Accessing Diabetes
Education Through
Telehealth
M. Dianne Brown, MS, RDN, LD, CDE
OU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center
Cynthia Scheideman-Miller, MHSA
Heartland Telehealth Resource Center
Oklahoma Telemedicine Conference 2014
October 16, 2014
Objectives:
1. Discus the benefits of a diabetes telehealth program for
patients and how it can be partnered with provider
education to improve diabetes management
2. List processes involved when selecting a diabetes
telehealth program for your patients
3. Outline key components of a diabetes telehealth
program including patient and provider site
requirements.
Why Diabetes
Tele-education?
2011
2013
Prevalence* of Self-Reported Obesity Among U.S. Adults, by State, BRFSS
State
Prevalence Confidence Interval
Oklahoma
32.5
(31.2, 33.9)
26
million
Americans
have
diabetes
Diabetes by the
Numbers
79 million
Americans have
pre-diabetes
7th
leading
cause of
death in
the U.S.
The research shows:
People with Diabetes
Providers
• Don’t follow through
on referral
• Are emotional /
shocked at diagnosis
• End up relying on
family / friends
• Believe they know
enough / can handle it
on their own
• Know importance of
DE, but don’t
necessarily prescribe
– or don’t prescribe
definitively enough
• Sometimes forget to
follow up with patients
to encourage
attendance
Diabetes Education Patient Benefits
Studies have shown people who receive diabetes education
Use primary
care /
prevention
services
Take
medications as
prescribed
Control glucose,
blood pressure,
LDL cholesterol
Have lower
health costs
Diabetes Education Process
Year 1
Patient
Diagnosed
with Diabetes
PCP refers
patient for DE
Patient
assessed by
CDE
*DSMT Class
(10 hours)
**MNT
3 hours (by RD)
Year 2
2 hour Refresher
Classes
*DSMT - 2 hours &
**MNT -2 hours (by RD)
*Diabetes Self-Management Training
(DSMT)
**Medical Nutrition Therapy (MNT)
Prevalence of Diabetes
(2011 Overall)
N/A
2.25% or Less
2.26% - 3.35%
3.36% - 5.04%
5.05% - 6.74%
6.75% - 8.44%
8.45% - 10.14%
10.15% - 11.84%
11.85% - 14.00%
14.01% or Greater
Where most Certified Diabetes Educators (CDEs)
Live in Oklahoma
Recognized or Accredited Diabetes
Education Programs in Oklahoma
34- Recognized by the
American Diabetes
Association (ADA)
17- Accredited by American
Association of Diabetes
Educators (AADE)
Telehealth benefit # 1
Provides access- multiple sites may
be used
 patients
 other health care providers
Telehealth benefit #2
Saves money
 patient & CDE saves “gas” money
 remote site “borrows” CDE
 informed patients reduce hospital admission
Telehealth benefit #3
Saves time
 patients & CDE do not lose
time with travel and information
is delivered in “real time”
 CDE can see more patients, reducing service
wait time for patients
Telehealth benefit #4
 Helps to address cultural diversity which
contributes to challenges of education, patient
compliance, and cooperation with treatment
regimens
 Increased ability for participation with diabetes
care team
Telehealth Concern #1
Budget Considerations
 technology set up on remote
 and originating sites
Telehealth Concern #2
Time needed for set up
 Training Staff
 Patient teaching tools and resources at remote
Telehealth Concern # 3
 Services are only reimbursable by Medicare if the
services were provided to a Medicare or Medicaid
beneficiary at an acceptable originating site.
Selecting a Diabetes
Tele-education Program
Define what you want vs need

ADA program for Medicare reimbursement

Champions

Technology – fits in your needs and budget

A program that is right for your organization
and population served

Sales pitches can be misleading
Selecting a program

Is this a program you want as a partner in
patient care or contract with for total delivery?

Do they follow the same State laws, Hospital
by-laws as on-site programs are required to
supply?

What are their references?

Are the providers (distant site) in Oklahoma?
Double Check the Contract








What if expectations aren’t met?
Who is responsible for what?
What staff will be needed at the originating site
before, during, after the classes?
Who gets the data?
Who tracks patient satisfaction?
Is there training for staff at the patient site?
No-Show policy
Telehealth Consent Form – who is responsible to
get this signed prior to services?
Developing a Diabetes
Tele-Education Program
Early Development
Champion Support


Administration
Providers
 Originating Site
 Distant site
Delivery Model



Multiple sites or single site
Contract vs direct billing
Individual sessions conducted remotely or on-site
Early Development,
con.
Program Components
Understand current process flow
and staffing:
 Multiple sites or single
 Optimal number and arrangement
 Mandatory documentation – define the who, where,
how
Resources


Consider health literacy & culture
What resources go with the patient or stay
Budget

Budget

Start up costs




Staff time




Equipment
Broadband
Marketing
Contract development
Liaisons
Staff prep for sessions
Consultants
Technology
Software






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Reliable
Image quality
ASC X12 encryption standard
Compatible with other software
Linkage of older to newer technology
Split screen capable
Transmission requirements
Technology
Distant (Provider) End

Computer






High-definition camera
Monitors – single will work, dual is better
Speaker/microphone
Projector
Software – some have split screen capabilities
Desktop – Self-contained



High quality image
Split screen capabilities
Frees up computer for EHR
Technology
Originating (Patient) Site

Patient Cart





High-quality image
Can be wheeled to patient bedside
Multi-purpose
Issue: mobility vs larger monitor
Wall-mounted Monitors



High quality image
Split screen capabilities
The closer to “real” size, the better
Reimbursement:
Medicare
Medicaid
• ADA approved program
• Service must be real time
using interactive
audio/video
• Eligible originating (patient)
site – rural HPSA – online
tool to determine eligibility
• Codes:
• 99201 GT modifier
• HCPCS codes G0108 &
G0109
• ADA approved program
• Service must be real time
using interactive
audio/video
• Eligible originating (patient)
site
• Codes: 99201, 9780297803 GT modifier
• Must be delivered using
appropriate equipment and
meet HIPAA, privacy &
security requirements
Reimbursement (con.):
Medicare
Medicaid
• Eligible originating site
• Office of physician/practitioner
• Hospital
• CAH
• RHC
• FQHC
• Eligible originating site
• Office of physician/practitioner
• Hospital
• CAH
• RHC
• FQHC
• School
• I/T/U
• Eligible provider
• Registered Dietitian
• Advanced Registered Nurse
Practitioners
• Nutrition professional
• Clinical Social Worker
• Eligible Provider
• Registered Dietitian
• Advance Registered Nurse
Practitioners
Food Models
Handouts such as: My Carbohydrate
Guide
Organize the
classroom
-Pens, highlighters,
sharpies
-Ketone chart and
strips
-Glucose wands
-Food models
-Sample of fast
acting glucose
-Etc.
Diabetes Education
Tele-health Patient
Take Home Resources
• Have topics organized by title and number
the file (or computer files)
• Have reference list to find resource topics
quickly.
Final Development
Staff training
 User training
 Cheat Sheet
 Troubleshooting Guide
 Help Desk
 Contingency Plan
 Helpdesk visit
 3rd level vendor support
Patient recruitment
 Marketing material
 tele-health brochure
 internal web page
 Clinician invitation
 Patient Mailing
 Telehealth Patient Consent Form
Diabetes Tele-education Pilot
 Instructors
 Dietitian at one rural location, nurse specialist
at the other
 Diabetes tele-education delivered at a lower cost
 LOS shorter for those who attended class –
reduced hospital costs
 Pre- and Post-tests comparable to on-site classes
 High patient and provider satisfaction
 Rapport between class attendees unforeseen plus
Telemedicine Patient Satisfaction Survey
Question
How comfortable did you feel?
(0, very comfortable; 5 very comfortable)
Score_________
4.2 ± 1.2 (19)
How convenient was the encounter?
(0, not at all convenient ; 5 very convenient)
4.4± 1.0 (19)
Was the lack of physical contact acceptable?
(0, not acceptable; 5 very acceptable)
4.3 ± 1.3 (19)
Concerns about privacy?
(0, no concerns; 5 very concerned)
1.1± 1.7 (19)
Overall satisfaction?
(0, not at all satisfied; 5 very satisfied)
4.3± 1.3 (19)
Would you do it again? (yes/no)
Diabetes Care, Vol. 26, No 4, April 2003
16/3
Quality Checks: Metrics
Utilization
Satisfaction
Sustainability
Outcomes
By location
patient
financial
health
By service
provider
support
care plan
By provider
staff
champions
no-show
Rynn Geier, MBA, RD, LD, CDE presented at AADE annual meeting Aug 6-9 2014
Summary:
 Establish goals for a telemedicine program
 Gain champion support
 Develop a budget
 Choose a vendor
 Take time for clinical training and well-planned
program deployment
 Develop strategies for program “buy –in”
 Build into your program
 Measure your outcomes: metrics
Don’t Forget Diabetes Education
for Providers
Providers have the same information as their
patients



Increases provider’s confidence that they have
the latest diabetes information
Reinforcement – patient’s hear the same message
Providers have a contact/mentor
“Prior to the study it was almost impossible for this type of
patient to get the consultation and specialized care that is not
accessible in a small rural community.” Rural Home Health
Administrator
Who knows what future
telehealth will look like?