Exploring the Cost and Clinical Outcomes of Integrating the

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Exploring the Cost and Clinical Outcomes of Integrating the Registered Nurse-Certified Diabetes Educator in the Patient-Centered Medical Home Rosanne Burson DNP, CDE and Katherine Moran DNP, CDE Madonna University, Doctor of Nursing Practice ABSTRACT Problem: It is estimated that by the year 2020, 52% of the adult population will have diabetes/pre-diabetes, with an annual cost of $500 billion; about 10% of health care spending.1 It is evident new models of care need to be introduced that provide successful clinical outcomes within a cost-effective venue. This study implemented/evaluated a care delivery model integrating the registered nurse-certified diabetes educator (RN-CDE) in the Patient-Centered Medical Home (PCMH) to meet the unique needs of this population. Literature Review: PCMH is a delivery system redesign that includes self-management education that has a positive influence on practices and patient outcomes.2 Diabetes education empowers the patient to utilize self-management skills that lead to reduced medical costs and positive clinical outcomes (average blood glucose, low-density cholesterol, fasting blood glucose).3-4 Methods: Thirty-four patients were recruited from two primary care offices. The intervention incorporated group and individual sessions over 14 weeks. Study measures were compared before and after the intervention, focusing on attainment of positive clinical outcomes and cost-benefit analysis. Surveys also investigated changes in the participant’s perception of their ability to self-manage their diabetes. Results: Comparison tests identified significant improvements in the psychological components of self-management as well as average blood glucose and aspects of cholesterol control. Cost-benefit analysis revealed a net program benefit. Conclusion/Relevance: Integrating the RN-CDE in the PCMH improves clinical outcomes and is cost-effective. It is critical with today’s limited resources that effective, appropriate providers and tools are used to assist patients to reach clinical outcomes.

METHODS

INTERPRETATION OF FINDINGS

Two principle investigators collaborated to examine the effect of a patient-centered diabetes education intervention that utilized strategies in the development of relationship to increase psychological measures and improve clinical outcomes. Patients were recruited from two primary care offices located in suburban southeast Michigan that were PCMH designated or nominated.

This study demonstrated that integrating the RN-CDE in the PCMH improves clinical outcomes as evidenced by improvement in FBG, A1C and LDL. The lack of improvement in BMI and BP may be due to the short program duration and/or because the main focus for this group, as determined by the participants, was to improve overall glucose control. As such, the AADE 7 curriculum was individualized to meet the objectives of the participants and focused primarily on A1C reduction strategies.

Inclusion criteria were (1) diagnosis of type 1 or type 2 diabetes, (2) adults between the ages of 18 and 80 years, (3) uncontrolled diabetes (A1C ≥ 8%) (4) English speaking and (4) no formal diabetes education within the past six months. Patients interested in participating were invited to call to schedule an initial assessment with the RN-CDE. There were a total of 34 participants (males n = 22; females n = 12) enrolled in the study. The majority were patients with type 2 diabetes (type 1 n=1; type 2 n= 33). The mean age was 53.24 (SD = 12.48). The sample was primarily white (82.4%), black (8.8%), and Hispanic (8.8%).

RESULTS

Diabetes mellitus affects nearly 25.8 million people in the United States (U.S.); approximately 8.3% of the population.5 Extensive activity exists currently to restructure primary care to achieve improved clinical and cost outcomes in caring for the patient with diabetes. This focus is due to the large and growing numbers of patients with diabetes that are seen in primary care and the costs associated with their care and treatment of complications. In United Health’s report (2010), 52 percent of the adult population will have diabetes or prediabetes by the year 2020, with an annual cost of $500 billion; about 10 percent of health care spending.6 These statistics alone are alarming; however, they are even more troubling when the complexity of managing this disease process is considered. Diabetes management can be an arduous undertaking because glucose control can be affected by multiple variables within the patient’s environment including the frequently asymptomatic character of diabetes, the involvement of many body systems, and difficulties in altering lifestyle.7 As a result of the complex nature of this disease, patients with diabetes require comprehensive management and support. PCMH is an emerging model for changing the approach to care.8 Quality of care, safety and enhanced access are hallmarks of the medical home.

Pre- and post-program comparison analysis revealed significantly increased scores of selfefficacy, diabetes empowerment, and self-rated health as well as a significant reduction in depression scores (Significance <.05).

LITERATURE REVIEW

The clinical outcome improvements realized included an overall decrease in mean A1C level from 9.6% to 8.0% and a reduction in the mean FBG levels from 208.20 mg/dL to 129.56 mg/dl. There was also a reduction in mean LDL levels for a sub-group of individuals with elevated LDL levels (>100 mg/dL ) from a mean of 122.22 to a mean of 106.11 mg/dL. However, there was not a significant change in BMI or blood pressure.

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The potential for financial benefit as a result of this type of care innovation was also identified. Revenue generation was identified through the use of a combination of T codes (teaching codes) and Evaluation and Management codes. This 4 month study demonstrated that implementing this care delivery model leads to a theoretical net pre-tax benefit of $5,467.35 for the primary care practice. The information provided in this forecast is not an income statement; rather it is a cost-benefit analysis of forward looking conservative projections. It is important to note that this final dollar amount also captured physician salary costs associated with participating in the group visit structure. Although the physicians who participated in this study did not attend the group sessions, a dollar figure was included for physician time as if the physician had participated in the group visits in order to capture all potential costs. Even after considering this extra cost, there was still a net benefit.

The intervention incorporated an assessment, four patient-centered monthly group sessions, and four individual follow-up sessions. Study measures included pre- and post-program surveys of psychological measures (self-efficacy, perceived health, diabetes empowerment, and depression) and clinical measures (average blood glucose [A1C,] fasting blood glucose [FBG], low-density lipoproteins [LDL], blood pressure [BP], body mass index [BMI]). Cost effectiveness measures included program costs, performance incentives, CDE revenue, provider timed saved, and patient health care utilization.

STATEMENT OF THE PROBLEM

Most patients with diabetes receive their care from a primary care provider.3 Unfortunately, successful diabetes management in the primary care setting may be a less than optimal venture because it is based on an old model of acute care. A patient visit is typically 10 minutes every 3 months. During this visit, it is difficult to have an in-depth conversation to set or review progress on goals.9 The practitioner may not counsel the patient on lifestyle behavior changes or diabetes self-management strategies.10 In fact, only 14.3% of all these visits include nutrition counseling, 10% include counseling on exercise, and 3.6% include weight reduction counseling.3 A recent study revealed that only half of physicians and nurses surveyed felt they had enough skills in lifestyle counseling; two-thirds of the physicians and one-half of the nurses believed their schedule was too chaotic to allow them to go into patients’ life situations.10 PCMH is a delivery system redesign that includes self-management education that has a positive influence on practices and patient outcomes.2 Diabetes education empowers the patient to utilize self-management skills that lead to these positive clinical outcomes, such as A1C (average blood glucose), low-density cholesterol, and fasting blood glucose, and reduced medical costs.3 The RN-CDE helps the patient implement successful treatment strategies in a relationship-based approach.4

In addition to the clinical benefits associated with integrating the RN-CDE in the PCMH there was also an improvement in the participants’ perception of self-efficacy, empowerment and health and as well as an improvement in depression scores.

The largest limitation in this project was time. The data presented here are a snapshot in time over just 14 weeks of intervention. It is important to evaluate patient progress over time to get a clearer picture of practice effectiveness. Another limitation is the number of participants and the relatively homogenous group of patients. Expanding the project to include more patients with a wider variety of demographics, could continue to build the evidence.

Changes in Psychological Measures Variable Self-efficacy Health Empower Depression

Mean 1.53 0.45 0.51 -3.21

SD 1.54 0.91 0.74 4.81

df 28 28 28 28

t 5.30 2.65 3.71 -3.59

Sig. .000* .010* .001* .001*

d .99 .49 .69 .67

*p<.05, two-tailed

Changes in Clinical Measures Variable A1c FBG LDL P<.05, two-tailed

Mean -1.61 -78.63 -16.00

SD 1.70 85.05 20.03

df 30 15 8

t -5.29 -3.70 -2.40

Sig. .000* .002* .042*

d -.95 -.93 -.80

FINANCIAL ANALYSIS

CONCLUSIONS/RECOMMENDATIONS

Program Benefita (n=34) Program expensesb Physician salary expenses

$ (6,977.07) $ (3,463.36)

Total T code revenuec $ 3,120.11 d Total group visit revenue $ 4,836.76 Total efficiency revenue $ 1,470.91 e Total performance incentives $ 6,480.00

Total Expenses

$ (10,440.43)

Total Revenue

Total Revenue

$ 15,907.78

Less Expenses

$ (10,440.43)

Total Financial Net Benefit

$ 5,467.35

aThis

$ 15,907.78

study did not include the potential cost benefits associated with successful primary prevention. bRN-CDE salary, physician costs, and supplies cRevenue attained through billable teaching codes dRevenue attained through billable Evaluation and Management codes ePerformance incentives are provided to the provider from insurance plans as a reward for meeting pre-determined outcomes (these vary from plan to plan).

It is critical in today’s limited resources that effective, appropriate providers and tools are used to assist patients to reach clinical outcomes. It is evident that the RN-CDE plays an important role in the success of emerging patient-centered care delivery models that focus on diabetes care and management. This care provider is able to educate and support the patient through diabetes self-management, collaborate with the practitioner in the management of the patient, assure continuity of care, complete pay-for-performance criteria, and bill for services that are critical to maximizing the practice’s bottom line. As new care delivery models continue to emerge, especially in the wake of health care reform, it is critical that the RN-CDE be included in the development process. Historically, care providers such as the RN-CDE, have not functioned to the full extent of their license or clinical abilities; especially in the primary care setting. This study demonstrates that there are opportunities to improve clinical outcomes and capture revenue that supports this role and adds to the practice financial viability. To this point, as the financial reimbursement climate changes over time, addition research will be needed. In conclusion, this study demonstrates that care delivery innovations that integrate specialized care providers in the PCMH setting, such as the RN-CDE, can be successful in improving clinical and fiscal outcomes.