Overview

A team-based, multidisciplinary approach to treating patients with uncontrolled type 2 diabetes

Organization Name

Brigham & Women's Hospital Advanced Primary Care Associates - South Huntington

Organization Type

• Academic Medical Center
• Community outpatient clinic

Local/Organizational Context

• Brigham & Women’s Hospital (BWH) Advanced Primary Care Associates – South Huntington is a Patient Centered Medical Home
  • It is an affiliate of Brigham and Women’s Hospital, an academic medical center affiliated with Harvard Medical School
• The clinic was founded in 2011 with the goal of implementing team-based care

Patient Population Served and Payor Information

Referral base is BWH primary care patients

Payor Case Mix:

• 20% safety net – Medicaid, dual Medicare/Medicaid eligibility, Neighborhood Health Plan
• 20% Medicare
• 50% commercial Massachusetts payers – i.e. Blue Cross Blue Shield Massachusetts, Harvard Pilgrim
• 10% national commercial payers

Leadership

• This clinic is led by Dr. Stuart Pollack who is medical director and attending physician at South Huntington Primary Care.
• He, along with clinic administrative leadership, developed the co-management program and hired the clinic’s pharmacist Kaitlin O’Rourke and dietitian Mara Sansevero with diabetes co-management in mind.
• The program has been refined by all participants over time.

Research + Planning

• The clinic conducted an analysis, consisting of research and discussion, to determine which types of non-physician providers could best deliver adjunct diabetes care across the spectrum of primary care. It was determined that pharmacists and dietitians have good access to patients and increase positive outcomes in type 2 diabetes patients based on previous interventions studied. (Kiel, PJ and McCord, AD. “Pharmacist Impact on Clinical Outcomes in a Diabetes Disease Management Program via Collaborative Practice.” Annals of Pharmacotherapy, 39:11, 2005.)

• • The pharmacist and dietitian involved were specifically hired with diabetes management in mind, with the clinic expecting about 50% of their time to be spent managing diabetes.
  • This is a team-based approach to diabetes care in which patients with uncontrolled type 2 diabetes see and communicate routinely with a dietitian and/or pharmacist.
  • High risk patients are identified by a medical provider when seen in clinic and/or by the Population Health Manager who monitors clinic-wide HbA1c’s monthly.
  • High risk patients are defined as having:
    • A1c ≥ 9.0%
      OR
    •  Uncontrolled DM2 (A1c ≥ 7.1% or A1c ≥ 8% for 70 yo) or Controlled DM2 (A1c < 7.0%, A1c < 8% for age > 70 yo) with at least one of the following issues:
      • Social complexity
      • Uncontrolled, high-risk diabetes complications
      • Other uncontrolled high-risk co-morbidities
• • A Collaborative Drug Therapy Management (CDTM) Protocol is signed by both the pharmacist and supervising physicians, and follows applicable disease state protocols and guidelines.  Pharmacist must also be approved by the institution credentialing committee.
• Certified Diabetes Educator (CDE) certification is encouraged for team members.

Tools or Products Developed

• Patient friendly handouts on diabetes topics designed in English and Spanish
• Periodic internal review of data from pharmacist/dietitian intervention

Training

• The pharmacist and dietitian maintain their appropriate licensure per state and federal regulations, including Continuing Education requirements which include diabetes related topics.
• The pharmacist must maintain active credentialing within the institution, updated CDTM protocols with supervising providers, and periodic competency exams.
• Providers, including attending physicians, residents and physician’s assistants, meet with the dietitian and pharmacist to learn about new medications and glucometers as needed.
• No clinic-specific training, but cultural competence and “soft skills” were prioritized in hiring decisions.

Tech Involved

• Epic
• Glucometer software
• Patient Portal

Team Members Involved

• Dietician
• PAs
• Pharmacist
• Physicians

Workflow Steps

1. Physicians first establish care with patient and after determining that the patient could use additional support to control diabetes, will refer to the dietitian and/or pharmacist. If available, the provider will introduce the patient to the dietitian and/or pharmacist during the visit for a ‘warm handoff.’
2. The dietitian and/or pharmacist typically divide patients based on patient needs: a patient will be scheduled to meet with the pharmacist if they need guidance with medication initiation/titration, and with the dietitian if the focus is lifestyle modifications. Both the pharmacist and dietitian can provide disease state information and glucometer/insulin teaching.
3. Patients are often scheduled to meet with the pharmacist and dietitian as a team, especially if the need is multifactorial. The pharmacist and dietitian then determine if both resources are needed for ongoing follow up, or if one will be the primary provider.
4. If patients require intensive follow up to manage their diabetes, they will be scheduled alternating between the pharmacist and dietitian so they are seen more frequently.
5. The pharmacist monitors appropriate labs, including HbA1c and prescribes/titrates diabetes medication(s) per the CDTM Protocol and applicable disease state guidelines.
6. In between clinic visits, high risk patients receive regular outreach consisting of at least 1 phone call/week from the pharmacist. More stable patients receive 1-2 phone call(s)/month from the pharmacist. Communication also occurs electronically through Patient Gateway.
7. In between clinic visits, the dietitian communicates with the patients periodically by phone or Patient Gateway messages, since lifestyle changes take longer.
8. All patient interactions are documented in an electronic medical record and communicated with the primary care provider.
9. The pharmacist and dietitian do not bill for their visits, therefore eliminating patient restrictions on number of clinic visits or outreach attempts.

Budget

Budget Details

• Pharmacist and dietitian salaries were considered when deciding who to hire.
• In Massachusetts, RNs can have similar salaries to pharmacists, however pharmacists can prescribe under CDTM and act as an additional drug information resource to clinic staff.
• Dietitians are less expensive than RNs and embedding them into the clinic provides optimal access for lifestyle focus.
• In other states, salaries for non-provider clinicians, including RN’s, may vary and therefore a clinic may prefer to hire an RN since they could titrate insulin under protocol.
• Budget set by BWH.

Where We Are

• This intervention is currently ongoing.
• BWH is planning to scale pharmacist involvement across primary care, but budget and inability to bill for services has delayed this process.
• In prior months, a shared medical appointment was conducted in which a provider, dietitian, and pharmacist met quarterly in a group visit with 5-10 patients with diabetes. The future phase of this will consist of a shared appointment with 10 patients co-led by the dietitian and pharmacist. These appointments will be education based.
• The pharmacist/dietitian work alongside the Population Health Manager to monitor and analyze the Internal Performance Framework (IPF) metrics for the diabetes registry at the clinic.

Outcomes

• For each individual patient, ability to reach HbA1C, lipid, and blood pressure goals are being tracked.

Benefits

• The main benefit of this intervention is to increase patient access to clinic resources. Patients can communicate with the dietitian and pharmacist more frequently than they can with physicians. The pharmacist and dietitian can spend more time focusing on pharmacologic and lifestyle factors, respectively, than a physician alone can.
• Teams are better able to devise solutions than individuals alone, and can contribute their expertise.
• The dietitian and pharmacist call patients weekly or monthly as needed, changing the frequency of outreach as patient’s acuity fluctuates. They can see patients on the same day or stagger appointments so patients requiring more intensive follow up can be seen more frequently.
• There is not a visit copayment or insurance limitation on frequency of visits, so patients have no barriers to access the pharmacist/dietitian schedule.
• Appointment length and frequency are more robust when scheduled with the pharmacist/dietitian in comparison to the limited access and short appointment slots often available for physicians.
• Physicians and PAs consult the pharmacist for new medications and updates to guidelines, increasing treatment options for uncontrolled diabetes.
• Patients can receive their glucometer and be trained in using it the same day. Demos are available for insulin, so patients can receive proper injection technique counseling prior to starting their medication immediately.

Unique Challenges

• There is no specific enrollment period, so actively managing all the uncontrolled diabetes patients at the clinic is improbable.
• Patients with social complexity, competing co-morbidities and/or lack of motivation create challenges for diabetes management.
• Resource constraints may limit how many patients with uncontrolled diabetes are seen.

Personnel Challenges

• Because this is a team-based model, communication and interpersonal challenges arise.

Glossary

Massachusetts Regulations for Collaborative Drug Therapy Management

https://www.mass.gov/files/documents/2017/12/18/247cmr16.pdf

Metrics

Key Quality Metrics: 

2018 MIPS Quality Payment Program (QPP) Measures:  Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Providers may be able to improve their performance on a number of these metrics by improving care for high risk diabetic patients. Sample metrics include:

•  Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
  • Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.  This is a high priority measure.
• Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  •  Percentage of patients – all considered at high risk of cardiovascular events – who were prescribed or were on statin therapy during the measurement period.  One high-risk subgroup includes adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

More details can be found here.

Medicare Shared Savings Program (MSSP) ACOs: Clinics associated with an MSSP ACO are required to report their performance on measures for Hemoglobin A1c (AbA1c) Poor Control (>9%).  More information about this measure and requirements can be found here.

HEDIS Diabetes-Related Measures: The HEDIS Comprehensive Diabetes measure for 2018 includes components for:

• A1c testing
• A1c control or lack of control
• Eye exam
• Attention for nephropathy
• LDL screening and LDL control

More information available here.

Medicaid ACOs: As of 2017, a number of states operating Medicaid ACO or ACO-like programs included measures related to diabetes care in order to assess quality.  Most commonly, these measures assess the percentage of patients with an A1c that is controlled/uncontrolled.  Most states require participating organizations to submit diabetes quality measure performance; in some cases, submission is voluntary.  More information can be found here.

Commercial Insurance: A number of large commercial insurers use provider performance on at least one diabetes metric (typically the HEDIS composite diabetes metric) to either award bonus payments or determine a provider’s quality tier. Examples of such programs include those sponsored by United Healthcare, Humana, and Aetna.  For information on programs offered by other insurers, providers should visit each insurer’s provider portal.

Direct Billing

Beyond services provided by physicians or nurse practitioners, practices may be able to bill for additional services provided.  Practices may be able to bill for dietician services delivered to Medicare patients with Diabetes if those services meet criteria for Medical Nutrition Therapy (MNT).  More information about billing for MNT can be found here.  Practice-embedded pharmacists may also be able to bill certain commercial insurers for their services, depending on the practitioner’s state and the specific insurer.  More information can be found here.