ProviderReferralstotheNationalDPPatDenverHealthTamaraSwigert,MSN,RN,CDEDenverHealth&HospitalAuthority24February2017Tamara.swigert@dhha.org

ACPMLISTENINGSESSIONONCDC’S6|18INITIATIVEATUNIVERSITYOFTEXASATHOUSTONSCHOOLOFPUBLICHEALTH

DisclosureStatement

•  TamaraSwigerthasnoconflictsofinteresttoreportinassociaZonwiththispresentaZon.

NationalStatisticsandDPPOutcomes•  Basedon2009-2001A1CandFPGdata,itisesZmatedthat37%ofU.S.adultsaged20yearsorolderhaveprediabetes(approximatelyhalfofthose≥65yearsorolder).1

•  InFeb2002,theNEJMpublishedfindingsfromtheDiabetesPrevenZonProgramResearchGroup.3-yrstudyincludedmorethan3000subjectsfrom27centersacrossthecountry.2

•  Ofthe3arms(lifestyle,megormin,control),lifestyleintervenZonwasmosteffecZveatprevenZngdiabetes.•  LifestyleintervenZonincludedcoaching,moderateexercise(goalof150min/week),caloriereducZonwithandweightlossgoalof7%.Actualweightlossachievedwascloserto5%.

•  Reducedriskofdevelopingtype2DMby58%(71%forthoseoverage60).Megormingroupreducedriskby31%

•  DiabetesPrevenZonProgramsOutcomesStudyshowedthattheeffectisenduring(somewhat)10yearslater.3

1)CentersforDiseaseControlandPrevenZon(2014).Na%onaldiabetessta%s%csreport,20142)TheDPPResearchGroup,NEJM346:393-403,20023)DPPResearchGroup.TheLancet2009:Vol.374,No.9702.

NationalDPP:Creation&Coverage•  BasedoneffecZvenessofDPPstudy,CDCoffered“recogniZon”toprogramsthatcapturedessenZalelementsoftheintervenZon.

•  DiabetesPrevenZonActof2009directedCDCtolaunchtheNaZonalDPP,which“providesaframeworkfordiabetesprevenZonefforts.Itbringstogetherpartnersfromthepublicandprivatesectorstopreventordelaytype2diabetesintheUnitedStates.”

•  InJuly,2016,TheCMSannouncedproposedcoverageforNaZonalDPPprograms.PaZentEligibilityCriteriainclude:•  EnrolledinMedicarePartB•  Bodymassindex(BMI)ofat≥25ifnotself-idenZfiedasAsianoraBMIof≥23ifself-idenZfiedasAsian

•  DxofPreDM:HbA1ctestwithavaluebetween5.7and6.4%,aFPGof110-125mg/dL,ora2-hourplasmaglucoseof140-199mg/dL(OGTT)

•  Havenopreviousdiagnosisofdiabetes(type1ortype2);excepZonisgestaZonaldiabetes(GDM)

•  Donothaveend-stagerenaldisease(ESRD)

DenverHealth

•  Hospital-basedFederally-QualifiedHealthCenter

•  525-bedacutecarehospital;10primarycareclinics,16school-basedclinics

•  Servesapprox.150,000paZents(25%ofDenverpopulaZonandonethirdofallDenver’schildren)

•  PopulaZonisatHIGHriskforDM(approx.11,000paZentsoncurrentDMregistry)andatHIGHriskforDM-relatedcomplicaZons

•  Inlate2012DHreceivedfirststategranttolaunchtheNaZonalDPP,withfirstclassinMarch2013

•  DHNaZonalDPPnowfundedbytheStateofColorado,CDCinpartnershipwithAmerica’sHealthInsurancePlans,andinternalDHfunds

ProgramSpeci>ics,Recruiting,etc.

•  RotateZmesandlocaZonstoaccommodatepaZents.•  Employ“lifestylecoaches”(communityhealthworkers)whoarebilingual/bicultural;providespecializedNaZonalDPPtraining.

•  Createa“DiabetesRiskRegistry”usingEMRinformaZon(BMIandA1cinpreDMrangeorpasthxofGDM);includingdemographicandcontactinformaZon,aswellasPCPandprimarycareclinic/locaZon.

•  Create/produce/placepostersandotheradverZsements(Eng/Span);paZentsmayselfrefer.

•  Encourageproviderreferralsby:1)Introemail,toincludeinstrucZonsonhowtorefer,2)In-clinicpresentaZonsonnewprogram,and3)later,emailingPCPswithalistoftheireligiblepaZentsasneededtofillclasses.

•  TokeepPCPs“intheloop”oncepaZentisenrolled,emailwithinstrucZonsonhowtolocateinformaZoninthepaZent’schart.

Closed-LoopReferralSystem

Piper,S.,Piper,S.,Beaqy,C.,Blais,L.,Ritchie,N.,andPereira,R.(November2016).AADEInPrac%ce,pp.32-36.

EnrollmentintheNationalDPPbyreferralsourcefromFeb2013toMarch2014(N=6,200)

Pt.Iden)fica)onSource Targeted Enrolled Enrollment

RateOddsRa)o 95%CI

Total 6,200 969 15.6% -- --

Provider-Referrals 860 358 47.1% 5.52 4.70-6.47

Self-Referrals 176 95 54.0% 6.91 5.09-9.35

Nopriorreferral* 5,173 521 10.1% 0.14 0.12-0.17*IdenZfiedthroughregistryonly

Findings•  Self-referredpaZentsaremostlikelytojoinandparZcipate,but

paZentsdonotselfreferatahighrate.•  Ofthosewhowerecontactedandofferedprogram,almost1in2

enrolledwhenitwasendorsedbythephysician;onlyonein10enrolledwhentherewasnoproviderencouragement.

•  Massmailingswerenotcost-effecZve.ThispartoftheprogramwasdisconZnued.

RecruitmentfocusedonlocaZonandlanguagepreference

NationalDPPOutcomesatDenverHealth

•  Infirstyearalone,10,260personswithpreDMorhxofGDMwereidenZfied,plusaddiZonal341referralsnotonregistry.

•  Nowover2,500paZentshaveenrolledsinceMarch2013.•  60%LaZno,20%white,18%black•  47%Medicaidbeneficiaries•  Eachsessionleadsto0.3%weightloss•  3.0%averageweightforallparZcipantswhoaqend4+sessions

•  In2015,duetosuccessandneedtoincreasereach,DenverHealthMedicalPlanandAmbulatoryCareServicesbeganfundingtheprograminpart.

•  Unsolicitedproviderreferralsnowfillclasses;nomoreregistryrecruitmentneeded.1in2referredpaZentssignsup.

ProviderSurveyFindings(year1)•  30PCPscompletedsurvey;27/30(90%)hadreferredatleastonepaZenttotheNaZonalDPPatDenverHealth.

•  ALLthoughtatleast25%oftheirpaZentswereatriskforDM,onethirdthoughtatleast50%ofpaZentswereatrisk.

•  ReportedrelaZvelylowabilitytomanageweightloss(2.3onaLikertscale,with1beinglowest,5beinghighest).

•  AvailabilityoftheNaZonalDPPatDHcontributedtoincreasedsaZsfacZonintermsofavailableweightmanagementresources(meanscoreof4.0).

•  Agreementwiththefollowingstatements:•  IncreasetheirpaZents’awarenessofdiabetes(meanscore:4.2)•  ImprovedtheirpaZents’health(meanscore:4.2)•  HighlybeneficialtotheirpaZents’health(meanscore:4.2)

PhysicianChampion:AliciaAppel•  PrimaryCareproviderattheDHWestsideCommunityClinic•  PopulaZoninherurbanclinicismostlyHispanic(Dr.Appelisbilingual),lowsocioeconomicstatus,highriskforDM

•  PaZentpanelisabout2000paZents;acuitylevelishigh–largeporZonaregeriatricpaZents

•  SeespaZentseachmorningsession(20-minuteappointmentblocks)

•  Asoflastmonth,Dr.Appelhasreferred179paZentssincestartofprogram

•  WorksdiscussionofdiabetesordiabetesprevenZonintoalmosteveryvisit

•  Whyrefer?KnowsshedoesnothavetheZmetocoachondiet,exerciseandweightloss;NaZonalDPPprovidesthisservice!

InsightsfromPhysicianChampion•  CurrentStrategies:•  WhenA1clabcomesbackindicaZngprediabetes,shehastheopZontosendleqer(inEnglishorSpanish).

•  MakesureprediabetesisonpaZent’sproblemlist(ifapplicable)•  Discuss&endorsebutdonotpushtoohard:provideinformaZonabouttheprogramandgaugereadinesstochange

•  Whendiscussed,“smartphrase”putsintochartnoteandautomaZcallyprintsprogramflyeraspartofayer-visit-summary

•  Ifdefinitelyinterested,sheputsinthereferral(NaZonalDPPstafftakesit)•  Alwaysasksatfollow-upvisit…a)howtheNaZonalDPPprogramisgoing(offersencouragement)orb)iftheyhavegivenitmorethought

•  Considering/WorkingonImplemenZng:•  Best-pracZcereminderpromptsinEMR(basedonproblemlist)•  MakingNaZonalDPPinformaZoneasiertofindonDenverHealthintranet•  NaZonalDPPstaffaddnotesinEMR(enrollmentdate,biometrics,etc.)

LetterSentOut

ForMoreInformationontheNationalDPPatDenverHealth:

Piper,S.,Beaqy,C.,Blais,L.,Ritchie,N.,andPereira,R.(November2016).PathwaystodiabetesprevenZon:TworeferralmodelsfortheNaZonalDiabetesPrevenZonProgram.AADEInPrac%ce,32-36.

Ritchie,N.,andSwigert,T.,(July2016).EstablishinganeffecZveprimarycareproviderreferralnetworkfortheNaZonalDiabetesPrevenZonProgram.AADEInPrac%ce,20-25.