Diabetes Continuum of Care and the Arizona Diabetes

Diabetes Continuum of Care and the Arizona Diabetes Alliance Donna Zazworsky, RN, MS, CCM, FAAN Vice President Community Health and Continuum Care

Objectives • Discuss the new advances and reach of Carondelet’s Diabetes Continuum of Care • Provide an overview of the Arizona Diabetes Alliance

Guiding Strategic Initiatives • Establish Carondelet Diabetes Care and Outreach as the premier source of diabetes education and selfmanagement • Build and strengthen partnerships with Carondelet, Carondelet Medical Group and the community to maximize and leverage resources • Establish the Carondelet Diabetes Education Institute to increase the number of qualified health professionals to teach diabetes in our communities • Continue to influence diabetes care through research in evidence-based practices and policy initiatives.

Carondelet Diabetes Care Continuum Carondelet Diabetes Education Institute In Patient Diabetes Educators In Primary Care Patient Community Partners Faith Community Nursing Diabetes Care Center Telehealth Services

In Patient §In Patient Advanced Practice Nurse Educators §Referrals to Out Patient DSMT & Diabetes Educators in CMG offices

Out-Patient ADA-recognized Diabetes Self Management Training Program §St. Joe’s and St. Mary’s Hospitals §Satellites at Carondelet Heart & Vascular Institute, Green Valley Medical Mall, Primeros Pasos & El Rio CHC (OB Gestational), St. Elizabeth Health Center (uninsured), Mt. Graham Regional Medical Center (Safford), University Physicians Hospital, Holy Cross Hospital (Nogales) §Physician Office Referral Pads: Type 1, Type 2 & Gestational §Barrier-free access: Medicare, Third-Party, Self Pay, Charity §Certified Diabetes Educators (RN, RD) & Promotoras §Provide over 5000 visits annually

DSMT A 1 C Results • • CSJ Pre 7. 6 % CSM Pre 8. 8% GV Pre 9. 75% MTG Pre 8. 8% Post 6. 4% Post 7. 0% Post 7. 1%

Carondelet Medical Group Diabetes Educators leased to Carondelet Medical Group (CMG) Primary Care Offices (n=11 offices) ØDiabetes Nurse Educators ØDietitians ØDiabetes Navigators

Diabetes Clinics with Health Plans § Annual Eye and Foot Exams § Medical Nutrition Therapy § Vital Signs and Labs

Community Health Outreach Workers • Lay Workers in Carondelet Diabetes Continuum • Promotores: Hispanic • Navigators: Primary Care Offices • e. Promotoras: Facilitate telehealth activities • General Certificate & Specialty training • Service Coordination, Self-management support, data collection & management 11

e Promotora/Navigator 12

Carondelet Telemedicine Services Tele. Diabetes Services -Tele. Ophthalomogly -Medical Nutrition Therapy -Tele. Diabetes Day Clinics Telederm Telecardiology Tele. Professional Classes -Diabetes -Cardiology -Neuro

Tele. Ophthalmology Improve number of Annual Retinopathy Exams

16

Dark Eye

Light Eye

Abnormal Eye

Tele. Diabetes Classes

CHN continues to provide Medical Nutrition Therapy Consults, Diabetes Day Clinics & Classes Page Amado

Diabetes Nutrition Teleconsultation Patient & Promotora Mariposa CHC, Nogales, AZ

Phoenix Indian Medical Center Diabetes Education Core Classes Carondelet Diabetes Education Institute Graduated over 1000 health professionals 150 in Rural Communities

CDEI Advance Classes Gestational Diabetes, Type 1, Insulin Pump, Wound Care, Renal Care, Promotora/MA Series

Diabetes Tele-Turnkey Models • Mount Graham Regional Health Center, Safford, AZ (ADHS Grant): established diabetes continuum of care • Southeast Texas Health System: 8 Critical Access Hospitals • St. Alphonsus, Boise, Idaho 25

Virtual Diabetes Day: UA Mobile Health Unit, MGRMC & Carondelet for Diabetes Day at Canyonland CHC in Safford

Telementoring from Tucson

Carondelet Person-Centered Care in Primary Care 28

CMG Diabetes Disease Management Program Diabetes Scorecard Patient Grade Annual Cost per Patient A $1, 621 B $3, 405 C $9, 720 D $21, 003

Carondelet Medical Group: Scorecard Elements Hb. A 1 c Blood Pressure LDL Neuropathy score Retinopathy score GFR 30

CMG Diabetes Intervention Grid • PCP Visits (EHR Diabetes Template) • Diabetes Nurse Educator Visits • Telehealth monitoring for high-risk patients • Dietitian Visits • Behavioral Health Visits for Chronic Disease • Diabetes Day Clinics for annual exams • Diabetes Navigator (Promotora) • Patient Incentives (Food Cards) • Pilot in CMG Offices 31

Telehome monitoring 32

Mercy Care Partnership beginning July 2011 Payment Reform LOI submitted: High Value Care Improved Chronic Care Personalized Care Plan Grade Assigned Shared Savings with Payee Better Outcomes Patient Identified Pay 4 Performance Cost Savings Payer 33