Standard Protocols for Diabetes Care Foundational to Success in Value-Based Programs

Below is an excerpted version of the conversation between H&HN’s Lindsey Dunn and Stacey Jenson, RN, senior vice president of partnership operations at Healthways. To listen to the entire discussion, click on the audio player above.

The importance of successful chronic care management has grown since the passing of the Affordable Care Act (ACA) in 2010, due in large part to a number of programs enacted by the law that penalize or reward hospitals for performance, including chronic care management.

For example, the ACA created the Value-Based Purchasing Program, the Hospital Readmission Reduction Program, the Medicare Shared Savings Program and the Bundled Payments for Improved Care program.

In response, health care providers are unsurprisingly examining how they manage their patients’ chronic conditions, and many providers are focusing on diabetes care, among other conditions. According to the Centers for Disease Control and Prevention’s latest data, an estimated 29 million Americans have diabetes, with a total cost of nearly $250 billion annually, according to the American Diabetes Association.

To discuss the impact of diabetes on health care outcomes and costs, as well as the impact of diabetes management on value-based care programs, H&HN’s Lindsey Dunn sat down with Stacey Jensen, RN, senior vice president of partnership operations for Healthways. Jensen has more than 15 years of experience leading and driving sustainable change and delivering total population health and well-being solutions.

How do you see diabetes as a significant driver in impacting health care organizations’ success in the various programs created by the ACA to drive value-based care?

Jensen: There are a couple ways that I see diabetes as a significant driver in the success of these the programs. The first significant part is just the incidence alone. Twenty-nine million Americans have diabetes and another 86 million live with pre-diabetes, and that is a number that will impact any cost-containment initiative.

Secondly, diabetes is often seen as a co-morbid condition in the overall treatment plan, and we definitely see this in the hospitalized patient. We tend to focus on the urgent issue at hand and may fail to understand how diabetes is impacting the core condition. Let's take an example. If a patient comes in for a hip or knee replacement under a bundled payment program and they have diabetes, are there systems in place to ensure that the glycemic control of that patient is managed well? If not, there's the potential risk for an adverse post-op infection, which can result in a longer length of stay or even a readmission. Both of those obviously impact cost, quality and the patient experience.

How can a health care organization best manage its patients who have diabetes to prevent unnecessary readmissions, provide high quality of care and lower costs?

Jensen: The first step is really just to identify the population living with diabetes under care. Are there procedures or systems in place to identify those with diabetes or even pre diabetes? In the ambulatory or pre-acute setting, do the physicians and their staff have a population health or panel management system that helps to not only identify the individuals, but also alert physicians on any missing standards of care or out-of-range values?

On the inpatient side of things, there are the same issues with patient identification. Is there a systematic approach to identifying patients with diabetes on the inpatient side regardless of their primary admitting concern? Are there protocols and nursing processes that ensure safe and effective glycemic control throughout the stay? Are there alerts on the inpatient side when a patient's glucose level goes above or below the target? Is the plan of care for the patient with diabetes broad enough to ensure things such as on-time meal delivery that syncs up with the patient's diabetes-related medications?

When you move into the post-acute side, it continues to remain critical to identify the ongoing care needs and treatment plan of the patient living with diabetes. One way to do this effectively is having care navigators or care coordinators supporting the patient throughout this transition process. Studies show that a care navigator program can further support the patient's individual needs — which is critical in these programs — and ultimately impact cost and quality, and again, the patient experience.

One provision of the ACA, the Value-Based Purchasing Program, uses a complex calculation to reward hospitals that perform highly on various performance measures. Can you share with us how the care of the patient with diabetes specifically impacts this?

Jensen: Under the program, there are four domains by which hospitals are evaluated: clinical process of care, patient experience, outcomes and efficiency. Within the clinical processes of care measures, there are no diabetes-specific measures. However, given all that we've already discussed about the overall impact of diabetes on the hospitalized patient, one can quickly see the critical importance of the strategic management of that population.

Next, take patient experience and satisfaction. People with diabetes take their diabetes medications often in a rhythm with meals. Patients are really savvy, and they know how to manage their own care at home. In the hospital, we don't always keep with that rhythm. And if that’s the case, the overall patient experience may be lower.

Under the efficiency measure, or Medicare spend per beneficiary, diabetes can have a big impact. For example, if we lose that rhythm I just talked about, we can end up with high, and then low, insulin levels, which can lead to longer length of stay. And of course, length of stay is a major factor in the cost of care.

The ACA also introduced a formal program for Medicare accountable care organizations (ACO) called the Medicare Shared Savings Program (MSSP). How does diabetes care fit into overall Medicare ACO performance and payments?

Jensen: This is definitely where CMS' triple aim comes into play. The goal is to control escalating costs; we've talked about it. Control those costs, enhance the overall quality of care, and achieve strong patient experience and caregiver experience. As we’ve noted, diabetes is dominant both in terms of volume and total cost of care. Here again, identifying the panel of diabetic patients is critical.

These patients tend to drive higher costs than the non-diabetic patients. As a result, the more successful MSSPs deploy care navigators and or care coordinators specifically to support patients living with diabetes. These roles span duties and responsibilities such as ensuring the gaps of care are met and all care team members are aware of the patient’s plan of care.

Diabetes, pre-diabetes and obesity are so prevalent among our country’s population today. Do you think the financial incentives contained within the various value-based programs introduced by the ACA will have to curb further growth of these chronic conditions?

Jensen: I don't know that these financial incentive programs will slow the rate of growth. The incentive programs seem very focused on the here and now around cost containment. For organizations to really move upstream to impact the growth of obesity and the diagnosis of diabetes, they really have to provide lifestyle management programs to their communities.

One program that has proven itself is the Diabetes Prevention Program [a program of the National Institute of Diabetes and Digestive and Kidney Diseases]. The outcomes of the DPP trial were strong enough that even CMS saw the financial and quality benefits and will begin reimbursement for pre-diabetes education starting in January 2018.

You’ve overseen diabetes care management for a large portion of your career. What have you seen as the biggest mistake hospitals make when they embark on efforts to improve management of this so prevalent chronic disease?

Jensen: I would not say I see huge mistakes so much as I see a lack of overall recognition of the impact of diabetes. We are often so focused on the primary admitting condition that we may not see the true impact of diabetes across the hospital. It's not a mistake, we just don't see it. We visually don't take it in. What we do see are stroke patients, cardiac patients, surgical patients, mothers having babies. Providers may not see or understand diabetes has a major impact on the overall length of stay and the possible readmissions if diabetes isn't the admitting concern. It is not uncommon for us to see a diabetes population staying a full day to a day and a half longer than the non-diabetes population.

And what’s the one piece of advice you’d pass on to organizations seeking to improve diabetes care management?

Jensen: Problem solve for ways to identify this population. If you can't see them, it's hard to appropriately deploy necessary resources and appropriate processes around them.

Secondly, deploy both what I call a systemic and concurrent intervention set that will blanket these patients. What do I mean when I say systemic concurrent interventions? It means developing standardized care protocols for a diabetic across the care continuum.

But keep in mind diabetes patients are diverse. What a healthy patient with diabetes needs when he or she comes in for an elective surgery is very different than what someone being admitted for uncontrolled diabetes needs. It’s about having clear protocols and having the right people, the right processes, and the right technology to manage the population across the full continuum of care.