VHA Innovations in Care
By Leonard Pogach, MD, MBA, FACP, National Director of Medicine, Specialty Care Services, VHA, VACO
The prevalence of diabetes in the U.S. population increased from 18.0 million (6.3%) in 2002 to 25.7 million (8.3%) in 2009 [including one-third undiagnosed]. The number of veterans with diagnosed diabetes receiving care in the Veterans Health Administration increased from about 600,000 (19.6%) in 2000 to about 1.45 million (23.7%) in 2010. In 2010, about 52% of veterans with diabetes were younger than 65 years compared with about 36% in 2000.Diabetes remains the major cause of visual loss, dialysis and amputation.
Because the individual needs of veterans vary by disease duration, comorbid conditions and age, the first version of the VA-Department of Defense (DoD) Diabetes Guidelines (1997) and all subsequent versions have emphasized the concept of risk stratification. This approach emphasizes individual goal-setting based upon the likelihood (i.e., absolute rRisk reduction) of benefits and risks of treatment and the veteran’s preferences. In each instance, the guidelines have incorporated a non-biased review of evidence by VA and DoD professionals. The guidelines include an algorithmic format allowing providers to follow a linear approach to critical information needed at the major decision points in the clinical process. The recommendations for individualized glucose control targets were validated and updated in 2010 by incorporating the landmark clinical trials — ADVANCE, ACCORD and the VA Diabetes Trial. The original framework of risk stratification from VA-DoD guidelines was recently adopted in other guidelines, including the American Diabetes Association 2012 Clinical Practice Guidelines and consensus statements.
Patient-Aligned Care Team
Most veterans with diabetes receive care within the new VHA system of primary care — the Patient-Aligned Care Team (PACT) — which is modeled after the Patient-Centered Medical Home. Within these teams, providers and staff members from multiple disciplines work together at the top of their scope of practice to provide the best possible care, consistent with the evidence and patient preferences.
In order to communicate key aspects of the diabetes guidelines into every day practice, a pocket card for diabetes shared decision-making was developed to educate and empower providers to engage patients in evidence-based discussions around medications and clinical measures in diabetes. A target range for HbA1c, based upon life expectancy, microvascular complications and co-morbid conditions, is a starting point for shared decision-making with patients. Patients are encouraged to make the final decision about a specific target value of glycemic control after a full discussion of the risks and benefits of therapy with his or her provider. Health numeracy (i.e., interpreting numeric values) is critical. The VA-DoD provider tool on A1c accuracy was adapted and published by the National Institutes of Health Diabetes Clearing House.Diabetes Clinical Programs
Shared Medical Appointments (SMAs)
An SMA occurs when multiple patients with a common condition have an appointment at the same time (typically about 90 minutes in length) with a team of healthcare professionals representing differing professions. During an SMA, participants receive education, participate in group discussion with other patients and interact with a multi-professional healthcare team that includes nurse practitioners, health psychologists, dieticians, clinical pharmacists and nursing, in addition to primary-care providers. While patients and the professional team discuss core education, it is done in such a way as to foster patient and family participation in their own care management and often provides support for others in the session. Medication adjustments are made as necessary. SMAs are strongly recommended for PACT teams to improve care quality and access for veterans with diabetes.
Prevention of Amputation in Veterans Everywhere
The VHA comprehensive team approach to amputation prevention includes:
1) Identifying patients at highest risk for amputation through annual foot-screening examinations;
2) providing timely and appropriate referral for professional foot care for high risk patients; and
3) tracking patients from the date of entry until they are through the system of care.
Amputation rates among veterans have decreased by more than 30% in the past decade. The Amputation Coalition of America recently cited the VA’s amputation prevention program in its Roadmap for Preventing Limb Loss in America as an innovator in amputation prevention through the use of evidence-based guidelines and the substantial use of the electronic health record.
In 2006, the VHA developed and launched an innovative program using digital retinal imaging with remote interpretation (i.e., teleretinal imaging) to screen for diabetic retinopathy. Teleretinal imaging is often performed in primary-care sites when patients present for routine visits. Such a program improves access by entering patients with diabetes into appropriate and timely eye care. Since the program’s inception, almost 900,000 unique patients have had teleretinal imaging at more than 420 VHA sites. Patient satisfaction surveys consistently suggest a high level of comfort and convenience, and rates of retinal screening have increased from about 65 percent to about 90 percent. Future work will explore the possibility of using this platform to also screen for other sight-threatening diseases in patients with diabetes.
Telehealth and Team Care
VHA has recently established the Specialty Care-Primary Care Neighborhood model to bring specialist care closer to veterans and primary-care teams, especially at Community-Based Outpatient Clinics. Primary-Care team expertise in diabetes is being enhanced by the Specialty Care Access Network-ECHO case-based learning model. Electronic consults are used to provide timely access to specialists for advice; and clinical video telehealth is used for group visits and individual patient consultations with specialist teams, which are increasingly including nurse practitioners, physician assistants and clinical pharmacists to assist the PACT team in management of complex issues.
Newer pharmaceutical agents are on the horizon for diabetes management. Closed-loop systems for type 1 diabetes, for which international testing is under way, will be a major advance. However, improved self-management will remain the key to individual success. VA is actively pursuing several approaches:
The MyHealtheVet website creates a secure portal where the clinical teams and veterans can collaborate to create an electronic record. Secure messaging, health diaries, access to laboratory results and interactive online patient education materials will allow veterans to be increasingly active partners in managing their diabetes. VA expansion into social media will provide a community where veterans can find VA information and connect to support from their peers.
Peer support is an evolving concept in which persons with diabetes are trained to provide empowerment-based diabetes self-management support interventions. The Diabetes Mellitus Interagency Coordinating Committee recently held a conference on Peer Care in Diabetes Support and Control, which included several studies conducted by VHA researchers. Implementation of peer support and self management support programs (which can include new technology) are being discussed at both the healthcare systems and patient community level.
The A1C Test and Diabetes. National Diabetes Information
Clearinghouse (NDIC). National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/. Last accessed October 31, 2012
VA Shared Decision Making Pocket Card (2012)
Last accessed October 31, 2012
Amputation Coalition of America: Roadmap for Preventing Limb Loss in America. http://acoa.convio.net/site/DocServer/Limb_Loss_Task_Force_Paper_2012-Web.pdf?docID=221&AddInterest=1061
Hill RD, Luptak MK, Rupper RW, Bair B, Peterson C, Dailey N, Hicken BL.
Am J Manag Care. 2010 Dec;16(12 Suppl HIT):e302-10. Review.