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DARLENE MELK, MD, FAAPDIRECTOR OF COMMUNITY PEDIATRICS

CHIRICAHUA COMMUNITY HEALTH CENTERS

IMPROVING CARE AND REDUCING COST: A COMMUNITY-BASED APPROACH FOR MANAGING TYPE

1 DIABETES FOR CHILDREN LIVING IN RURAL ARIZONA

Type 1 Diabetes1

Barriers to Care2

The Chiricahua Model3

AGENDA

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I. Type 1 Diabetes

TYPE 1 DIABETES (T1D)

Art by Mike Natter

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In 2009, 1/518 (2%) youth <20 years had T1D in the US

Between 2002-2012, new cases of T1D in youth increased by:

1.8% each year for all youth

4.2% each year for Hispanic youth

The average cost for a DKA hospital admission = $7,500

In rural areas, there are many barriers to achieving and maintaining good glucose control

STATS

II. Barriers to Care

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GEOGRAPHICAL

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SOCIOECONOMIC

85-90% Medicaid patients

Uninsured patients

Single parent households

Working multiple jobs

Split families

Decreased health literacy/numeracy

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CULTURAL

Language barriers

High carbohydrate diet

Concurrent obesity

Resistance to medication

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III. The Chiricahua Model

THE CHIRICAHUA MODEL

INTENSIVE PRIMARY CARE

COMMUNITY OUTREACH

CONNECTION TO SPECIALISTS

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INTENSIVE PRIMARY CARE

DIABETES CONTROL AND COMPLICATIONS TRIAL (1993)

Intensive treatment with the goal of maintaining blood glucose

concentrations close to normal range decreases frequency and

severity of diabetes complications.

More frequent visits = better glucose control =

less long-term issues

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PROVIDER “SPECIALISTS”

Devyn Thurber, PNP Darlene Melk, MD

PROVIDER “SPECIALISTS”

Monthly diabetes follow-ups

Monthly A1c

Download software

On-site pump trainings

Primary care/acute visits

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PROVIDER TRAININGS

MOBILE MEDICAL UNITS

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INTEGRATED HEALTH

NUTRITION

BEHAVIORALHEALTH

DENTAL

CARE COORDINATION

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PHARMACY

340B PROGRAM FOR UNINSURED PATIENTS

Medication Retail Cost Sliding Fee Price Savings

Pen Needles 32.55 13.54 19.01Test Strips 11.26 8.74 2.52Humalog 337.23 4.42 332.81Levemir 440.41 4.42 435.99Total Monthly Cost 821.45 31.12 790.33

For a 90-day supply of insulin:• Retail price = > $2,000• Sliding fee price = $10

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INTERPRETERS

FUTURE: HOME VISITATION

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CONNECTION TO SPECIALISTS

PATIENT-CENTERED MEDICAL HOME

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TELEMEDICINE

FUTURE: VISTING SPECIALISTS

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COMMUNITY OUTREACH

TRAININGS FOR LOCAL NURSES

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504 PLAN MEETINGS

SUPPORT GROUP

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SUPPORT GROUP

LIBRARY EXCHANGE

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CONNECTION TO GREATER TYPE 1 COMMUNITY

CONNECTION TO GREATER TYPE 1 COMMUNITY

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SO, HOW DO WE MEASURE UP?

LOW ED/HOSPITAL UTILIZATION

Each year, approximately 7% of patients with T1D are admitted for DKA.

Between 2017 and 2018, 3.3% of our patients with T1D were admitted for DKA.

Between 2017 and 2018, our 30 patients were seen in the ED a total of 2 times for issues related to their diabetes.

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IMPROVING ED/HOSPITAL UTILIZATION

According to our Medicaid claims data, between 2017 and 2018, our 15 patients with type 1 diabetes had a:

20% reduction in number of hospital admissions

31% reduction in days spent in the hospital

51% reduction in number of ED visits

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DECREASED COST TO THE SYSTEM

For one of our patients with T1D:

2017: 1 ED visit, 1 hospital admission = $3,117 PMPM cost

2018: 0 ED visits, 0 hospital admissions = $459 PMPM cost

For a total cost savings of:$2,558 per month$30,696 per year

FUTURE RESEARCH

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REFERENCES

Diabetes Control and Complications Trial (DCCT) Research Group. (1993). The effect ofintensive treatment of diabetes on the development and progression of long-termcomplications in insulin-dependent diabetes mellitus. The New England Journal ofMedicine, 329, 977-86. doi:10.1056/NEJM199309303291401

Hamman, R. F., Bell, R. A., Dabelea, D. (2014). The SEARCH for diabetes in youth study: rationale, findings and future directions. Diabetes Care, 37, 3336-44.

Ilkowitz, J. T., Choi, S., Rinke, M. L, Vandervoot, K., Heptulla, R. A. (2016). Pediatric Type1 Diabetes: Reducing Admission Rates for Diabetes Ketoacidosis. Quality Management in Health Care, 25, 231-37. doi: 10.1097/QMH.0000000000000109

Maldonado, M. R., Chong, M. A. O., Balasubramanyam, A. (2003). Economic impact ofdiabetic ketoacidosis in a multiethnic indigent population: Analysis of costs basedon the precipitating cause. Diabetes Care. doi: 10.2337/diacare.26.4.1265

Mayer-Davis, E. J., Lawrence, J. M., Dabelea, D., Divers, J. D., Isom, S., Dolan, L.,…(2017).Incidence Trends of Type 1 and Type 2 Diabetes among Youth, 2002-2012. New England Journal of Medicine, 376, 419-29. doi: 10.1056?NEJMoa1610187

Innovative Approaches to Treating Pediatric Obesity:

MEND Family Activity and Nutrition Camp

Kyla James, MPH, MAProgram Coordinator, Family and Child Wellness

El Rio Health

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El Rio Health • Federally Qualified Health Center in Tucson, Arizona

• Serve 106,000 patients across 12 clinic sites

• 35,000 pediatric patients

• ≈ 50% of patients are below 100 % of federal poverty level (FPL)

• 25% of patients identify as being best served in language other than English

• El Rio is the only Healthcare for the Homeless grantee in Southern Arizona

• Level 3 patient-centered medical home designation from National Committee for Quality Assurance

Pediatric Obesity Nationally

• Chronic health condition

• Pediatric obesity highest nationally in Hispanic population at 26%

• Adults with obesity have greater risk of Type 2 diabetes, heart disease, some cancers

• Diabetic patient has 2.3 times greater annual cost of care

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Pediatric Obesity at El Rio

• 34% El Rio pediatric patients overweight/obese

• 23% of MEND referrals (7-14 years old, >85th percentile BMI) have: prediabetes, elevated blood pressure, abnormal lipid panel, fatty liver disease

• Including asthma, depression, oppositional defiant and anxiety disorders 47% of MEND referrals

• Already have comorbidities

What is MEND?

• Mind, Exercise, Nutrition, Do it!

• Evidence-based family program for patients 7-13 years old, > 85th

percentile BMI, and their parent/guardian

• Activity based: nutrition education, physical activity, behavior change, group support

• Contact hours: 32, over 8-10 weeks, 2x per week

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Results

Year One:• 44 referred pediatric patients completed, 116 total completers • -0.05 kg/m2 reduction in BMI

• -17.61 beats per minute reduction in recovery heart rate

• 93% of parents report decrease in soda consumption for whole family

• 83% of parents report increase in fruits and vegetables consumption in children

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“At the beginning, this class was really hard for me, reality is hard to accept. The fact that I was feeding my children such horrible food made me feel bad … I am very happy that I stayed. The kids and I have learned a lot. Rodrigo has now taken responsibility for his health, he exercises every day and always tries the vegetables that I cook. Rebeca loves exercise and is always looking for MEND friendly foods and reading labels. This program has made us a healthier family” - parent

“MEND has not been your typical diet classes/camp, for us it was a bonding time to learn how to be creative, supportive and while being healthy. My kids even want to retake the classes!” - parent

Qualitative Results

• Children like the fun and team element of MEND

• Adults like the group support

• Adults like having additional class rather than only being given papers at medical visit they say frequently can not understand

• Reported change in parent-child dynamics

• Increased self-confidence in children

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Barriers

Barriers

• Time• Work schedules of single parent household

• Household where parent had chronic disease

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Barriers

•Culturally relevant • Materials

• Food

• Scenarios

• Family dynamics

• Language

Barriers

•Geographically accessible and desirable

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Solutions

Barriers

• Time• Work schedules of single parent household

• Offered at variety of times

• Household where parent had chronic disease • Other family members can bring – limited success

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Barriers •Culturally relevant

• Materials • Food

• Scenarios

• Family dynamics • Iteratively adapted materials/examples

• Staff member from community delivered or trained

• Language• Offered in English and Spanish

Barriers

•Geographically accessible and desirable• Offered transportation (Lyft/Uber)• Geographically varied sites• Used referral zipcode concentration to determine sites• Non-clinic sites

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Takeaways • Iterative process evaluation

• Patient directed implementation of an evidence-based curriculum

• Culturally relevant

• Think outside clinic box for location

• Patients cared most about: • Family bonding time, supportive relationships

Where we are going

• How do health trajectories change?• Longitudinal tracking in electronic health record

• A1c, blood pressure, hyperlipidemia, depression, medications

• Continued support • Diabetes Prevention Program model

• Family physical activity and Cooking Class

• Longer curriculum to incorporate stress and coping

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Thank you

• Thank you to Gloria Montijo, Shelley Whitlach, Holly Bryant and Lorena Verdugo from El Rio Health, Shelli Ross at Arizona Alliance, Miguel Garcia and Arely Montijo from Oury Community Center, Rosa Maria Escalante at Wakefield Resource Center, and Chris Espersonfrom National Association of Community Health Centers.

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References Center for Disease Control and Prevention. Retrieved from http://www.cdc.gov/obesity/data/childhood.html

American Diabetes Association. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/infographics/adv-staggering-cost-of-diabetes.html

UDS Report 2017, El Rio Santa Cruz Neighborhood Health Center. Arizona. 2017 May 21. [Internal Report].

UDS Report 2018, El Rio Santa Cruz Neighborhood Health Center. Arizona. 2018 April 4. [Internal Report].

Sacher PM, Kolotourou M, Poupakis S, Chadwick P, Radley D, Fagg J. Addressing childhood obesity in low-income, ethnically diverse families: outcomes and peer effects of MEND 7-13 when delivered at scale in US communities. Int J Obes (Lond). 2018 Aug 3. doi: 10.1038/s41366-018-0158-2.

Kolotourou M, Radley D, Gammon C, Smith L, Chadwick P, Sacher PM. Long-Term Outcomes following the MEND 7–13 Child Weight Management Program. Child Obes. 2015 Jun;11(3):325-30