Hi, everyone, and welcome to today's webinar. This session is the second installment in the Hands-on Tips to Improve Diabetes Care webinar series for 2023-2024. Today our panel will share their experiences and tips to organize team-based care for people with diabetes in the primary care setting, and we're glad you've joined us. I'm Rosalina McCoy, and I'll be moderating today's webinar. To share a little bit about myself, I'm an associate professor of medicine and an endocrinologist at the University of Maryland School of Medicine in Baltimore. I also have the privilege of serving as chair of the American Diabetes Association Diabetes and Primary Care Interest Group, which brings you this webinar and is here to support primary care practitioners as they care for people living with diabetes. I also want to note that prior to moving to University of Maryland, I practiced as a PCP for eight years, so I'm very excited to learn from my esteemed colleagues joining us today. We'll spend the next hour together by following the agenda on the screen. We will be using interactive features during today's session, so we'll use the chat box to ask you questions throughout the presentations, so be sure to pull it up and prepare to answer in the chat. We will also send you important links throughout today's session, so please locate it on your control panel now and be sure to click on it when you see a notification pop up or when you're asked to use it. And we'll be using the Zoom Q&A, which you see on the bottom, at the end of the presentation for panel questions, so be prepared to answer questions when they pop up on your screen. If you think of a question as our presenters are speaking, use the Q&A box on your control panel. There's no need to wait until the end. We'll address all questions that have been submitted once we get through to the Q&A session. Finally, we'll be using an interactive tool called Kahoot today during the webinar. It allows us to give you both knowledge-based and open-ended questions and collect your response answers in real time, so let's talk about connecting to Kahoot. If you have a mobile phone or a tablet nearby, that's often the easiest and best method to use, but if you don't have anything else nearby, you can use whatever device you're using right now. You just need to open another window or tab on your browser. So once you have your way to connect to Kahoot, open the internet browser and type kahoot.it as you see on the screen. When the Kahoot Join screen comes on, you're in the right place. You can now wait until we show you the joining information in just a moment, and I'll give everybody time to connect. So you'll see the game pin. That's what you enter, and you will be in. If you have any technical issues during the talk, you can use the chat or Q&A as well, and we'll be helping you as we go. So now I'll quickly like to review some of the other upcoming ADA webinars coming up. So if you look on the screen now, you'll see several upcoming webinars that are aimed at diabetes professionals. So to learn more or register for any of the webinars you see on the screen, including this session later this afternoon, please visit the link that we're going to post in the chat box. And I also want to call out an additional program on innovations in the latest treatments for type 1 diabetes, and again, we'll put a link to register in the chat. So now I'm really excited to introduce our panelists for today's webinar, who you see here. So first, we'll hear from Dr. Caitlin Nass. She's the clinical director of diabetes transformation at the University of Maryland Baltimore Washington Medical Center. In her population health leadership position, she's focused on improving diabetes care in primary care and during care transitions. She's an expert diabetes nurse practitioner, experienced in chronic disease management, quality improvement, clinician education and research. She's authored articles on cardiac risk reduction and chronic kidney disease. We'll then hear from Dr. Matthew Crowley, who's a Duke University associate professor of medicine with tenure in endocrinology and a core investigator at the Durham VA Center for Health Services Research. He's an expert in clinical diabetes care, as well as a prolific health services researcher. Dr. Crowley's research seeks to improve outcomes in diabetes and other chronic diseases by developing, testing and implementing practical health services interventions for individuals that respond suboptimally to clinic-based care. And finally, Joan Brook initially worked in the women, infant and children program for six years and accumulated eight years of experience in the field, serving as a dietician and clinical consultant for a medical advantage TTC group. In his role, he offers dietician services while functioning as a care manager within a centralized capacity for physician organizations across Michigan. His responsibilities encompass various aspects of patient care, spanning different age groups and insurances with a particular focus on diabetes care. He has recently extended his expertise by providing clinical consulting to a prominent physician organization in Michigan, aiding clients in achieving success in value-based reimbursement contracts and programs, including the Michigan Collaborative for Type 2 Diabetes Program. At this time, I'll let our panelists introduce themselves and state their disclosures. Hey, everybody. My name is Matt Crowley. I have no disclosures, no conflicts to disclose. I'm Kaitlin Nass, and I also have no disclosures. I am John Brook, and I have no disclosures. Thank you. And we're excited to hear from Dr. Nass. Hi, everyone. My name is Dr. Nass, and I have no disclosures. I'm Kaitlin Nass, and I also have no disclosures. Hi, everyone. My name is John Brook, and I have no disclosures. I am thrilled to be here and part of this panel, sharing with all of you this afternoon. It is particularly special for me to have the chance to talk about one of my favorite subjects which is why it is so crucial that all patients with diabetes be offered diabetes education from an expert clinician and what invaluable members they are of the care team. We're going to start off with a question. So I want you to respond true or false. The statement is approximately 65 percent of people with diabetes in the United States receive formal diabetes self-management training. All right, so you are all right, it is not 65%, it is a very small percent of our folks with diabetes in the United States who actually receive the formal diabetes self-management training that is so critical to their self-care. Among Medicare beneficiaries, the estimate is fewer than 55% when that was researched and among patients with private insurance, the estimate was less than 7% of people with diabetes who would benefit from diabetes self-management training actually get it. So, diabetes self-management training is critical to patients with diabetes and as a clinician in diabetes care for the last 10 years, I could not have been successful with my clinical practice if I was not always working hand in glove with an expert diabetes educator. I have had great success working with RNs, RDs, PharmDs and I could not do it without them and I mean that wholeheartedly. There is only so much that any one person can absorb of all the information that they need to understand to care for their diabetes. There's only so much time that a prescribing clinician like myself, I'm a nurse practitioner, I don't have a PhD, I have an MSN and patients need time with a trusted provider who is focused just on their care needs, just on their educational needs to understand where they're struggling, what they need support with and to help with the feedback necessary to make appropriate medication adjustments. This is standard of care and it is my mission to make sure more people get it. So, I didn't really appreciate how privileged I was working in a diabetes center, first at a VA and then at an academical medical center because I always had a diabetes expert at my side, an educator to collaborate with. This map gives you a sense of the great disparity in the availability of endocrinologists across our country. At the time this map was developed, there were about 26 million people with diabetes in our country and the estimate was that we had about 6,500 endocrinologists, adult clinical endocrinologists practicing in the country. So, we all know that the more recent estimates we have 37 million people, more than 37 million people living with diabetes and the number of adult endocrinologists in clinical practice has barely changed. So, we do not have the endocrine workforce to meet the needs of our patients with diabetes, only some of them. So, out of necessity, by default, 85% of diabetes care is likely delivered by primary care providers. So, we're fortunate there are many, many more primary care providers distributed across our country. It's not to say there are enough, but there are hundreds of thousands instead of 6,600. There are many diabetes care and education specialists to support those patients, well more than we have endocrinologists in this country. Unfortunately, where they're practicing is not ideal. We need to make sure that more patients are able to see an expert diabetes clinician in their primary care office. This is where it happens. This is a huge part of where the need is and we need them to support the patients, their families, and all the clinicians around them who have been managing diabetes all along without that next level of expert support that everyone will benefit from. Here in Maryland in 2020, a request for proposal came out from the Maryland Health Services Cost Review Commission and I almost couldn't believe the description because they were offering incredibly generous amount of financial support and a five-year time frame to dramatically expand patients' access to diabetes prevention and diabetes self-management training across Maryland. I really, really, this is one of those situations where you have to pinch yourself to recognize that someone else, a team at the state level understood just how crucial diabetes self-management education is to all of the patients who are struggling with diabetes self-care. I'm going to describe a bit about our experience implementing this grant and what we've learned about the return investment with increased access to diabetes educators. So, as I said, I was working in an academic medical center at the time. We had three different office locations and we had one full-time certified diabetes education specialist supporting all the patients and clinicians across those practices. We know, of course, as they always have, there were PharmDs, MDs, advanced practice providers, registered nurses performing diabetes education, but they weren't in a role specifically devoted to that, billing for that, so that we could quantify the education that was being delivered. By definition, diabetes education was aligned with the endocrinology clinic, which was the only place you could get it, and I think that was a huge barrier. I think patients and providers both thought that someone had to be followed by an endocrinologist in order to get access to the diabetes education, which was not the case. The other thing was because it was so rarely offered to people outside of endocrinology, I think patients, again, and providers also, if they understood diabetes education, they probably thought that it had most to do with nutrition therapy, and there were dietitians more readily available to patients, but that's only part of what someone with diabetes needs to truly care for themselves, and it's not enough. So, I want someone with two credentials, the RD and then the diabetes care and education specialist as well, because it's the next level. It's a very specific specialty. So, we knew that not only did we have to hire a whole team of educators and make sure that we had standard practice and tools for them and opportunities for them, but we had to convince everyone, patients and clinicians alike, that diabetes education is where it's at. This is what's been missing. This is what you need to have, and my own personal practice, diabetes education is by far the most frequent referral I would make. If I'm seeing patients full-time, I'm offering it to them. I'm offering it to patients several times a day. If patients turn it down, I'll likely bring it up again in the future if they have struggled or have reached a transition point in their care, and I sell it. When I would tell someone that I wanted them to see a dietician, and I use the word dietician, they were more likely to turn me down, and I think that has to do with a lot of things, but a lot of the stigma and shame that patients with diabetes experience, the judgment that they encounter among healthcare providers and even family members, when I started using the term diabetes educators, their ears were more open, and then I just perfected my spiel about the crucial impact of diabetes education on their care. We had to make that same pitch to clinicians across our health system, inpatient and out, administrators, office staff. We had to make people understand this was the next step. This was great. This was going to transform their practice. It was going to have an incredible impact on the well-being of their patients, and they just needed to let us in, so we were very fortunate to partner with Johns Hopkins Community Physicians, which is a very large primary care practice, and we worked with individual offices, strategically picked busy practices, and then we aligned ourselves and the educators with all the people who were already there doing the work of diabetes care, so that they became a complement to the existing team, and these were the people that we onboarded, so after it used to be just this one gentleman in the upper left-hand corner working at two sites, and as of a few weeks ago, this was the full team, and these were all the different locations, and you can see we certainly expanded access in the diabetes centers to diabetes educators, but we focused on spreading it out across the health system in primary care practices, and we had to pick really special people for this team. In addition to their clinical acumen and their compassion, they had to be independent self-starters. The ones who are working in primary care are supporting two different practices and also have a telemedicine practice, so it is not a small role that they took on. I think one key to the success was that we were able to unite them with each other, and there's regular ongoing follow-up and feedback for professional development and case discussions. So, we really rebanded diabetes education, and for many people, we introduced it for the first time for the full scope of what it is, truly comprehensive and compassionate diabetes assessment, education, and care management. This is something that is standard of care. It's been standard of care from, according to the American Diabetes Association, we just haven't been offering it to nearly enough people. It's something that everyone with diabetes should be offered any kind of diabetes, and I offer it across the board, and nutrition education is one component of all the education that people with diabetes need. The seat-of-the-pants estimate we make on that team was that about 20 percent of the focus would likely be on nutrition, and that leaves a lot of that time and a lot of that energy spent on understanding blood sugar testing, understanding medications, dealing with stress, dealing with burnout. There is so much more that patients with diabetes need than just medications and nutrition information. So, we rebranded it both in terms of selling the concept of what it is, and then we positioned it in a way that people realized they did not have to see an endocrinologist in order to get expert diabetes education. So, their diabetes expert was a member of their home primary care team, and since they were working in the field with diabetes, we needed to make sure that they had all the same equipment that the diabetes educators working within the diabetes centers have. So, we equipped them with laptops, with software, so that they could download glucometers, continuous glucose monitors, insulin pumps. Reviewing the patient's home data is critical to success for someone who's struggling with diabetes, so that is a big part of what the diabetes educators are doing, is digging into the data with the patients, and in primary care that may not be as common. We wanted to make sure they had all the teaching tools that you would expect, so allow people to practice with insulin syringes, insulin pens, the other injectables, introduce the new easier use forms of glucagon that are now available, and we positioned them, in addition to those tools, they were among their colleagues and able to orient them to the technology, the newer medications, the strategies for medication management, and have become really valuable members of that team and key resources in each practice setting. This is just a list of, again, some of the kinds of equipment I felt is important to be in any practice, where you are launching patients on diabetes medicines, making the diagnosis, and planning to care for them for the first time. They need to practice with devices, they need to be taught how to use a glucometer, they need to be taught how to use a continuous glucose monitor, and that means hands-on training. I just want to thank the members of the leadership team who are carrying on this mission. In 2022-2023, thousands and thousands of patients have had diabetes education for the first time across that health system, and well over 10,000 visits have now been conducted, so incredibly proud of that work. I'm going to stop here and hand off to the next speaker. All right. Well, thank you, Caitlin. That was a wonderful talk, and congratulations on your success. My name is Matt Crowley. I'm an associate professor at Duke, and I do research here at Duke Health Services Research and also have a research role at our VA, where I do much of my work. Whoops, overshot. I just wanted to briefly show my funding and, oops, well, I guess we're going to segue quickly then to our Knowledge Chat question. I wanted to talk to you, have you weigh in on whether there are opportunities to improve upon how we've utilized telehealth for diabetes since the COVID-19 pandemic. Hopefully not too much of a brain buster, but this will make sure you're all on your toes. Yes, all of you are correct. There are plenty of opportunities to improve upon how we've utilized telehealth for diabetes since the pandemic, and that's much of what we want to talk about today. In particular, I want to focus on patients who have persistently poor diabetes control despite receiving standard care and think about how we can use intensive team-based approaches to really improve outcomes in this group. I'll share some examples of how we are doing that, both within the VA and then an ongoing example of how we're trying to develop the capacity to provide intensive team-based care at Duke. The work we're doing at Duke, I think, is probably going to generate a lot of really generalizable lessons for how folks might do this in their practices too. Congrats on the folks on our scoreboard here. To start, I wanted to just sort of mention that diabetes self-management is incredibly complex for patients. This is something I think most of the folks on this call know well. There are a number of factors that determine diabetes control for our patients. Those include sort of intrinsic things like genetic factors or insulin resistance, include behavioral factors like diet, exercise, medication taking, and of course include a number of social determinants of health as well, like food insecurity or financial stress. There are obviously a lot of determinants. Diabetes self-management is incredibly complex, and the factors that determine diabetes control are very complex as well. When you think about how these factors all relate to each other, it becomes even more daunting to think about how we can improve diabetes control for those patients who don't respond well to what we might call standard care. The problem that I focused a lot of my work on and that I wanted to discuss with you all today is the fact that many of our patients with type 2 diabetes remain poorly controlled over time despite receiving quote unquote standard clinic-based care. Now telehealth represents a potential strategy for addressing these many factors that underlie persistently poor control in our patients from the prior slides I shared with you. Those can include system issues too, like insufficient engagement between the patient and the care team, self-management limitations that are in need of greater self-management support, and then things like therapeutic inertia, which are an ongoing issue in our clinics. Now telehealth is sort of a grab bag term that essentially just refers to any use of electronic communications for the benefit of our patients and leveraging those interactions for our care. There are a number of different types of telehealth modalities that we might use. Just in the interest of time, I won't go into detail on all of these or reiterate what's on the slide, but I will say that this sort of intensive team-based approaches that we've studied for these folks who have persistently poor control sort of blend elements of all these different approaches, and we'll come back to that in a moment. Now you might be thinking, don't we already use a lot of telehealth in practice and haven't we done that since the pandemic? Well, certainly the COVID-19 pandemic was a huge disruptor and drove much greater uptake of telehealth nationwide, and these graphs that you can see on the screen clearly demonstrate that. However, I would make the point that a lot of what we do by and large that we call telehealth really is not leveraging the benefits of these telehealth-based approaches. And what I mean by that is that a lot of the telehealth we've delivered since the pandemic is mainly entailed conducting what you might refer to as clinic-like appointments just by phone or by video, and a lot of these telehealth-based approaches we're using day-to-day have a lot of the same limitations as clinic-based care, so when we look at patients who are struggling over time with their diabetes control, despite getting available care, whether it's clinic-based care or clinic-like care by telehealth, what we really need to be doing is thinking about how we can leverage telehealth more effectively for these folks. And we do know that intensive team-based telehealth is effective or efficacious in research settings, but we've rarely seen implementation of really complex telehealth interventions that leverage the full benefits of this modality as part of standard care. So I want to share with you a little bit about a program that we've implemented that we initially developed and studied and now are implementing within the VA system. And the program I'm going to tell you about is called Advanced Comprehensive Diabetes Care, or ACDC, and this is a telehealth intervention that we developed for veterans with persistently poor diabetes control despite full engagement with VA care. The program combines telemonitoring, self-management support, and medication management, and crucially, this program was specifically designed for practical delivery within the VA system using existing clinical staffing and infrastructure. And this is going to be a theme I kind of hammer on as we go through this talk. The idea of implementing telehealth, complex telehealth interventions in practice, really relies on being able to adapt these approaches to the infrastructure you have available to you. Here's a recent randomized trial we conducted looking at the ACDC approach and comparing it to a simpler telehealth approach. Now we did not use a usual care or clinic-based care arm for this study because all of the patients we were recruiting had proven resistant to clinic-based care, so we thought it would be inappropriate to use that as one of the study arms. What we found is that the comprehensive team-based approach resulted in greater improvement in hemoglobin A1c versus a simpler telehealth approach resulted in improvements in diabetes distress, diabetes self-care, self-efficacy, and that hypoglycemia rates were low and similar across the arms. So the research really does bear out the value of intensive team-based telehealth. Even more exciting than the research, though, is the fact that we've now been able to take this ACDC intervention, actually put it into practice at VAs around the country. Currently, ACDC is being used at 30 VA sites nationally. And here's the map you can see right here. You know, excitingly, we see that the effect of the program has been quite robust, even in clinical practice. This is all real-world data. Anybody who even started the program, 755 veterans through September of 2023, had a mean A1c of 9.7 at baseline and a really nice improvement by six months that was sustained out as far as 36 months. So by using these intensive team-based approaches, we're finding that we can really take these refractory patients who have not responded to what's typically clinically available and achieve sustained improvements in this group. Now, why has ACDC worked so well within the VA? Well, as I said, we're leveraging existing resources within the VA system. This means that when we bring the program to a new VA, they're going to be able to implement it effectively and that it's really amenable to dissemination across the system because a lot of our VA sites around the country have very similar infrastructure. Another thing about VA is it has a very well-established path for incorporating patient-generated data into the EHR. Resources are consistent, as I said, and then there are sort of established reimbursement pathways for this sort of care within VA. Now many of these things that are sort of facilitators of ACDC within the VA system are not widely available within our wider healthcare system. So the question becomes, how do we make this sort of intensive team-based approach work well outside of the VA? And to that point, I'll share a little bit about another study we're doing here at Duke called EXTEND, or Expanding Technology-Enabled Nurse-Delivered Chronic Disease Care. This is a study that is targeting endocrinology and primary care patients who have persistently poor diabetes control and poorly controlled hypertension, and the goals of this study are really to understand the data infrastructure and staffing needs for delivering intensive team-based telehealth within an academic system like Duke, to examine the effectiveness of the program through a randomized trial, and then to really study the implementation context and opportunities for reimbursement so that this is a sustainable approach in a fee-for-service system. Now the trial that we're doing is ongoing. We've randomized 220 patients to receive EXTEND, which is a mobile health technology-enabled self-management intervention versus EXTEND+, which is a mobile health-enabled nurse-delivered intervention that sort of approximates what we did with ACDC on the VA side, namely by pairing mobile monitoring, self-management support with medication management. Now we've tried to embed this program clinically using clinic-based resources to the greatest extent possible, and we're looking at A1c and blood pressure as our outcomes. One of the big challenges with trying to roll out this sort of intensive team-based care within our system here at Duke was building the data infrastructure necessary to enable patients to transmit their data from their environments into the EHR, where it can be used to power an intervention like the EXTEND+, intervention. My co-PI on this project, Ryan Shaw, is an informaticist and really drove this piece, but we've developed a system that should be replicable at other centers for getting data from patients into the EHR. Here are some of the data displays that we have. You can see these are fairly typical displays of blood glucose data, blood pressure data, but the exciting thing about this is that these are fully embedded within the EHR. We're not having to use vendor systems or outside systems in order to do this. Patients can transmit their data in an automated fashion into our EHR, where then our teams can use it to deliver the EXTEND+, intervention. Our progress to date, building this infrastructure for incorporation of the data was a really major undertaking, but very necessary in terms of thinking how we're going to be able to export the approaches we've used within VA to the academic setting. Our recruitment is complete, intervention and delivery is ongoing, and our implementation aims for this project will yield a lot of really valuable data regarding barriers and facilitators and then reimbursement opportunities. Just to conclude, again, many of our patients with diabetes require care delivery innovation in order to achieve improved control. In other words, there are folks who are really struggling and their persistently poor control is not responding to what care they can't access. Intensive team-based telehealth is more effective than simpler telehealth approaches or continued based care, and telehealth really, as we've seen with the VA project and then with the Duke project I shared, really needs to be designed and implemented in a practical and system-specific manner that leverages the available clinical infrastructure. So to wrap up, back to your knowledge check question, we really do have a lot of opportunities to improve on how we're delivering telehealth-based care currently and since the pandemic, and the use and implementation of intensive team-based approaches like this is going to be a big part of how we need to do that for our persistently poorly controlled patients. So thank you very much for your attention, and I'll pass the baton on to John. Hello, everyone, thank you, Matt and Caitlin, it's an honor to be here with some very intelligent people. I'm going to move on to my part of the presentation, which is organizing team-based care for diabetes and primary care, and I'm going to focus a little more effort on the rural side of Michigan where I reside. I do want to highlight the quote at the bottom, no aspect of our physical or psychological existence is not affected in some way by nutrition, the dietician, of course, I feel very strongly about that. The quiz question, diabetes care can be involved, which of the following health care professionals? Give it a few more seconds. Obviously, it was a no brainer because everyone got it right, all above. And that's another part of the talk today is the importance of involving every single healthcare professional in the office. And that is, you know, more of my experience is with independents in Michigan, as well as there are some organizations, larger ones too. But you would, I was surprised by how many people that didn't get that concept. So that's one of my focuses of this presentation as well as the work I do. So I'm gonna focus some time on organizing team-based care, of course, but I wanna step back as to, I've been on the other side of actually providing care. So I've worked as a registered dietician, nutritionist. Going back to Caitlin, I do not like the dietician word. It would be preferable to have some different, but here we are. So I worked with a larger physician organization across multiple Michigan counties for this PO. And that was primarily in Flint, Michigan. And I was providing dietician services to patients across the lifespan and insurance type. RDN services provided as part of an accountable care organization. So for a part of an ACO, as well as there are two grant-based programs that work concurrently with the ACO. And that was across 40 plus primary care providers, PCP sites, and they're mostly independents. And of course, to the dietician, diabetes was a common referral. So I was very, very busy. In the work I did, I was in different settings. So I was in the PCP office. I was working remotely. I would drive to PCP offices that were very far away because they're in a very rural setting. Patients could come see me at an actual office, but in those very rural settings, that was not the case. And it better suited the patient for me to go straight to them. And part of the centralized care management team is this concept that we worked on. The PCP offices had an embedded care manager, and that could be a nurse, that could have been a licensed national social worker embedded in the site. And then for the centralized care management team, the part that I was with was also a licensed national social worker, dietician myself, and then a PharmD as well that patients had access to. So embedded care manager could see a patient and say, you know, visit a diabetic patient, which I'll go on the next slide. Here are all the options that are available to you that we can help with your diabetes care or whatever the care need was. So the basic concept of the structure, I receive referrals from embedded RN or licensed national social worker via a shared electronic medical record, as well as the PCP could also send referrals directly, whether it's just a paper form. Like I mentioned, I worked in multiple locations and formats that would drive the patient's offices, the PCP offices. Patients could see me at a more centralized role as well as I worked remotely, telephonically. And the key piece, coordination of care amongst all members of the team. Within the care that was provided, the billing aspects, there was care management billing codes for, I don't know if it's, I'm not sure, I'm not an expert on all states, but for Michigan, there's a set of billing codes for care management that a lot of insurances are covering, except for Medicare, Medicare is a bit different. And for the ACO, the care that was provided to patients in the ACO, it was just wrapped up in the services that the PCP offices were part of. So I wouldn't bill any Medicare patients, it just wrapped up into what was available to them. And unfortunately, those grants, those grant-based programs, they did end a couple of years ago, but care management continues on. I want to highlight one patient case study that focuses more so on diabetes care. Of course, diabetes was a common referral. Many cases, a diabetic patient was referred for the entire suite of healthcare professionals available. So the PCP was involved, the RN was involved, or the social worker, myself, dietitian, or the PharmD. And there were also specialists within the same PO that we would have contact with too. As you can see, diabetes affects the entire body. So many folks were involved with the care of a diabetic patient. And the set story that I will always remember is a 41-year-old patient with morbid obesity, diabetes. So prior to them, prior to this patient seeing the entire suite of team members, the A1C was at 14.1%, extremely high, probably one of the highest I've seen, and had several mental health disorders. So he obviously saw the social worker, that was a big piece. But then after three months of service, just three months of everyone being so intensely involved, that patient's A1C was reduced to 7.2%, just in three months. Very, very effective, but it does involve the entire team. So I'm moving to kind of expanding my career so far. I provided care as a dietitian, and then I kind of moved more towards the administrative side. And there's a program called Michigan Collaborative for Type 2 Diabetes. And there's some unique opportunities with value-based reimbursements. So MCT2D seeks to engage and empower medical providers across the state, and I'm talking the entire state of Michigan, UP included, to accelerate dissemination and implementation of evidence-based strategies to prevent or slow disease progression of type 2 diabetes. So support for the program comes from Blue Cross Blue Shield, as well as BCM. And it partners with PCP and specialist offices and physician organizations that provides VBRs, value-based reimbursements, for participation in the Continuous Quality Improvement Collaborative. It's a very interesting program. It's been such a pleasure to be part of it, and its expanse of the entire state of Michigan. There are three pillars of the program, or initiatives. It's supporting lower-carbohydrate eating, expanding access to and use of continuous glucose monitorings for type 2 diabetes, and trying to remove the barriers to prescribing the newer classes of drugs, SGLT2s, GLP1s. And as that expands, there'll be more and more. And the structure of it is there's an MCT2D Coordinating Center. There is the Physician Organization Administration, myself. I'm the clinical champion for the PO that I work for, which expands all of Michigan. Unlike many other physician organizations in Michigan, they focus on a smaller location, like maybe U of M. But the one that I work for involves so many places, and that's why I want to focus on the rural side. And I'll get into that in the next few slides. So the program so far, it works with the PO and the Coordinating Center, the PCPs and specialists, and it's a way to interact with the program itself, those three pillars. And it has many different activities that are involved with interacting with it, the website, and these regional meetings, and so much more that's available to them. It's an extremely great program. So the bottom slide, bottom points, I'm the PO Clinical Champion. I do work with 11 PCP offices across the state of Michigan. Several of them are in a very rural area. But each office has a dedicated clinical champion. So there's all this top-down communication so it can go back and forth. The VBR opportunities, I mean, that's part of it, right? You're incentivizing better care, which is a big piece, getting paid for doing the extra work that's involved. So MCT team Blue Cross develop a VBR plan each year for each practice's clinical champion. And then myself, I get involved with other opportunities as well. So everyone is part of working with the program throughout the year. And that VBR works as a percentage increase on identified billing codes for the PCP-aligned patients. Working collaboratively with each practice's clinical champion, that is kind of, it's a pillar. I mean, it's its own pillar in its own way for the program is that I get to involve and get involved with all the different clinical champions that are across states. So I get to see what are the barriers for the Detroit area? What are the barriers for very rural areas? What are the barriers for the West side of the state? We're going to see all of that, interact with it. It's really nice. It was initiated in 2021. And for this year, 2023, 2024, essentially our PO was working on focusing some effort on CGMs and developing a goal for the VBR year around CGMs in particular. So next piece to go into that rural part of organizing care across Michigan. And like I said, what I'm involved with includes many geographical locations across the state of Michigan, but the rural side is I think the most challenging because of how far away some patients are from their PCP office and the challenges of getting there, the challenges of what's available to me, the challenges of staffing. There's so much that goes into keeping diabetes care moving. As I said, most challenging has been in the rural areas of Michigan and for the program, the MCT2D and for the PO that I'm involved with too, just generally, are the federally qualified health centers, FQHCs. They're complicated. They have a lot more going on than on surface. So FQHCs are important safety net providers in very rural areas. FQHCs are outpatient clinics that qualify for specific reimbursement systems under Medicare and Medicaid. They include health center program award recipients and lookalikes and certain outpatient clinics associated with tribal organizations. Main purpose is to enhance the provision of primary care services in underserved, urban, rural and tribal communities. And from the work that I've done, identifying a clinical champion in involving all care team members is so absolutely crucial. Like I said, I've seen all different areas of how care is being provided in Michigan and you'd be surprised that that concept isn't understood. The concept isn't put into place. When it is, things change dramatically. So one of the last notes, integrating your practice providers with the whole health community, joining in partnership to own the health outcomes of your patients with diabetes will have a major impact. And I've seen it, I've implemented it and I teach on it is knowing your community resources, what's available to you and especially, I think especially during the pandemic, those community resources were changing so rapidly. People are coming in and out and how do you provide the same services during a pandemic? So like being on top of your community resources and what's available, who's providing it, how has it changed? Are there new rules? Knowing those things and, you know, like the back of your hand is incredibly important. And those are resources that are indirectly or directly involving patients, diabetes care, and patients that are running out of food sources, patients that are running out of house, that they're gonna lose their home and those kinds of things. Of course, it's directly and indirectly, but paying attention to that is extremely important. And then training all your levels of staff and providing an extra layer of services to your patients. So when a patient comes in, a diabetic patient comes into your office, they know when they come in, it's not just a doctor talking to them. It's not just the provider. It's if they know that every single person is involved and knows how to take care of them. Thank you. I moved my mic while I was listening. I'm sorry about that. But again, remember the five key tips and takeaways. And I really want to thank our panel today for their wonderful presentations. If you haven't already, please ask your questions for today's presenters by typing them into the Q&A box in the Zoom. And as we give you time to submit your questions, I want to share a quick announcement about an exciting ADA webinar that is coming up. So I hope you can join other professional members of the ADA for a live one-hour panel discussion webinar on how to make an AID system work, which will be a case-based review. So Drs. Matthew Benson and Leah Wilson will review available automated insulin delivery systems, how they work, followed by various cases to highlight how to optimize these systems to achieve better outcomes. So please register, and the link will be in the chat. So please use the Q&A box to answer your questions. And as we're waiting for questions, I was hoping to ask each of our speakers to briefly comment. I think all of you shared exciting programs that worked really well, but they all started with grant funding. And I was wondering if you can kind of give advice to our audience on how do they get started with even a smaller version of what you do if they don't have a grant opportunity, but they want to get started for their patients. So maybe we'll kind of go in the order that our speakers spoke. So Kaitlyn? So Gene Arnold, who is the program manager for the Diabetes ADA Center at Hopkins and who is the mentor and supervisor of many of the diabetes educators we've brought on, he knows the facts about reimbursement and referral and CMS requirements for diabetes education like nobody else, and he ended up teaching it to all the people around him across the organization. The focusing on diabetes self-management training alone would be hard to make a break-even proposition, but if you can mix it with medical nutrition therapy as well, the reimbursements are higher. If you have providers who are able to get credit and reimbursement for the CGM interpretations that they're doing, you can make a business case for it. I mean, we all know the critical importance, but just doing diabetes self-management training itself might be a harder sale, would be a harder sale. Thank you. Matt, what are your thoughts about starting with telehealth? It's not super easy. As you know, one of the central ideas of my talk was to really focus on what infrastructure you have available. Any telehealth or really care delivery writ large innovation that you do within your clinical context has to be able to leverage the resources you have available. Building resources or new capacity often does require external funding, which we often do get in the way of grants for research studies. But think about how you can take the principles that we know are effective and apply them in your clinical context using what you have. It may be a smaller scale to begin with. And then the other piece is obviously knowing how to leverage what reimbursement opportunities are available in order to make things sustainable. And that is a work in progress because these reimbursement opportunities are evolving all the time. So not a real easy answer for you, Rosalina, but I think it's a great question and something we're certainly thinking about. And John, what are your kind of experiences, especially working with ACO as part of an ACO, which others might be as well? Yeah, it was the ACO and then there are the other two grant-based programs, which evolution of it allowed and opened up other health insurances in Michigan to reimburse for these care management codes and set up 12. And certain insurances allow MAs to bill for them, but social workers, dieticians, nurses, while you go through these certain trainings, the care management billing opportunities are huge. They allow for not just specific diagnoses, it's pretty wide open as to what patients you can touch on. So it allows quite a bit. And I don't know what it's like in other states, but Michigan might be a pioneer. It's hard to say, but that is what really has opened up the doors for many patients to be touched on. Thank you. We have a question in the chat, which I'll start by directing it to Matt. Can you describe the work and challenges that went into getting patients' home glucose monitoring results into the EHR, including the clinic staff that were involved? That, I believe, is directed towards me. The challenges were really on the data side of things. In our system at Duke, we use Epic as our electronic health record, as I imagine probably a number of academic centers and probably other folks do, too. What we tried to do was work with our local health technology group in order to think about how to utilize evolving infrastructure within our system and to do it in a way that might eventually be generalizable. So probably a more detailed discussion of exactly how we did it might need to happen offline, and I'm very happy if anyone wants to reach out to engage in discussions about that. But it's a big lift, but something that needs to happen in order to really innovate with the way we deliver care for these hard-to-control folks. And Caitlin, is that something your team did as well to get glucose data into the EHR? So we did. The educator team absolutely did. And I told them, this is our best marketing tool. When you have a referring clinician who pulls up your note and there's the Dexcom report snapshot in there as well, showing that the patient has made this kind of progress, they're able to use this tool, we're talking about it. Our team at Hopkins, they worked on integrating one of the CGM data sources into the electronic medical record, and they're likely will work on one of the other CGM glucometers. It's really hit or miss. If you're not seeing an educator, I don't know that anyone's downloading them. I really didn't have an appreciation for how little home blood sugar testing happens outside of endocrine centers. And I can't imagine managing patients with diabetes without it. And so now we have easier methods for patients to do it, more likely to want to do it and get more benefit from it. But we have to have that data, at least for the encounter. Thank you. And hopefully we have time for one. Oh, yeah, go ahead. I was just going to say one of the challenges is something you alluded to. That's the fact that so many of our patients use different technology and different glucometers, certainly different CGMs will require different solutions. And as a challenge, the technology solutions we build have to be able to account for that. Great. Well, unfortunately, we have just one minute to go, but really appreciate everyone being here. So before we end today's session, I wanted to let you know what to expect from this point. So later today, you will receive a post-test by email. Please complete it so you can claim your CE credits. Be on the lookout for today's webinar recording from the ADA's Institute of Learning page within a few weeks. And you can remind any fellow ADA members that they can watch this webinar for one CE credit through November 2024. And you can rewatch it as well. And I really want to say thank you once again to our panel for sharing their expertise and guidance for all of us today. And thank you to each of you for joining today and for participating. And we hope to see you at future ADA webinars. So this concludes our session, and I hope you have a great afternoon. Thank you very much. Great to be here. Thanks, everybody. Thanks, everyone.

team-based care

diabetes

primary care

ACDC program

telemonitoring

self-management support

medication management

patient outcomes

telehealth

recommendations