DCCR RFP grant proposal: Home visits to improve diabetes control
Stage 1 Brief Proposal
1. Description of the need to be addressed, how the need was determined and the
population affected:
We know that in Durham County 8.2% of the population has been diagnosed with diabetes. There
are multiple health problems associated with diabetes, including a 2-4 fold increase in risk for
cardiovascular disease, increased risk for stroke, blindness, kidney failure, and extremity
amputationsi. Costs for hospitalizations related to diabetes in Durham County have increased by
251% from 1990 to 2002ii We have been following diabetic patients at Duke Family Medicine
Center and in 2005 we noticed that patients with HgbA1c >9% were less likely to access care and
follow up and make changes in their diabetes to get to goal. We focused efforts on our Medicaid
patients and then Duke Select patients with HgbA1c > 9% without much success. We learned that
these individuals would be accessible at home by the Carolina Access social worker or by PRIMA
case manager but would not get to the office or get their labs done. We now wish to try to focus on
this group in a different way and to expand the same focus to other diabetics in Durham County.
We will do this by geomapping diabetes and by identifying patients at community health clinics who
also have diabetes with HgbA1c >9% and have not been attending visits with their PCPs.
2. A description of all the Team members and their experience in working with the
population served:
Gloria Trujillo MD Medical Director DFM teaches chronic disease management to students and
residents, helps with IT development via feedback of chronic disease management working group
for electronic disease registry development and leads the Diabetes Collaborative at DFM.
Viviana Martinez-Bianchi MD Associate Residency Director DFM-teaches and implements resident
training chronic disease management and is physician representative for Group Visit RFP
proposal. She is also our community trained faculty for community sites in Durham County.
Brian Halstater MD Residency Director DFM-teaches students and residents and implements
resident training in chronic disease management and works closely with the medical director for IT
development surrounding chronic disease management.
Sarah Mc Bane Pharm D Campbell University/ DFM faculty- Teaches pharm D, family medicine
residents, physician assistant students, and medical students chronic disease pharmacy
management and sits on Diabetes Collaborative Duke Family Medicine. Major impetus in initial
development of in-office group care.
Nancy Weigle MD Assistant Predoc director DFM-teaches chronic disease management, in
collaboration with Dr Joyce Copeland, for student clerkships at Duke Family Medicine.
Michelle Easterling, RD Clinical Team Program Manager Health Department Durham Countycurrently works with high risks group needing nutritional counseling and chronic disease
management at county health department.
Nicole Weedon MSW Durham County Social Services-community social worker currently targeting
high risk Diabetics in the community and works with the Diabetic Collaborative at Duke Family
Medicine.
Neil Willams Pharm D CPP Medication Management. Vice President Clinical Services-currently
contracted with Carolina Care Network/BCBS to setup escribing specifically targeted to Chronic
Disease Management.
David Lobach, MD Endocrinologist and ebrowser development for Chronic Disease Management
Kimberly Yarnall, MD Medical Director Community Health Clinics
Fred Johnson, MBA: Business plan development.
3. A preliminary description of the potential change, and benefits to the population
served that would be addressed in the team ‘s plan
Our plan is to identify all patients at DFM, LCHC, Walltown, Lyon Park and DOC with HgA1c higher
than 9 % and visit them in their home initially. We would then help them to transition their diabetic
management to a community based group visit within their neighborhood, at the Family medicine
Center or at a community health site that the patient will identify as their medical home.iii The team
for the home visit would include a provider (faculty/midlevel provider/resident), pharm D student,
PA student or medical student, resident and Social Worker. We would have the point of care
testing for hgbA1c, LDL, microalbumin/Cr ratio for urine on site in the home and for the group visits.
This point of care testing will allow immediate feedback at the time of the visit and face-to-face
counseling at the time of the visit, which in turn can lead to improve complianceivv. We would also
have access by mobile laptop connection via internet to their medical record and have the ability to
electronically transmit all of their medications to the pharmacy. We will obtain glucometers that
download into the computer so if students/resident or SW sees patients in intensification visits
outside of the provider visit, medications can be titrated by nursing staff/pharmacist by
intensification protocols developed for medication management of glucose level and blood
pressure.
The goal of the home visit would be to build trust in the individuals who have not been to their
medical home clinic or do not have access to a medical home clinic and engage them and
transition them to the community based group visits (being proposed by another group) and
possibly back to their medical home clinic. If a patient is unable to make their community group visit
or medical home appt then we would have a tracking system in place to set a reminder to go and
re-visit the patient in their home in appropriate disease management intervals to get these patients
to goal and hopefully prevent long term complications, hospitalizations, ED and urgent care visits.
Our hope would also be to have EMR integration at least at lab and medication level that can be
accessed from all sites in Durham County, whether patients are seen in the ED, urgent care of the
Duke System or LCHC system or community provider. Our hope is to have the medications
prescribed, and point of care labs accessible from all the systems. Our ultimate goal for the EMR
would be to have a universal electronic system to Durham residents so that providers in the
medical home, the ED or Hospital and patients would have access to that unique system. Patients
would have an EMR card or number that they would carry identifying them as part of the diabetes
project.
Ultimately, this approach in diabetes management would reduce co morbidities and long term
complications of renal disease (dialysis cost), blindness (disability handicap), Cardiovascular
events including heart attack, stroke, or long term care. The universal Durham county electronic
medical record (EMR) and escribing product would allow for decrease in rework and improved
continuity of the uninsured and those without primary care medical homes. These individuals would
have community site medical homes which may be mobile. The cost reduction in long term medical
care locally would allow for us to use the resources to continue to support the health of the
community.
4. Preliminary estimate of the total Funds needed to create a plan The estimate should
delineate the roles and responsibilities of the team members/partner organizations with
respect to resources, in-kind and direct.) $100,000.00
Project Breakdown
Description
% Effort/Cost
$100,000
5% FTE effort
Data Analysis Effort
Fred Johnson/Trujillo/Yarnall(?)
Provider effort:
DFM,DOC,LCHC,Walltown,
Lyon park
Clinical Pharm effort/protocols
Trujillo/Martinez-Bianchi /Halstaer/ Greenblat/
Yarnall or other community health providers
Geomapping analysis
Indentify of patients in sites Medicaid
then uninsured
Site Education and training of provider
Mobile Medical Home
Sarah McBane
Neil Williams
Medication protocols and intensification
plans
$1,000
Heath Department and DCSS support
and nutritional counseling
Easterling/Weedon
Linking to medical home site and
nutritional support/education/materials
$3,000
AEMR analysis and effortDHTS/HAC/Practice partners
Community sites-connectivity
analysis/universal access
Trujillo/Williams/Yarnall(?)/Lobach(?)
Work with DHTS/LCHC pathnet for
AEMR POC collection universally
accessible analysis and ability to
actualize
$20,000 for
software
developmentpathnet?
Project Manual Development
Halstater
Development of Mobile Medical HOME
goals objectives- For information,
guidelines, usage of equipment/contacts
integration to community group visit sites
2000
copies
Project training staff and rollout support
Integration coordination with group visit
sites
Equipment POC
5% FTE EFFORT
5% FTE
effort
$6,000
Clinical administrative support
Trujillo/McBane/ MartinezBianchi/Trujillo/DHTS contact
Glucometer with laptop connectivity
Mobile equipment and software
analysis
$30,000
Tracking reminder system-universal to all
community locations
Laptop per clinic/laptop connectivitycontracts vs. other
American Diabetes Association. National Diabetes Fact Sheet. Available at: http://www.diabetes.org/diabetes-statistics/nationaldiabetes-fact-sheet.jsp
ii N.C. State Center for Health Statistics, 1990-2002
iii
Please see grant proposal titled IMPROVING DIABETES OUTCOMES AMONG DURHAM ADULTS USING A GROUP CARE
MODEL AND A COMPREHENSIVE APPROACH
iv Immediate feedback of HbA1c levels Improves Glycemic Control in Type 1 and Insulin –Treated type 2 Diabetic Patients, Gagliero,
Levina, Nathan. Diabetes Care 22:1785-1789, 1999
i
Point-of-Care Testing in Diabetes Management: What Role Does It Play? Judith Belle Brown, PhD, Stewart B. Harris, MD, MPH,
FCFP, FACPM, Susan Webster-Bogaert, MA and Sheila Porter, RN Diabetes Spectrum 17:244-248, 2004
v
2.5% to 5% FTE
effort per provider
$16,000