye Exam Reported 100% 90% 97% 80% 70% 74% 80% 70% 60% 60% 50% 50% 47% 50% 40% 40% 30% 20% 10% 23% 30% 20% 10% 10% 4% 5% 0% Baseline (p 0.667) End (p <0.001) 0% Baseline (p <0.001) End (p <0.001) Cases (<0.001) Controls (<0.001) Cases (<0.001) Controls (0.51) 100% 90% 80% 70% Nutritional Counseling 82% 90% 80% 70% 60% Documented Foot Care Education 75% 60% 50% 40% 30% 20% 37% 46% 50% 40% 30% 20% 32% 20% 34% 10% 10% 0% Baseline (p <0.001) End (p <0.001) 0% Baseline (p 0.003) End (p <0.001) Cases (0.05) Controls (0.18) Cases (<0.001) Controls (<0.05)

Integrated Continuous Care 2006 Change Package: Nicaragua 2006 Implementation Evidence Based Clinical Guidelines Supplies Communication Coordination IMPROVEMENT OF QUALITY OF CARE BETTER QUALITY OF CARE Programa Educativo Blood Glucose Control Clinical Information System Educational Program Blood Glucose Control Training DM management Foot care Education Pan American Health Organization Prevention of Complications Change Package: El Salvador Change Package: Costa Rica 2006 Pan American Health Organization Prevention of Complications Change Package: Guatemala 2006 Integrated Care Electronic Record INFORMATION EDUCATION IMPROVE EDUCACIÓN: Family Schools Health Services Comunitaria PREVENTION/ CONTROL DIABETES, METABOLIC SYNDROME & OBESITY STRENGTHEN LOCAL NETORKS levels, institutions & community BETTER CONTROL OF DM Groups COMUNICATION CAPACITY BUILDING Pan American Health Organization Pan American Health Organization

Collaboration

Measure Implement Measure

Self-Management % of population with documented goals 100 80 60 40 20 0 Target Cycle 2 Cycle 3 Cycle 1 Cycle 6 %with highest rating 90 80 70 60 50 40 30 20 Patient Satisfaction (average for 2-week period - all diabetic patients returning surveys) identify all patients for survey include in plan for each patient visit target = 75% Glycemic Control Average % HbAlc 10 9.5 9 8.5 8 7.5 7 Target Cycle 4 Cycle 5 Cycle 7 Cycle 8 Cycle 9

Chronic Care Model HEALTH SYSTEM COMMUNITY Healthcare Organizations Resources & Policies Self- Management Delivery System Design Decision Clinical Information Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Chronic Care Model HEALTH SYSTEM COMMUNITY Healthcare Organizations Resources & Policies Self- Management Delivery System Design Decision Clinical Information System: CDEMS, DM CARD Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Chronic Care Model HEALTH SYSTEM COMMUNITY Healthcare Organizations Resources & Policies Self- Management Delivery System Design Decision : CHRC Clinical Information GUIDELINES Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Build up on existing strategies such as the CHRC guidelines, the Caribbean Protocol for Nutritional Management of Diabetes and Hypertension,, CCH3

Collaboration

To Do List Share information with the PAHO local office Define national and local teams Organize initial meeting Define scope (public, private, national, demonstration sites?) and select clinics Measure baseline Organize LS1: Implementation of the CHRC Guidelines. Pocket guide at least 30 health providers. Report by the end of January 2009 Implement changes, measure again and report Bring results to ILS-2 (March 2009)