The Right Care at the Right Time Integrating

The Right Care at the Right Time: Integrating Nutrition Care for Diabetes into Primary Care Academy of Nutrition and Dietetics September 6 th 2017 This presentation is provided free-of-charge and is supported by Grant Number 1 L 1 CMS-331480 -01 -00 from the U. S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

Amy Allen, MPH RDN Amy Allen serves as a Member of the Nutrition Services Payment Committee for The Academy of Nutrition and Dietetics. She received her bachelors of Art from Kalamazoo College in Kalamazoo, MI, and completed her Registered Dietitian Internship and earned a Master’s degree of Public Health, Human Nutrition & Dietetics in Environmental Health Sciences from the University of Michigan. She has worked in this field for seven years.

Disclosure Nothing to disclose

Objectives Ø Describe how Medical Nutrition Therapy (MNT) improves outcomes in populations with diabetes Ø Integrate nutrition care for diabetes and related chronic conditions into various primary care models Ø Estimate the potential revenue streams for nutrition services provided by RDNs in primary care

National Diabetes Statistics Report, 2017 Ø 30. 3 million people have diabetes Ø 23. 1 million diagnosed Ø 7. 2 million undiagnosed Ø 12 million among those aged 65 years or older Ø 132, 000 children & adolescents < 18 years of age Centers for Disease Control

What is Medical Nutrition Therapy (MNT)? Ø An evidence-based nutrition service provided by RDNs to prevent, delay or manage diseases and conditions Ø A personalized, in-depth assessment, nutrition diagnosis and intervention treatment plan Ø Provided over multiple visits to positively impact nutrition behaviors and allow for continued personalized monitoring of the patient/client

The Nutrition Care Process Includes ü Nutrition Screen/Referral ü Nutrition Assessment ü Nutrition Diagnosis ü Nutrition Intervention ü Nutrition Monitoring and Evaluation ü Nutrition Documentation ü Outcomes Management

Alignment with National Practice Guidelines Standards of Medical Care in Diabetes

MNT Improves A 1 c & Reduces Cost Ø 0. 3 -2. 0% reduction in A 1 C 1 st 6 months (UKPDS) Ø 2% reduction in newly diagnosed when the A 1 C > 9% (LOADD study) Ø 0. 5% reduction in A 1 C in persons with Type 2 DM for ≥ 9 years with sub-optimal control Ø More cost-effective than adding a third medication (LOADD study) Ø 9. 5% reduction in hospital utilization (Lewin Group)

Impact of Reduced Glycemia Ø Lower A 1 C levels are associated with reduced onset or progression of microvascular complications. ” Ø 1% ↓ mean A 1 C levels associated with risk reductions: 21% for death related to diabetes 14% for myocardial infarction 37% for microvascular complications = ↓ avoidable spending (saves $)

Risk Factors for Complications of Diabetes ü Smoking ü Overweight and Obesity ü Physical Inactivity ü High Blood Pressure ü High Cholesterol (Hyperlipidemia) ü High Blood Glucose (Hyperglycemia) National Diabetes Statistics Report, 2017

Revenue from Services Provided by RDNs?

Codes for Medical Nutrition Therapy (MNT) CPT® codes Description Key Information 97802 Initial assessment and intervention Time-based code (15 minutes/unit) Individual face-to-face and via telehealth 97803 Reassessment and intervention individual face-to-face, and via telehealth 97804 MNT delivered in a group setting 2 or more individuals Time-based code (15 minute/unit) Time-based code (30 minutes/unit)

1 4 When Patients Need More Care: MNT beyond the standard benefit (3 hours/2 hours) Required: 2 nd referral from treating physician Criteria: medical necessity G 0270 Reassessment and subsequent intervention(s) 15 minutes following 2 nd referral in same year individual, face-to-face G 0271 30 Same as above, but for groups of 2 or more minutes individuals

Minimum Revenue Per Patient Standard Medicare benefit for MNT 2017 CMS fee schedule national rate/unit: 3 hours of individual MNT (1 st year): 97802 x 4 units @ $29. 89 = $119. 56 97803 x 8 units @ $25. 93 = $207. 44 = $327. 00 2 hours of individual (subsequent years) 97803 x 8 units @ 25. 93 = $207. 44 $534. 44 per client for 1 st two years

Improve Access to MNT via Telehealth

Related Services to Improve Care & Outcomes RDN Can Provide “Incident to” services: Ø Intensive Behavioral Therapy (IBT) for Obesity Ø Chronic Care Management Services Ø Annual Wellness Visit (AWV) Ø USPSTF Preventive Screening & Counseling

Integrating Nutrition- Getting Started

Business Relationship ü Employ an RDN (PT or FT) ü Independent Contractor ü Consultant ü Referrals to RDNs Private practice RDN or within IPA, medical group or system

Operationalizing Nutrition Care ü Population Management ü Services ü Practice Resources ü Delivery ü Measure outcomes/effectiveness

Set the Stage for Success ü Share confidence in the process, person and experience ü Explain what patient might expect ü Warm hand-offs ü Referral to an RDN to help patients live well with diabetes ü “Team sport” culture

Implementation Plan Do Act Study

Stories from the Field ü RDNs in Medical Homes ü Medication adjustment per protocol ü Manage registries ü Monitor labs ü Clinical quality targets ü Self-management ü Food insecurity pilot ü New service delivery methods

www. eatright. org/find-an-expert

Sources Ø UK Prospective Diabetes Study (UKPDS 7). Response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism. 1990; 39: 905 -912 Ø Coppell/LOADD study, cited by Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Ø Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2014: 7; 65 -72 Ø American Diabetes Association Standards of Medical Care in Diabetes 2017 Ø Stratton, I et al. , Association of glycaemia with macrovascular and microvascular complications of Type 2 diabetes (UKPDS 35): prospective observational study, 321 The British Medical Journal. 2000; Aug 405, 409 Ø Sheils J, Rubin R, Stapelton D. The Estimated Costs and Savings of Medical Nutrition Therapy: The Medicare Population. J Acad Nutrition and Dietetics. 1999; 99(4): 428 -435.

Q&A

Business Case For Nutrition Care-Academy of Nutrition and Dietetics Resource http: //www. tcpisan. org/wp-content/uploads/2017/09/Patient. Centered-Nutrition-Services-Payment-Model_-FINAL-9 -29 -16. pdf Organizational contact for this resource is the Nutrition Services Coverage Team at the Academy of Nutrition and Dietetics : reimburse@eatright. org or 800 -877 -1600.

Thank you! Amy Allen, MPH, RD Allena@careoregon. org Member, Nutrition Services Payment Committee Academy of Nutrition and Dietetics