Hi All,

Below is a condensed version of a NEW white paper just released by a multi-association "Diabetes Working Group" (*) (DWG).

The full white paper can be accessed at: https://www.aace.com/sites/default/files/20120123-DWG-WhitePaper.pdf

Executive Summary

Given the high and growing prevalence of diabetes, the chronic nature of the disease, lack of success in achieving desired patient outcomes, and the high cost of treating complications resulting from poor diabetes control, the barriers to providing optimal diabetes care must be brought to the forefront of the national healthcare discussion.

Many obstacles to achieving optimal diabetes care exist, including patient barriers (behavioral, psychosocial, and socioeconomic), structural and technological hurdles, and provider and delivery system concerns, among others.

While all interconnected and important, the DWG was formed in 2009 to focus on one crucial aspect of this problem:  provider and delivery system barriers to diabetes treatment.

Many obstacles to achieving optimal diabetes care exist.  The Diabetes Working Group (DWG) was formed in 2009 to focus on one crucial aspect of this problem:  provider and delivery system barriers to diabetes treatment.

To better understand these issues, the DWG undertook the following initiatives:

1)  Comprehensive literature review of peer-reviewed articles on current

     standards of diabetes care, outcomes evidence, and current health

     economics data of diabetes care and treatment

2)  Provider survey fielded to large sample of diabetes care providers

     in U.S.

3)  Theoretical Standards of Care Delivery Model designed to estimate

     necessary resources to consistently deliver current standards of care

     to diabetes patients inU.S.

The model illustrates the gap between the current provision of care and what is needed to improve patient outcomes to meet current guidelines.

The results of this extensive provider survey illustrate 5 provider-specific barriers:

1)      patient adherence

2)      time with patients

3)      compensation for care

4)      team coordination

5)      care management

BUT, 3 key provider barriers to optimal diabetes care emerged from original research conducted by DWG through the provider survey and economic model:

1)      Time with patients

2)      Inadequate reimbursement

3)      Patient adherence

The white paper provides recommendations on overcoming these key provider barriers to optimal diabetes care.

Care Management

1)  Increase use of shared decision-making opportunities with patients in

    the office setting to maximize patient engagement in self-

    management of diabetes

2)  Leverage existing HIT tools fully to assist patients in diabetes self-

     management and track performance

3)  Create strong provider teams and share roles and expectations with

     patients.

Payment Reform

1)  Appropriately reimburse providers for meeting standards of care in

     treating their patients by paying adequately for all services delivered

2)  Test and implement payment models that reward providers for

     supplying optimal care to patients with diabetes.

Workforce Supply

1)  Work to make diabetes care an attractive choice for new medical

     professionals through educational loan forgiveness

2)  Promote the importance of providing optimal diabetes care as an

     essential aspect of the healthcare system

3)  Expand access to diabetes modules to educate primary care providers

     on treatment of diabetes.

*DWG experts who contributed to paper represented:

• AmericanAcademyof Pediatrics
• American Association of Clinical Endocrinologists
• American Association of Diabetes Educators
• American Diabetes Association
• diatribe
• Endocrine Society
• Juvenile Diabetes Research Foundation
• Pediatric Endocrine Society
• Dr. Irl Hirsch, and Dr. William Tamborlane
• Avalere Health, LLC, who assisted DWG with coordination, research and writing efforts.

My first reaction is that we have heard this before (many barriers and solutions in Chronic Care Model) BUT it is all still so critical and relevant!

Have we made any progress in implementing these solutions?  

Your thoughts? 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Wow.  How timely.  That white paper is dated about one week ago.  I am currently working on preparing a proposal for the establishment of an exploratory committee to look at "Group Medical Appt." delivery of care for the ESC of our clinic.  The findings of the white paper totally support using group medical appt. care delivery system although they are not specifically mentioned in the paper.  Providers can bill for more patients in a designated amount of time and the pt's get more extensive "time" with a variety of provider groups such as pharmacy, podiatry, CDE, RD's etc...as well support group interaction with other pt's, in a similar amount of time spent attending a regular appt.  If you count waiting times!  JJDI's has a great powerpoint series on coding/billing for group/shared medical appt's which address the pay for svcs issues in the white paper to some degree.  Thanks for posting this.  Does anyone out there have experince working with a group medical appt. care delivery system and do you feel that it address the issues mentioned in the white paper from your observations.  I would love to hear about it. 

 Hi Sonia,

You blogged:

"JJDI's has a great powerpoint series on coding/billing for group/shared medical appt's which address the pay for svcs issues in the white paper to some degree.  Thanks for posting this."

I am one of the reimbursement instructors at JJDI (Johnson and Johnson Diabetes Institute) in San Jose, CA.!!  

Teaching about SHARED MEDICAL APPOINTMENTS (aka GROUP MEDICAL APPOINTMENTS) is one of my favoriate modules to teach there!  I'm actually presenting there next Thursday!

Let me know if I can help you with your project.  I have extensive PowerPoints from other presentations I've given on this new model of delivering chronic care management and education which outline in detail the reimbursement for SMAs (for all the disciplines involved), but also the detailed logistics on how to set them up, the study outcomes, etc.

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder

hodorowicz@comcast.net

PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Mary Ann -

THANKS so much for bringing our attention to this timely and important White Paper. It's now on my reading list!

You have encouraged me to mentioned two new fresh off the press publications:

- January issue of Health Affairs is on the Confronting the Growing Epidemic of Diabetes http://content.healthaffairs.org/content/31/1.toc.

- Systematic Review of Macronutrients, Food Groups and Eating Patterns in the Management of Diabetes, Madelyn Wheeler, RD, et al in Diabetes Care, Feb 2012.

This is one reason why I LOVE this eTalk. We share, we learn!

Hope Warshaw, MMSc, RD, CDE
Nutrition Section Editor, PRESENTdiabetes.com

Thanks for offering your support Mary Ann, I will most assuredly be calling on you for assistance.  When I listened to the GMA PowerPoint and recording in JJDI's website, I was really pleased that the speaker had experience in the military health system, as this is where I practice.  I plan to ask our coders look at that in the future.  I love this network opportunity.  I must say "coding" was a dirty word and I avoided all knowledge of it as my practice has never really required me to look at it much.  Someone else has always taken care of the details.  But after the presentation I sat in at JJDI by Reinhard Wolfgang, my understanding of the purpose and importance and practicality was greatly expanded.  I still don't like it, but you have to make money to keep providing services!  Might as well do it more efficiently so you have more time and resources to support the patients. 

I will add that my experience this past October at JJDI was the catalyst empowering me to be more of an influence where I work.  I gave a presentation to the clinical teams in my facility and spoke about CPG's (emphasizing "early insulinization" and offering my support in that endeavor) and gave an overview of DSME.  I got a significant increase in referrals after that.  My JJDI experience also caused me to  look further at Group Medical Appts.  The experience of doing case studies with a table group composed of Pharmacy, CDE's, Dietitians and Medical providers etc. really gave a greater sense of the benefit of using the team approach.  During the process of preparing the presentation of our plans for the care of the patient to the other groups in the room, I observed several changes in plans based on feedback of other disciplines focus on the patient as the discussion ensued.  The "big picture" perspective of multiple disciplines was incredibly valuable for the patient to get the best care decisions.  This just doesn't happen.  Group medical appts could give the best opportunity for this to happen maybe not fully, but to a greater degree.  So to all who have not attended, I highly endorse signing up for the opportunity to attend JJDI! 

Thanks for this information, Mary Ann. I hope this white paper results in some positive changes.

Is there a way to send some of the topics in the discussion on to others, aside from cutting and pasting?  This is such great information

Is anyone else disturbed that one of the top barriers mentioned is patient adherence? We've had this discussion before, and I know I'm repeating myself here but I feel it bears repeating:  folks follow the diabetes self-care programs that make sense to them and fit into their lifestyles. Their goals may not be the same as our goals, and when we label our patients as non-adherent or non-compliant, we're missing a golden opportunity to find out what is truly going on with that person and how we as health professionals can best help them achieve their health goals.

Instead of patient adherence as a barrier, I would list "providers not listening and/or not being trained to clearly communicate with our patients".

Amen Lynn.  I also suspect group medical appts would be a great opportunity to education other members of the health care team on where the real deficits in "patient compliance" actually exsist.  Everyone in the health care team would be able to observe the "entire process" and the effects of increased pt interaction times with a team of  HC provider,s and each other, and be amazed at improved outcomes.   Pt's with such an overwhelming, complex diagnosis with complex management just plain need more focused support.  In the current "acute care focused" delivery/reimbursement  method, these pt's are just more difficult to assist in the standard appt. slot times,  so it's easier to blame the pt than to acknowledge we've been given an impossible task with no easy solutions in site.

Exellent thought on the value of group medical appointments as a way to not only provide superior education to our patients, but also for providers to learn from each other and work together with the PWD to meet their needs.

Hi Lynn,

You blogged:  Is anyone else disturbed that one of the top barriers mentioned is patient adherence? We've had this discussion before, and I know I'm repeating myself here but I feel it bears repeating:  folks follow the diabetes self-care programs that make sense to them and fit into their lifestyles.

I'm sure this will stir up the pot, but here goes:

No matter how much we customize our pt's care plans to fit their lifestyle, and willingness and ability to change, many will still be non-adherent!

Why?  It's pretty simple.  In diabetes self-management and MNT, this is what patients perceive:  

1)  We add what they hate

2)  We take away what they love

And that's the plain truth!  

I often tell my audiences at CE programs that if we also took away sex, we would,  for sure,  NEVER SEE THEM AGAIN!

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Mary Ann, I'm going to respectfully disagree with you again about labeling folks nonadherent. You said:

Why?  It's pretty simple.  In diabetes self-management and MNT, this is what patients perceive:  

1)  We add what they hate

2)  We take away what they love

I agree that when medical practitioners dictate what folks need to do, or tell them what they should do, we're going to often come to an impass:  medical practitioners believe we're doing the right thing and are frustrated that our patients are nonadherent; and PWD are frustrated that their medical practitioners aren't listening to them or meeting their needs.

In short, we're miscommunicating. When we truly communicate, we listen to each other and the PWD guides the decisions about what changes she wants to make. There's no adding what they hate, because they make that decision themselves. There's no taking away what they love, because they decide what changes they want to make.

Sure, none of this is simple or easy and often no changes are made, at least not right away. That's OK, because in my mind, it's far worse for a PWD to feel frustrated and ignored than it is for us to tell them what they should be doing - and then they don't do it.

Until the medical practitioners change the way we work, stop labeling and dictating and start listening and communicating, we're not going to get anywhere.

Hi Lynn,

Beleive it or not, we ARE on the same page here!  I agree 100% with what you just said!  No DIS-agreement here at all! 

1) Labeling pts as "non-adherent" is incorrect: agreed!

2) Listening to them MORE than speaking/dictating to them is key: agreed!

(I teach this in my MI talks as the 80/20 Rule: pt to do 80% of the saying and doing; HCP to do only 20% of)

3) Need to individualize their care plans: agreed!

4)  They will change when they're ready and not before:  agreed!

But do some pts change, and revert back?  YES!.  Does this happen a lot?  YES. Do some pts never change?  YES! Why?  Because of human nature:

a) We all like what we like, and our habits get ingrained in our DNA the longer we live.

b) Humans tend to live in the moment or in present tense terms (aka, Scarlett O'Hara: "I'll worry about it tomorrow.")

c)  As such, most of us focus on today's QUALITY of life, not QUANTITY of life long term; most people do not have at the forefront of their brains when eating a piece of double fudge cake "This is going to shorten my life; I'm going to eat carrots instead".  Then we come along and have a MI discussion about the benefits of eating carrots instead of fudge cake, and ask them how carrots, instead of cake, will help them achieve their long term goal of health and quantity of life. 

Let me be a bit more specific about "taking away what they love and adding what they hate" in a more personal way.  No matter how well we do 1) through 4) above, it is human nature to not want to or like to modify what gives us pleasure.  

It's just the opposite: we SEEK pleasure in as many ways as we can get it!

In my own family, there are many who have diabetes.  They all see their

own HCPs (not me).  But we all talk about DSM and medical care because of what I do.  

I have watch their lifestyles deteriorate before my eyes over the years, in terms of eating, exercise, monitoring in a not-so-healthy way.  One of these individuals in my husband's cousin, a 51 y/o PHYSICIAN who now weighs 350# and is disabled due to the complications of DM.  When I met him he weighed 150#.

Despite what he knows, his thing is to "live for today".

When I had breast cancer 6 years ago, despite how horrible the treatments were, I was told to eat whatever I wanted so as not to continue to lose weight from the chemo (on my already thin frame). I was in heaven over this!  How often are we given permission from a HCP to eat whatever we want for our own medical benefit?

If this were the case with PWD, we'd be home free!

Carrots or chocolate cake, anyone??  

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

I agree with so much that has been said about the term "non-adherence". I am certain we all can give examples of health professionals...even diabetes educators....who do not, as they say "practice what they preach"

I think that no matter how much we try to individualize a regimen for a person with diabetes, we need to have the following

1. Their involvement in the decisions while the regimen for glycemic control is established

2. The understanding that there is no one time lifetime regimen...situations can change...and regimens established to achieve glycemic control also can be changed if they do not fit well as life progresses

3. We, as Diabetes Educators, need to have a person with diabetes who is in the acceptance phase regarding being a "person with diabetes" who is truly interested in having a regimen to achieve glycemic control.

It would be interesting to see how many patients Diabetes Educators  see for Diabetes Self Management Education that are truly at the acceptance stage. I would guess not a great number if you are working in a large health care system.

I think that no matter how much we try to individualize a regimen for a person with diabetes, we need to have the following

1. Their involvement in the decisions while the regimen for glycemic control is established

2. The understanding that there is no one time lifetime regimen...situations can change...and regimens established to achieve glycemic control also can be changed if they do not fit well as life progresses

3. We, as Diabetes Educators, need to have a person with diabetes who is in the acceptance phase regarding being a "person with diabetes" who is truly interested in having a regimen to achieve glycemic control.

I really don't like or understand the statement in # 3.  I feel the disconnect exsists when we only think a pt is successful if they have arrived at the "acceptance" stage.  I count success if a pt has made any progress in any of the stages  and if they just come in or back!  I feel it is my job to help them in the process.  Some people are by nature conformists and adapt easily and quickly to requirements, plans, rules. They respond to the teaching part of our jobs quickly. Others struggle and or have differing tools or strengths to work with.  Some need baby steps that don't match "our timeline".  They have no less validity.  They require the counseling we provide before the teaching will have much benefit.  Their weaknesses and strengths may differ and I search for strengths that may help progress in a different way than the "typical compliant patient".   Everyone has a different life experience and perspective and you have to understand everyone doesnt see things the way you do.  I understand the "urgency" HC providers feel to prevent longterm complications, but if you convey urgency sometimes it ends up taking longer because some people inately put on brakes when you do that.  Sometimes I sense a need  of healthcare providers to place blame with the patient because the patient has not reached the healthcare providers goals in the providers timeline.  That's not patient centered and it causes additional roadblocks because the patients sense it more than you know.  They tell me about it BTW. This is a lifetime process and everyone goes back and forth in the course of their lifetimes.  I have had this disease for so long and have been through every stage , some of them more than once. I consider myself pretty sharp and picked up quickly on the "teaching" but I responded best when I found educators who were good at the counseling part too. It's just like the grief process.  It's not necessarily a linear process sometimes.  I feel the need to accept the pt where they are and go from that point and I do it on a visit by visit basis.  If they have a "backslide" it is not a failure if they still come in or answer my calls.  I plan to have long term relationships with my patients as much as they'll let me.  I am pretty low pressure and let the pt's decide how much they want to engage, and I tend to make more progress with "difficult" pt's than some others who have had HX with the same patients.  If you only have  one picture of success in the field of DSME/T then you might think some patients are "non-compliant and I have to ask if you really understand the concepts in "motivational interviewing".  Failure is when they quit engaging, not when they are not at all their goals or not making changes, and the failure is mine not theirs. I just haven't successfully engaged in the "motivational interviewing process" or pt centered care.   You won't change my mind on that one. The job is that of counselor as well as teacher when billing is done.  I take the counseling part seriously. 

I really appreciate your well-thought out comments Sonia and I agree completely with you that there are several different ways of defining progress and success. Simply helping people move through the different stages of change on various aspects of diabetes self-management is success.

Here is my approach:

What can I do to help this person improve their health?  Not, what can I do to get this person to do x,y,z (my agenda)?

Just because a person had diabetes does not mean they are going to do what WE THINK they should do-EVER!  I think it is our job to determine what they WILL do and work from there.  What are they WILLING to do?  Can I negotiate with them from that starting point?  Etc.

One of my students recently wrote this on a case study:

"Considering that he is type 1, he needs to be very disciplined in keeping his glucose readings"

Another one wrote:

"I don't care if the patient is unhappy about checkign BG, if they want an insulin pump it is absolutely essential"

I was talking to a colleague that was working with a pump patient who wasn't bolusing correctly.  I explained that there was probably a reason WHY the patient was bolusing the way they were and she said, "yes, because they don't care"

In my opinion, these attitudes are the problem on our end.  Yes, the patient has a problem, but isn't it our job as EDUCATORS to educate?!  Because we are usually dealing with adults, I think an essential part of the education process is meeting them where they are at and moving forward WITH them from there. 

How very true that patient "success" can and should be measured in a multitude of ways!  

And, to go one step further, it is the PATIENT who can and should do the choosing anf measuring of their own selected goals (behavior and clinical)...as it is their perspective that counts, and not our's. 

Below is PART of the form I gave to pts in my DSMT program for them to select and track (measure) their own behavior goals (based on the AADE 7 behavior goals).  Pts choosing and tracking their own is an AADE accreditation requirement for DSMT programs.  The third column below should have the same content as the 2nd, but it would not copy correctly in this blog...the spacing is all wrong also.

If anyone wants the form in its entirety, just email me at:

hodorowicz@comcast/net

                                BEHAVIOR GOALS IN DIABETES

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Re: my statement #3. We, as Diabetes Educators, need to have a person with diabetes who is in the acceptance phase regarding being a "person with diabetes" who is truly interested in having a regimen to achieve glycemic control.

Hi Sonia

Thank you for pointing out my statement listed above that could, I am sure, have been clarified by stating it differently.   I have always stressed achievable goals when assisting people with diabetes along the continuum of their life...as well as when I prepare nurses to feel competent in assessment, plan of care (often changing along the continuum) and Diabetes Self Management Education. Success can often be in baby step progression, but each step is success if the goal is achievable.

What I meant was that getting the person with diabetes to the acceptance stage is the ultimate success. It is then that the person with diabetes owns the concept of self care being the reality of successful glycemic control that give the desired quality of life and prevents diabetes-related complications. That is what , I think, we all strive for with our patients.

Patricia, I apologize if I misinterpreted your statement, I have no doubt that your intent was as you just stated in follow up.  It just hit me wrong when I read it and and I reacted.  I hope you will forgive my strong words in my response.  Sonia

No problem, Sonia

I always welcome feedback. That is how we all learn about areas of  self improvement.

Thank you SO MUCH for introducing the white paper and other reading materials everyone. I would like to add to the reading list the patient's perspective from a very talented writer Sara Sklaroff in the Health Affairs article:"On Our Own: Why We Who Struggle To Live With Diabetes Could Use A Helping Hand."

This is a must-read for everyone planning coordinated care for your practice, expressing the thoughts of many of us PWDs.

Thanks for posting Sara's article, Bonnie. Several of her comments and suggestions hit home with me, but this made the biggest impact:

"One thing was striking about my magazine’s readers: the individuality of their diabetes. No one’s diabetes is quite like anyone else’s. What’s more, it can be unpredictable within a single body. What works one day might not work the next. We can do everything “right,” and still things will go wrong. "

I'm thinking I'd like to print this paragraph on all of our handouts and give it everyone I see with diabetes. I may even have it made into a poster for our office wall.