Florida’s Diabetes Master Clinician Program Offers Patients Higher Quality of Life | Health
Dr. Edward Shahady, Associate Faculty Member at St. Vincent’s Hospital leads the program locally and statewide; Baptist Primary Care office in Ponte Vedra one of eight clinics recognized as a Center for Diabetes Excellence
Bridging the gap between knowledge and patient performance, the Florida Academy of Family Physicians (FAFP) Foundation Diabetes Master Clinician Program offers physicians an edge on a disease that’s the sixth leading cause of death in the United States, the leading cause of renal failure (end-stage renal disease), non-traumatic limb amputations and blindness, and the leading contributor to cardiovascular disease.
Higher quality of life, lower mortality rates, and yearly cost savings totaling more than $4.4 million are the documented patient results since the program launch in 2003. There are now 104 Florida practices participating in the Diabetes Master Clinician Program (DMCP) representing 18,657 patients and 83,371 visits. The yearly cost savings for all patients in the DMCP program is based on information from the Bridges to Excellence website which provides an actuarial evaluation of the estimated per-patient savings for physicians who achieve recognition through the Diabetes Physician Recognition Program (DPRP), a national program cosponsored by the American Diabetes Association (ADA) and the National Committee for Quality Assurance (NCQA).
"Diabetes is a complex disease that may be the most difficult of all chronic diseases to manage in primary care settings. The Florida Academy’s DMCP offers tools to help primary care physicians and their patients attain life-sustaining goals that surpass the national average for hemoglobin A (A1C), LDL cholesterol and blood pressure,” said Dr. Edward Shahady, DMCP medical director for the FAFP Foundation in Jacksonville, Clinical Professor of Family Medicine at the University of Miami, and associate faculty member in the residency program at St. Vincent’s Hospital in Jacksonville.
Using an Internet-based diabetes registry, a team approach and group visits, physicians have access to reports that facilitate patient population management and make one-on-one office visits more efficient and of higher quality. A “patient report card” listing patient weight, blood pressure, hemoglobin and cholesterol numbers among other indicators empowers patients to better self-manage their diabetes.
“The complications associated with diabetes lead to excessive suffering, increased use of healthcare resources and excessive costs,” Dr. Shahady said. “That’s why the use of the FAFP Foundation’s DMCP is so essential. Based on goals set by the ADA, we’ve seen patients reach 57 percent goal achievement for A1C, 56 percent goal achievement for LDL, and 55 percent goal achievement for blood pressure. Nationally, only 48 percent of patients are able to reach the A1C goal, and only 33 percent reach the LDL and blood pressure goals.”
Perhaps even more striking is the dramatic increase of goal achievement for all three indicators for patients in the Florida Academy DMCP. Twenty-three percent in the Florida program are achieving all three numbers versus only 7 to10 percent of patients nationally for all three indicators at the same time.
A tangential but important benefit of the FAFP Foundation’s DMCP is increased physician, patient and team satisfaction. Physicians are armed with clear results with the updated, evidence-based data. The registry produces reports that eliminate the time involved in searching through paperwork to determine whether a patient has had needed tests important to managing his disease, saving physicians critical time by organizing all the pertinent details and reducing frustration in the hunt for information. Team members including nurses and medical assistants are empowered to perform needed tests and to educate patients and enhance their care. And, patients are empowered through “report cards,” one-on-one visits and group visits that encourage more interaction with their physician and his staff.
“I think FAFP’S DMCP really empowers patients because they’re able to see their numbers every three months and how their diet is affecting those numbers,” said Dr. Christopher Benjamin Scuderi, assistant professor of community health and family medicine at the University of Florida College of Medicine in Jacksonville and medical director for the UF New Berlin Family Medicine Center in Jacksonville.
Dr. Scuderi continued, “The DMCP offers positive reinforcement and also empowers the staff who become diabetes experts. The program elevates diabetes knowledge all around whether for staff, physician or patient. One patient in particular has experienced tremendous progress with her sugar (A1C) which was 13.9 but dipped into the mid-sixes with constant vigilance. The ADA target is less than 7 on the report card. The program lets us know whether we’re doing our job.
It’s easy to go on feel but this registry offers hard, objective data. We’re really improving disease markers and outcomes. The better controlled early on, the less likely there will be complications. Our staff gets very excited and it empowers them to participate more in patient care.”
With intense pressure to achieve life-sustaining goals for their patients and evidence-based, accountable healthcare delivery systems, the Florida Academy DMCP offers physician practices immediate reports that also aid in the patient centered medical home (PCMH) certification process.
According to the NCQA in collaboration with the American Academy of Pediatrics, the American Academy of Family Physicians, the American Osteopathic Association and the American College of Physicians, a patient centered medical home provides accessible, continuous, coordinated and comprehensive patient-centered care managed by the family physician and the medical team -- exactly the model for Florida Academy’s DMCP.
The appeal for all providers is improved approaches to chronic care, consumerism and new healthcare-related information and communication technology. The model, according to these physician groups, shows growing evidence in primary care’s value assuring higher quality at lower cost with more equity.
“Everyone is beginning to see that this is the way healthcare is going and we’re producing workshops to educate physicians and their medical teams about PCMH,” said Tad Fisher, FAFP Executive Vice President.
FAFP will offer a workshop about achieving PCMH certification during its Hollywood, FL meeting April 29 and another in July in Orlando. The physician organization is also producing online training.
Although there’s no charge for the Florida Academy DCMP, Fisher believes that as health reforms kick-in the issues surrounding meaningful use and being reimbursed for making these changes becomes more important. “PCMH is very useful for anyone with a chronic condition so that the patient and the medical team manage the disease and the patient is encouraged to self-manage, bringing down cost and improving quality and patient health,” he said. “From a patient standpoint, he or she really has an advocate.”
The Baptist Primary Care office at Ponte Vedra was one of eight clinics in Florida to be recognized as a Center of Diabetes Excellence by the FAFP Foundation recently. Dr. Adam Dimitrov, family physician at the Baptist Primary Care office at Ponte Vedra and Chair of the PCMH Task Force for Baptist Primary Care said, “I find this program is very helpful for patients in tracking and understanding their condition. They can now tell me their goals for glucose control, cholesterol, blood pressure, and other indicators. This is in large part from the report cards that we hand them. In fact, I have patients who’ve had diabetes for years who now understand what A1C or HDL numbers mean to their health.”
Dimitrov says that the program is helpful to physicians for a number of reasons. First, because diabetes is such a complex disease, physicians are addressing a myriad of issues at once. “It can be overwhelming, both for patients and physicians. Due to shortages in primary care physicians, doctors are busier, which means visits are shorter and must be more efficient. With a system in place like the DMCP, physicians are better able to serve patients. The program also encourages staff participation in a team-based approach. This is gratifying for our staff, and is consistent with the principles of PCMH by increasing quality, coordination, and advocating the utilization of other team members in the practice. For those practices wishing to receive NCQA medical home recognition, this program goes a long way in meeting those criteria.”
How to become a participating practice
The Florida Academy’s DMCP is funded through grants and there’s no charge for participation. Each practice is required to have a high-speed Internet connection and must agree to have an independent research assistant enter all of their patients into the database. Subsequent updating of the database is done by the practices and the research assistants.
The practice team of a clinician, medical assistant or nurse receives evidence-based training through interactive group seminars, visits to the clinician’s office and educational e-mails during an eight-to-twelve-month period. Alumni meetings are also held yearly and the office manager and other office staff receive an orientation for the project. The comprehensive training includes current published clinical standards of care, how to enter data in the registry, how to produce and interpret quality assessment reports, and how to conduct group visits for high-risk patients.
Kathy MacNeill, RN, CDE (registered nurse and certified diabetes educator), is the Associate Director for the DMCP and Health Educator for Heartland Rural Health Network, one of nine rural health networks throughout the state. MacNeill works with nine practices in Central Florida’s Highlands, Hardee and DeSoto counties as well as rural portions of Polk and Charlotte counties. Many of the 2,565 patients are unemployed or uninsured.
“Our physician practice partners pay to be members of our network and we’re talking with our partners about PCMH. The biggest plus of the program is that it helps organize the practices so that the needs of the patients and the practice are met. We’ve saved about $1.5 million in the three years since we’ve instituted the program or about $500,000 a year in direct and indirect healthcare costs. It’s very exciting and probably one of the most rewarding things I’ve ever done because of the results in people’s lives.”
So far, three of the Heartland practices have achieved a 10 percent difference in their patient numbers for all three indicators (A1C, BP and cholesterol) and in their achievement for patient annual screenings. “Since the program started we’ve had a 635-patient growth and we’re now getting ready to grow our number of participating practices. The difference in our health system is that I work fulltime serving as a liaison with the practices to support them. I go into their offices and go over the numbers with them. We (myself and a number of community educators) get them set up with the initial data entry and ready to begin group visits. Our community health workers also go into homes to help patients achieve goals.”
Why does she believe the program’s so successful? “Everybody wants to know that their doctor cares about them and that someone’s paying attention,” she said. “And, when physicians facilitate group visits, the patient believes that’s even more important that the doctor spends an hour with them. The report card is also important because it acts like a communication tool. The doctors are more comfortable because they have a teaching tool and patients and staff something to work from. The program is more critical now as the economy changes because healthcare is even less accessible for patients.”
A Team Approach
Group visits, one of the three key aspects of the DMCP, offer an innovative way to overcome barriers and achieve quality of care. According to Dr. Shahady, surveys of 350 patents indicate that group visits strengthen the trust between the physician and the patient, patients feel they know their physician and nurse better, and that they have the power to control their diabetes. (Available at www.fafp.org/diabetes_mc.html)
“Group visits empower patients to better self-manage their diabetes within a supportive setting where they feel safe asking questions and expressing their concerns,” said Dr. Shahady. “These visits are not lectures and are more effective when conducted by a clinician and a nurse or MA who have an established relationship with the patient.”
The two-hour group visits usually consist of no more than 12 patients and are charged to the patient as with a regular visit. Patients are free to bring family members and several patients with well-controlled diabetes are invited who can offer advice to the others. Groups are asked to stay together for at least three visits, six weeks apart.
Vero Beach physician and former FAFP president, Dr. Dennis Saver, specializes in family medicine and geriatrics. He’s been part of the program from the beginning – first as the control and now as a participant. “I’ve been facilitating group visits for about five years and have about 150 diabetes patients who are part of the registry. And, out of that number, I have about 28 or 30 patients who are in group visits. I’m getting people’s diabetes as well as their BP and cholesterol in better shape because I’m paying attention to the numbers and focusing on the basics of diabetes care. Because I’m paying more attention, so is the patient. He’s making a commitment to take care of his own diabetes.”
Dr. Saver believes that participants in the program are achieving “way more” than 23 percent for goal improvement of all three indicators (A1C, BP and cholesterol) and that 30 percent of his patients are achieving all three simultaneously. “It focuses me and it focuses the patient and I think they do better. I’m showing more interest and care and they’re reciprocating – it’s a partnership. In my case, group visits include patients whose numbers might not be good for various reasons. Group visits are a wonderful vehicle because of customization. There’s an educational component, group process and motivational component. You can do so much more in 90 minutes that what you can accomplish in 10 to 15 minutes.”
Dr. Saver continued, “The person in charge of the process is really the patient and the more that we can do to enhance people’s self-care the better. Group visits are more efficient and fun. We’re also going through the PCMH process and one of the qualifiers is that you work with a registry. It’s a marvelous program and I think, underutilized. We’re extraordinarily lucky to have Dr. Shahady as the leader.”
FAFP Foundation’s DMCP facilitators will aid participating practices in coding, charging for, and documenting group visits.
Tipping the balance
With the complexity of diabetes making it difficult to understand and self-manage compounded by the additional barriers of medication costs, depression, transportation and lack of confidence in the ability to control their disease, less than 50 percent of patients nationally achieve ADA goals for A1C, LDL cholesterol and blood pressure. But, with the Florida Academy’s DMCP, those numbers are changing and the odds are favoring the patients.
Dr. Nadine Ramdeen-Wright, medical director for the Harris Family Medical Center in West Melbourne, specializes in internal medicine and pediatrics. She’s been part of the program since ‘07 and believes it opens the door to communication and it gives patients something tangible to take home as well as a way for physicians to track patient numbers.
“The program helps us track our patients. I can pull up reports and target those patients who are not well controlled. It empowers me to make sure that they get the appropriate care that they might need and track referrals. The data and follow-up also empowers patients. It’s an opportunity to update tests and there’s an alert for the patient and the physician. I’ve seen patients really take their numbers seriously and show them to a family member or friend. It’s a lifestyle and usually family members are an adjunct to therapy. We’re helping patients to better control their disease. It’s tangible and objective data and for me that makes a huge difference.”
For more information and to join Florida Academy of Family Physicians and the Diabetes Master Clinician Program, call toll-free (800) 223-3237 or (904) 726-0923, or visit FAFP online at www.fafp.org.