Everyone with Diabetes Counts: Acumentra Health Partners with Communities and Clinics to Increase Access to Diabetes Self-Management Education

September 14, 2015   |  Tags: Blog   |  Tags: Interview , Diabetes Care , Patient Engagement , Self Management , CMS , Chronic Disease Management
Tracy Carver

According to the Centers for Medicare & Medicaid Services (CMS), Diabetes is a serious public health concern in the United States. It affects 25.8 million people, or 8.3% of the population. Nearly 19 million people are diagnosed with the disease, but more concerning is the estimated 7 million people who have diabetes but are undiagnosed. In addition, another 79 million people are estimated to have pre-diabetes, a condition that puts people at increased risk for the disease. Among U.S. residents aged 65 and older, 10.9 million (26.9%) were diagnosed with diabetes in 2010.

To learn more about local work to address diabetes, we spoke with Tracy Carver, MPA, of Acumentra Health, who is the project lead for the Everyone with Diabetes Counts (EDC) initiative for Oregon. EDC is funded as part of the Medicare Quality Improvement Organization (QIO) Program. Acumentra Health implements this work as the Oregon affiliate for the HealthInsight Quality Innovation Network-QIO.  The initiative started in August 2014 and runs through July 2019.

What work is Acumentra Health doing with diabetes self-management?

TC: The focus of the EDC initiative is on improving access to diabetes self-management education (DSME), particularly in underserved populations. Our efforts emphasize implementing the evidence-based Stanford Diabetes Self-Management Program (DSMP) where there is a need, improving the process for provider referral to DSME, and connecting providers to resources and education related to diabetes care and accreditation for DSME. 

Through this initiative, we are working with local communities to either establish a new DSMP program or grow an existing program. DSMP is a resource for people with diabetes as well as their families or caregivers. It utilizes trained leaders who are certified by Stanford and operate through a licensed organization. The DSMP workshops are held once a week for six weeks. According to Stanford University’s website, the program focuses on:

  • Techniques to deal with the symptoms of diabetes, such as fatigue, pain, hyper/hypoglycemia, stress, and emotional issues like depression, anger, fear and frustration
  • Appropriate exercise for maintaining and improving strength and endurance
  • Healthful eating  
  • Appropriate use of medication
  • Working more effectively with health care providers.

Participants make weekly action plans and learn how to problem solve to become better self-managers.

Medicare beneficiaries who complete the DSMP as part of the EDC initiative are asked to complete a questionnaire before and after the workshop series, with questions standardized nationwide by CMS.  We are also working with clinics to collect clinical outcomes data on a subset of Medicare fee-for-service beneficiaries. We will use this information to look at whether these measures improve after beneficiaries complete the program, and whether the improvement is sustained.

What have you seen clinics you’ve worked with do provide successful diabetes care?

TC: Our work with clinics is in the very early stages, but one of our goals for the coming year is to help communities identify and test provider referral models. One community where things are coming together is McMinnville, where we have been working with West Hills Healthcare Clinic.  They are a Patient-Centered Primary Care Home that did not yet have a diabetes program. We connected them with NW Senior and Disability Services, the local Area Agency on Aging, which implemented a DSMP class on-site at the clinic. Providers identified the patients that they wanted to attend the class. Once the clinic registered the patients, NWSDS followed up to confirm their participation.  As a result, they successfully filled their first class and have requested additional classes. This is a great result, and we are excited to see how we can help other clinics and community resources succeed together like this.

You spoke earlier about resources that Acumentra Health has available to these clinics – can you tell me a bit more about those?

TC: We have focused our work thus far on building capacity for programs at the local level. For clinics that sign up with EDC and commit to refer patients to DSME, we provide a range of educational opportunities related to diabetes and other topics that support positive outcomes, such as blood pressure control for cardiovascular disease—a common comorbidity with diabetes—and quality data reporting. Our goal is to build a framework for integrating community-based DSME into the healthcare system in a way that is most meaningful to the patient.

What major challenges are you encountering in your work so far?

TC: Obstacles to implementing self-management education vary, depending on the community and their needs. The greatest issues are around program sustainability, since community-based DSMP programs are not yet billable under Medicare. A few innovative communities are actively developing payment models for evidence-based self-management education through their Coordinated Care Organization. We would like to further explore with the health care community how community-based self-management support fits into the larger continuum of care, especially for people with diabetes. We are hoping to learn more about what providers need and want from these programs to help support their patients. We believe these programs ultimately can help clinics improve patient access to self-management education, reduce the burden on the health care system, and work synergistically with other types of diabetes education.

Tracy Carver, MPA, is the Project Lead for Medicare’s Everyone with Diabetes Counts initiative in Oregon. Prior to joining Acumentra Health, Tracy worked for the Oregon Health Authority and was part of the state team that established the Stanford Chronic Disease Self-Management Program in Oregon. She has more than seven years of experience leading innovative quality improvement and population health initiatives. Tracy’s career has focused on working with Oregon communities to design systems that improve chronic disease management and self-management support, address health disparities, and improve medication safety. Tracy is experienced in working with a broad range of stakeholders and facilitating diverse organizations towards a common aim. She holds a Master of Public Administration degree from Portland State University