Kenyatta Lee, MD UF Assistant Professor of Community Health & Family MedicineAssistant Medical Director, Shands Jacksonville Commonwealth Clinic

Diabetes Rapid Access Program (D-RAP)Disease Management Prototype

Creating Creating Healthy Healthy CommunitiesCommunities

Jacksonville• 2006 Census Estimate

• Metropolitan population of more than 1.3 million• Third most populated city on the East Coast, after New York City and

Philadelphia • Largest population of African Americans in the state

UF/Shands• Academic teaching hospital affiliated with the University of Florida

• Located in downtown Jacksonville in the most populated area of the urban core

Community Affairs Department, 1989-PresentElizabeth Means, VP established the department toaddress unmet medical needs in underserved com-munitiesThe initial goal was to provide health education, health promotion, and community outreach in targeted communitiesPrograms are primarily funded through grants, strategic partnerships, faith-based organizations and community supportThe goal has expanded to provide freeand reduced comprehensive healthcare to the medically underserved inthe urban core.

Historical Overview

Community Affairs Department“Community Responsive Medicine”

Community Programs

DisparityTraditional

Durkeeville

Soutel

Brentwood

Eastside

Paxon

Murray Hill

College Park

Soutel

Heal Thy People

Shop Talk

Healthy Start

Little Miracles

Health Fairs

HIV/AIDS

Sickle CellBrown Bag

C. B. McIntoshWellness

Vice PresidentMedical Director

Free Script

Hep. C

Hispanic Initiative

Clinical Programs

D-RAP

REACH

HY-LIP

CARE

Anti-Coag

Renal

Case Management C. B.

McIntoshPediatricChildhood

ObesityDelta Care

Women’s Health

Initiative

Consultant

Grant WritingJUDI

Hybrid

ClinicsVirtual Disparity Community Network

Proposed

MRA

PQRI

DiseaseMgmt.

CaseMgmt.

Winn Dixie

"Americans can always be counted on to do the right thing...after they have exhausted all other possibilities.”

[Winston Churchill]

Diabetes Rapid Access Program

(D-RAP)

Disease Management Prototype

Background: What Factors Inspired us to Start D-RAP?

JUDIJUDI

Issues on the Horizon that could have a Devastating Impact on the Urban Core

PQRI MRAP4P Healthcare Bubble

Chronic Disease Crisis

According to the Centers for Disease Control and Prevention (CDC), chronic diseases are responsible for seven out of every 10 deaths in the United States -- taking the lives of more than 1.7 million Americans every year. Chronic diseases are also the primary driver of health care costs, accounting for more than 75 percent of the more than $2 trillion dollars spent each year on health care in the United States.

The Perfect Storm…

Population - 127,512 (850,251)Gender - 53% female (48.7%)Adolescents ages 10-19 - 15.9% (14.2%)Adult ages 20-64 - 55.8% (61%)Senior adults 65 and older - 14.5% (10.7%)Race - 83% African American (29%)Median family income - $28,307 ($44,740)Children below poverty level - 38.4% (15.4%)Percent of population below poverty - 28% (11.9%)Unemployment - 9.9% (4.8%)Uninsured - 45% (9%)

Leading health disparities health zone of the 6 health zones in Jacksonville and Duval County, Florida, in cancer, strokes, diabetes, HIV/AIDS, teen pregnancy, STD’s and infant mortality.

*(Parentheses denote figure for Duval County, Florida.)

“Healthcare Bubble?”

Who will be most affected?

Much like the housing bubble those individuals on the lower end of the economic spectrum are the most likely to be affected-Urban CoreWill access to care be affected?

Health insuranceMedicationsPhysicians

If there is a bubble the government is going to respond and what seems volitional (EMR, EHRs, performance based reimbursement) may become mandatory. Those institutions/physicians that are unable to adapt rapidly to the changing healthcare environment will be vulnerable.

“Healthcare Bubble?”

If a “healthcare bubble” does exist, it is perhaps better to be Ford than GM. It is Judi's mission to develop mechanisms that allow us to position urban core patients and physicians to bridge the void and prepare for a worse case bubble scenario.

Pay for Performance (P4P) Implications for the Urban Core

ProsImproved systems Virtual Community Disparity NetworkThe light will be focused on disparities

ConsMedical DarwinismMargins are tightBarely Funded Mandate

A New Model of Chronic Disease Care

New models: Chronic Care Model (CCM), Future of Family Medicine, Medical Home Model.Regardless of what you ultimately call this (CCM, FFM or MHM) a new model of chronic care must emerge.Regardless of what we do it will take 2-3 years for this system to mature and for us to began to see improvement.

Issues in our own houseProvider Disconnect:• Apprehension by PCP- to see patient more than once a month and

by Specialists - more than 2 times per year• Fear of presumed perception of churning by payer and patient• Hesitancy to treat if not at goal and will attribute diseases not to goal

to patient issues (non-compliance)• Provider hesitancy to adopt EMR, which is key to managing and

addressing medical disparities (Journal Watch - Aug 2008)

Patient Disconnect:• Lack of trust that disease is life threatening or is of eminent cause of

morbidity• Lack of funds• Presumed system (provider) is churning for financial gain

Disparity Program: D-RAPMethod :

Physician driven nurse executed Started with A1c > 9.0.

educated concerning diabetes and lifestyles changesassessed as to whether or not they are taking medication or can't afford medication/co-paylong acting insulinactive participants in the program

Communication to Patient Addressing Areas of DisparitiesLetters are mailed on a continuous basis for patient to come in and follow-up on labs and PCP visits Patient on registry are assessed quarterly through the registry programNurses go through the PQRI forms everyday If the results are outNurses go through the PQRI forms everyday If the results are out of range, the of range, the patient will get a letterpatient will get a letter

D-RAP: A1c > 7 and/or glucose > 200 referred to D-RAP, then letter and/or phone call to patientREACH: Systolic > 140, Diastolic > 90 referred to REACH, then letter and/or phone call to patientHY-LIP: LDL > 100, Trig > 300 and CK > 350 referred to HY-LIP clinic

Forms go to Registry Specialist to enter data into the registrieForms go to Registry Specialist to enter data into the registriess2,492 letters were sent for the month of January 2009 for HealthMaintenanceApproximately 710 letters sent to patients concerning abnormal labs for the month of January 2009

Disparity Program: D-RAP

• Patients encouraged to come in every three days at the site of their choice until goal

• Patients encouraged to call in daily glucose(s)

• Patients monitored closely until glucose is within normal range

D-RAP

Life StyleChanges

glucose <150 fasting

Continuef/u

No

Review lifestyle changes

Freescriptpgm.

Start long acting insulin

Follow-up every 2-3 days

A1c checked every 3 mnths

Short acting insulin before

meals

A1c <= 8.0/ fasting < 150

A1C >= 8.0/ glucose>200mg/dl

fasting

Metformin (start at 500mg – qd

(max)/Education

Add Symlin/JanuviaShort acting insulin

(? Covered)BMI >= 40

Waist circumferenceFemale >= 35Male >= 40

yes

Yes No

Follow-up every 2-3

days

Review barriers

Cost an issue Edu.

A1c checked every 3 mnths

A1c <= 7.0/fasting < 110

Yes No

Taken meds as ordered

Continueto f/u

Not covered consider insulin

add Januvia ( ? Covered)BMI = 40Waist cir.

female >= 35Male >= 40

NC w/multiple injections

add Januviaincrease Lantus

Diabetes PQRI Form

PATIENT NAME:

PROVIDER:

DATE: MRN:

A1C – Patients aged 18-75. Report with 99201-99215, 99341-99350, 99304-99310, 99324-99337, G0344. Report at least once per reporting period.

Measure & result Actual Last Value Date of Last Value CodeMost recent A1C level within 12 months <7.0% 3044F

Most recent A1C level within 12 months 7.0% to 9.0% 3045FMost recent A1C level within 12 months >9% 3046F

A1C not performed within 12 months, reason not otherwise specified 3046F-8P

PHYSICIAN'S PQRI DATA COLLECTION SHEET - DIABETES

A1C

CREATININE LEVEL: TODAY'S GLUCOSE READING

LABS SENT TO: SHANDS _________QUEST ________ LABCORP ________

A1C ____________ LIPID ___________ CREATININE _________LABS DRAWN: YES ___________ NO _____________

Diabetes Registry DM TRACKING

Patient nameDate of Birth SEX MRN Date A1C LDL CK Date A1C LDL CK Date A1C LDL CK

ABRAHAM,FRANCISCA 24-Oct-52 F 1335382 9/10/07 6.9 103 1/14/08 7.9 124 6/19/08 7.4 140

ADAMS,RANDY 1-Jan-66 M 754699 4/23/08 6.2 218

ALLEN,LENORA 21-Nov-48 F 624164 8/24/06 6.2 N/D 2/8/07 6.7 127 6/13/07 7.4 N/D

ALVIN,NELLIE 27-Mar-33 F 3402106 6/5/08 13.3 134

AUSTIN,CHARLENE 18-Jan-58 F 640401 10/22/07 8.4 111 2/19/08 8.4 114 6/23/08 7.4 104

BANKS,MICIAH 15-Jun-66 M 101307 5/7/08 6.0 139

BARTLEY,JAMES 16-Feb-60 M 9373 9/29/07 15.3 138 3/27/08 6.8 149

BARTLEY,STEVE 22-Jun-60 M 615467 12/15/06 14.4 163 2/13/07 11.2 141 7/17/07 10.5 111

BENTON,JOANN 27-May-50 F 194254 6/30/08 6.7 170

BESHEARS,JOE 6-Sep-46 M 580352 1/18/08 8.7 96 7/7/08 8.4 80

BLUE,JUNE 18-Feb-30 F 182430 10/26/07 11.9 127 3/31/08 7.2 137

BOSTIC,JANICE 7-Apr-53 F 317714 5/9/08 8.8 100

BROOKINS,ORSIE 15-Aug-21 F 66693 6/26/07 7.0 N/D 8/3/07 9.3 N/D 12/20/07 6.4 N/DAverages 9.2 136 Averages 8.2 125 Averages 7.8 118

RESULTS AT START 1st RESULTS AFTER START 2nd RESULTS

SHANDS JACKSONVILLE655 W. 8TH STREET

JACKSONVILLE, FLORIDA 32209

Chief Complaint• Patient is here for BP check-up, glucose check-up.PCP is Dr. Reluctant.

Vital SignsRecorded by bmarcus on 09 Sep 2008 03:29 PMBP: 158/100, LUE, Sitting,HR: 76 b/min,Height: 68 in, Weight: 240 lb, BMI: 36.5 kg/m2.Assessment

• Benign essential hypertension (401.1); on HCTZ- 25mg• Diabetes mellitus (250.00); A1c– 3/08– 11.0 due 6/08

Accu-CheckFasting: 230mg/dldenies hypoglycemiaFasting whole blood sugar glucose reference range: 60-99mg/dL

NotesAre you having trouble getting your medications? NoAre you taking your medications daily? YesHave you been to the ER? NoHave you had any low blood sugars? NoWhen is your next scheduled visit with your provider? appointment next week with PCP

Coun/EduPatient is made aware of the importance of monitoring HgbA1c every three months, having a yearly dilated eye exam, checking feet regularly for damage to the skin, monitoring cholesterol, seeing an endocrinologist yearly and maintaining a diet consistent with diabetes care.

discussed results of A1C, to return for labs

Teaching re: Hypertension, accurate monitoring includes daily BP check by viable tester, nurse,health care provider, fire department to be taken same time each day. Documentation card topatient. Agrees to return in one week for re-evaluation.

PlanDecrease salt intakeCheck blood sugar twice a day at different times regularly and bring log to next appointment.Discussed with patient how to take medication prescribed.Reviewed medications, bottle dated within 30 days

Patient: APPLE TESTMRN: 13650730

Encouraged patient on medication compliance.

Return in 3 days.F/U with PCP at appointment next week

denies dizziness or headache. Instructed pt to go to ER or call PCP if he should start having symptoms

consider adding ACEconsider increasing Lantus to 25units nightly

SignatureSigned By: Bobbie Marcus ; 09/09/2008 3:58 PM EST.

Disparity Program: D-RAPResults:

• Program began in June 2006 with study group of 300, average A1c - 11.0

• Eleven months into the program average A1c - 8.5 at which time all diabetics enrolled

• Seeing a fast growing population of UF non-Commonwealth providers and patients utilizing the disparity clinics

• Patients are assessed each visit through PQRI and outliers are followed up by the nurses in disease management

11.0

8.5 8.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

D‐RAP

AVERAGE A1C RESULTS

1st Avg. 2nd Avg. 3rd Avg.

National A1c Average – 7.7

NUMBER OF UNINSURED/INSURED CUSTOMERSIN THE D‐RAP PROGRAM

37

229

Uninsured Insured

Disparity Programs

• Diabetes Rapid Access Program – 2,212

• COPD/Asthma Respiratory Enhancement – 246

• Hyperlipidemia – 2,784

• Hypertension – 4,111

• Renal Clinic – recently started

• Anti-Coagulant – 205

• Free Script – > 5,000 prescriptions

Factors Integral to

DRAP’s Success

HybridDisparity Traditional

322 54

322 08

322 09

322 06

322 04 322 02

3

32 2 1 632 2 0 7

32 2 1 1

32 2 7 7

2 2 2 132 2 1 0

32 2 0 5

32 2 1 8

32 2 1 9

32 2 2 0

5

4

21

Commonwealth

College Park

Shands

Murray Hill

SoutelEastside

Brentwood

Durkeeville

C.B. McIntosh

SoutelWellness

JUDI-affiliated clinics and programs reflect the major causes of morbidity and mortality in Jacksonville, in both purpose and location.

Clinics

Improved Access Strategically located throughout the Urban CoreFlexible hours of operationSame day Walk-ins

Disparity clinics have access to Electronic Medical Record System (Allscripts) (Virtual Disparity Community Network – proposed)Disparity clinics have access to the Shands Hospital’s Electronic Medical Record System (Portal)All clinics have access to Case Management Participating clinics have access to our Registry Specialist.Office MAs send PQRI forms to clinic for registry and actions.Hispanic based system available.

Provide care for both uninsured and insured patients

Decrease inappropriate utilization of ER as source or primary care•Hospital discharges•ER discharges

Total encounters for FY08: 12,528

Hybrid Clinics:Eastside, Brentwood, C.B. McIntosh

Traditional Clinics

Total encounters for FY08 – 41,204

Disparity ClinicsServices:• No cost (funded and Un-funded)• Screening (HTN, Diabetes, Hyperlipidemia)• Monitoring• Education• Treatment

Programs:• Disease Management• Pharmacy Initiative

Statistics:• Soutel patient visits FY08 – 5,992• Durkeeville patient visits FY08 – 4,336• CB McIntosh (New)

Registry Specialist Letters are mailed on a continuous basis for patient to come in and follow-up on labs and PCP visits

Non revenue generating position turned it into a revenue generating postion

Patient on registry are assessed in real time through the registry program

> 3,500 letters were sent for the month of December 2008

Free ScriptsBackground:Provide certain medications to disparity patients with no means of paying for their medications

Results:To date, greater than 5,000 prescriptions have been filled; 201 patients in program

Future Initiative:Negotiation to expand the Free Script program with Winn-Dixie

Registry Impacting ER Utilization

• Data on the number of case of diabetes in the ER

• Query of the under and uninsured non-emergent ER encounters of the Shands ER population

• (700) Patients sent letter offering a Community Affairs Clinic as an alternative

• Number of Uninsured Patients Sent from Shands ER and patients discharged from hospital between 2005 - May 2008 to Eastside and Brentwood were a combined total of - 1,654

Walk-ins from Commonwealth Group

2008 PaxonCollege

ParkMurray

Hill Soutel Eastside BrentwoodCB

McIntoshMarch 805 70 174 78 243 74 6April 929 73 106 61 214 68 3May 994 77 110 43 287 106 3

Total 2,728 220 390 182 744 248 12

Number of ER Self-pay Cases

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000 32,641

28,912

24,969

22,14220,031 18,977 18,029

2001

2002

2003

2004

2005

2006

2007

ER Impact by Clinic

Overall Number of Walk-ins (2004-May 2008)Eastside: 14,422 $4,687,150 SavingsBrentwood: 695 $254,425 Savings

Number of ER Follow-ups (2005-May 2008)Eastside: 1,816 $590,200 SavingsBrentwood: 135 $49,420 Savings

Number of Hospital Discharges (2005-May 2008)Eastside: 368 $701,040 SavingsBrentwood: 51 $97,155 Savings

Core Principal: Access

Results•Decreased ER utilization by the uninsured approximately 14,000 since the start of program

•Decreased bed days

•Decreased length of stay

•Improved A1c, blood pressure and lipid profiles•Decreased ER utilization for asthma/COPD

Goals•Secure more funding for Freescripts

•Secure funding for labs (CK,CR,Lipd,HgbA1cLFT)

•Secure funding to guarantee the security of present positions currently funded by the hospital

•Secure funding for Medical Director and specialty oversight currently done on a voluntary basis

•Establish clinic in North Jax to complete disparity coverage in Healthzone 1 and on Jax’s Southside to provide services for the African-American, Hispanic and at risk underserved white (other) populations outside of Healthzone 1