November: National Diabetes Month

Guest Blogger: Laurie Smith, LMSW, CDE MedNetOne

Happy Fall! We've just passed Halloween, Thanksgiving is right around the corner, and the Christmas season is upon us. It is also National Diabetes Month, a time to reflect on a disease that (by CDC estimates) is projected to affect one in three U.S. adults by the year 2050. 

While the American Diabetes Association (ADA) estimates that nearly 26 million Americans are living with diabetes, it also estimates that nearly 25% of those persons remain undiagnosed. The ADA also estimates that another 79 million people are now pre-diabetic. Therefore, the danger (and perhaps opportunity) of this disease lies at the intersection of early detection and treatment.

The concept of a Patient-Centered Medical Home (PCMH) provides an ideal framework in which to transform the way in which providers and patients engage in the prevention and treatment of chronic illnesses such as diabetes. Through this physician-led team-based approach to healthcare, patients are now receiving increased access to providers (RelayHealth online patient portal, extended hours access, etc.) and their team. Evidence-based care (annual depression screenings, preventative testing, etc.) is being delivered in more coordinated and effective ways at reduced costs and information technology is being used to better manage the health of PCMH patient populations.

Are you using Wellcentive to alert you to place reminder calls to your diabetic population to obtain their yearly foot exam? 6mth A1c? Other lab values? This is a tool available to us that can both increase our HEDIS scores and improve patient health and outcomes, not to mention patient satisfaction.

Another key feature of the Patient-Centered Medical Home is the use of a Care Manager. A Care Manager can assist the PCMH team with diabetes management in a number of ways: a coaching call between visits to address potential barriers to adherence; further disease education and/or clarification of PCP’s orders; goal-setting and problem-solving related to diet and exercise; closer tracking of referrals to specialty providers; brief intervention for depression and/or anxiety; etc. 

With the costs of treatment for diabetes in the US estimated at $245 billion in 2012, one of the most important strategies to combat this disease is prevention. The Patient-Centered Medical Home and use of a Care Manager are essential tools in this approach. Through targeted population-based health management, PCMH teams can utilize patient registries for early detection of this disease through identifying patients exhibiting other risk factors (such as family history, ethnicity, obesity, hypertension, hypercholesterolemia, etc.) and screening them earlier and at regular interval. Beginning to identify and treat pre-diabetes is key to reducing costs and improving overall treatment outcomes.

Finally, it is important to remember that the most beneficial prevention and treatment for diabetes can be seen through lifestyle change. Increasing our steps per day and reducing our portions are small steps that each of us can make on a daily basis to prevent diabetes. Sharing knowledge and encouraging our patients to set small, achievable goals can result in improved patient satisfaction. Reaching out to families and caregivers and getting involved in our community to promote healthy lifestyle intervention sends a message to our patients that we are as committed to combating this disease as they are.

For further information see the links below:

·       Visit the National Diabetes Education Program at www.YourDiabetesInfo.org for more information.

·       Small Steps. Big Rewards. Your GAME PLAN to Prevent Type 2 Diabetes helps people assess their risk for developing type 2 diabetes and implement a program to prevent or delay the onset of the disease. This resource includes an activity tracker and a fat and calorie counter.

·       Practice Transformation for Physicians and Health Care Teams is designed for health care professionals and administrators who want to change systems of health care delivery around diabetes.

MedNetOne – PCMH information: http://www3.mednetone.net/Providers/PCMHN.aspx

Are You Ready for 2015?

It’s that time of year again. Here in Michigan, autumn is in the air, the leaves are changing, the weather is turning colder and we are readying our homes and cars for winter. As our lives change with the seasons, so does health care. The title of this blog, “Are you ready for 2015?” is not a typographical error. In order to be ready for the future, we have to prepare in the present.

In July of this year, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would update current payment policies and rates for services furnished under the Medicare Physician Fee Schedule on or after January 1, 2014. The proposed rule in its entirety can be found at www.federalregister.gov. If the proposed rule becomes a final rule, physicians will be able to bill for managing select Medicare patients’ complex chronic care management needs. This is a positive step toward rewarding physician practices that provide chronic care services, especially those patients with multiple conditions and needs requiring additional resources. CMS is delaying payment till January 2015 because it knows physician practices will need the extra time to develop, manage and put the systems and processes in place to meet the standards.

The scope of services in the proposed rule may include some of the following:
§  Patient access to a health care provider  24/7 for urgent chronic care needs with access to the patient’s full electronic medical record even after the office closes;
§  Creation of a comprehensive care plan to address all aspects of a person’s health, congruent with the patient’s choices and values;
§  Management of care transitions including  referrals to other clinicians and timely follow up care after discharge from an ER visit, inpatient stay or skilled nursing facility, including the electronic exchange of  information;
§  Coordination of community based referrals; and
§  Utilizing secure messaging or other non face-to-face consultation methods with the patient.

Many of the proposed standards for providing complex chronic care management services are tied to the most recent Health and Human Services regulatory standards for Meaningful Use. The EHR must be integrated into the practice to support access to care, care coordination, care management and communication. For physician practices that are operating as patient centered medical homes (PCMH), there are suggestions to consider a nationally recognized PCMH practice as one means of meeting the care coordination standards for complex chronic care management services.  

Practice Transformation Institute (PTI) is a southeast Michigan leader in helping primary care practice teams transform to a patient centered model of care. PTI has classes available to help your practice attain the proposed changes coming in 2015. To meet the needs of national PCMH programs, PTI has trained coaches for NCQA’s PCMH Recognition program and URAC PCMH Certified Auditors for their Achievement program.

PTI is ready. Are you?  

Health Literacy

By Ginny Hosbach, RN, MSN

Health literacy is the ability to read, understand and act on health information. About 90 million Americans (nearly 1 in 2 adults) do not understand basic health information, according to the Institute of Medicine (IOM) Report.  By some IOM estimates, low literacy levels cost the healthcare system more than $58 billion annually.  The Partnership for Clear Health Communication is the first national coalition of organizations who are working together to promote awareness and solutions around the issue of low health literacy and its effect on health outcomes. This organization supports the findings in the IOM report, “Health Literacy: A Prescription to End Confusion.”

The organization’s first initiative is “Ask Me 3”, a quick and effective tool designed to improve communication between patients and providers. “Ask Me 3” promotes three simple but essential questions that patients should ask their providers in every health care interaction: What is my main problem? What do I need to do? And Why is it important for me to do this?

“Ask Me 3” provides tips for clearer health communication.  Some of these tips include having the patient commit to asking these 3 questions, bring a friend or family member to help at their doctor visit, make a list of health concerns to tell their doctor or nurse, bring a list of all medicines, and ask their pharmacist for help when they have questions about my medicines.

Is your patient able to read their prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms? What is their numerical or computational ability to calculate or reason numerically? With the development of the Internet as a source of health information, health literacy may also include the ability to search the Internet and evaluate websites.

There are three tools that were designed to specifically measure health literacy, The Test of Functional Health Literacy in Adults (TOFHLA), The Rapid Estimate of Adult Literacy in Medicine (REALM) and the Newest Vital Sign (NVS). Check these out for use in your situation.

Offer help confidentially, provide privacy and be non-judgmental. Offer assistance and get feedback from the patients to identify what they know.  Use the teach-back and show-back strategies to identify the patient’s understanding of the information provided. 

PTI and NCQA in Austin, Texas!

Austin, TX

Practice Transformation Institute’s Lisa Allen, RN, BSN, and Carla Irvin, RN, BSN, braved the hot, humid weather of Austin, Texas to attend training on NCQA’s Patient Centered Medical Home (PCMH) Recognition Program. With the comprehensive knowledge they gained about the requirements, application process and documentation of the NCQA PCMH Recognition Program, they can now help practices work toward this important national achievement.

With over 6000 recognized practices in nearly every state, NCQA’s PCMH Recognition Program is the most sought after and widely accepted PCMH program in the nation. Becoming NCQA recognized requires deliberate strategies and efforts in transforming a practice into a medical home.

NCQA is a private, non-profit organization dedicated to improving health care quality located in Washington, D.C. They are committed to providing health care quality information for consumers, purchasers, health care providers and researchers.

URAC Patient Centered Health Care Home Practice Achievement Program

Practice transformation realigns an office to become patient-centric. This is a tough job for a practice to accomplish as it takes a lot of time, effort and patience. All team members need to be engaged in the transformation process to make it a success. If a practice wanted to be formally recognized for their efforts, there are many PCMH recognition programs at the state and national levels.

One of the reasons that PTI recommends URAC’s Patient Centered Health Care Home (PCHCH) Practice Achievement Program is because it requires a comprehensive onsite review. Only through a physical onsite can a true culture change and transformation to a PCMH model of care be determined. This cannot be done by uploading paperwork to a website.

An onsite review:

·      Determines behavior change

·      Reveals adaptation to the PCMH philosophy

·      Shows how your team has transformed

·      Validates how your policies, procedures, processes and documents support 
 URAC PCHCH Standards and Elements

·      Establishes how the practice monitors quality improvement activities

The objectives of practice transformation are to become a better practice, a better team and a cheerleader for your empowered and engaged patients. Don’t just go through the motions. Improving quality of care is the primary goal. Let that be your inspiration.

Prepare, Transform, Improve: Website Makeover

Practice Transformation Institute underwent its own transforming process recently as we undertook a total redesign of our website. As in any change process, we had to start where we were and ask ourselves numerous questions to lay the groundwork: What information to keep? What type graphics would we like to use? What keywords or phrases will people use to search for our services? What do we want it to look like and what DON’T we want it to look like? What company do we choose for designing it? What is our budget? How long will it take? Will the web company’s deadlines mesh with our internal workload? Who will maintain it once it is done? These and many other questions were discussed and bantered about. Once completed and we were testing it, more questions came up: Is the website easy to read?  Is it easy to navigate? How consistent are the graphics, typeface and content throughout the site? It took a team effort to make these decisions and more as every department was affected.

Was it work? Yes!

Was it fun? Yes!

And the new site was worth the effort. It looks fresh, is easy to navigate and allows PTI staff to update it as our program offerings change. We invite you to visit the site at www.transformcoach.org.  While perusing our new site, connect with us on Facebook, Twitter and Linked-in.  We’d love to hear what you have to say.