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ELEGANT-DM2
Share PrintHas your facility struggled to meet diabetes related matrices? Do Veterans with diabetes and providers caring for them feel overwhelmed managing the expansive field of diabetes therapeutics? Has an access to endocrinology services been a barrier in advancing care for Vets with diabetes? If your answer to any of these questions is yes, then let's connect! Our approach, ELEGANT-DM2 is an innovative and collaborative approach to address each of these issues. It uses virtual modalities for collaboration and dashboard tools to provide proactive care addressing each of these barriers.
Origin:
September 2020, Pittsburgh VA Medical Center-University Drive
Adoptions:
7 successful
Awards and Recognition:
Office of Health Equity Quality Initiative funding
Partners:
Clinical Pharmacy Practice Office, Diabetes and Endocrinology, Health Equity, Office of Primary Care
Recent Updates
Overview
Problem
As of FY23, over 1.67 million Veterans (27.25% of enrolled Veterans) carry a definite diagnosis of diabetes mellitus type-2 (DM-2) while over 175K Veterans remain undiagnosed (data source VSSC data cube). This is a more than twice the burden of DM-2 when compared to non-Veteran population. Further, the majority of care for DM-2 occurs within the primary care
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As of FY23, over 1.67 million Veterans (27.25% of enrolled Veterans) carry a definite diagnosis of diabetes mellitus type-2 (DM-2) while over 175K Veterans remain undiagnosed (data source VSSC data cube). This is a more than twice the burden of DM-2 when compared to non-Veteran population. Further, the majority of care for DM-2 occurs within the primary care services (PCS) thus placing a huge burden on PCS to actively engage Veterans. A review of corporate data warehouse (CDW) shows that the percent of Vets with poor control, reflected by matrix DM23h_ec reflecting either A1c over 9% or missing, varies anywhere from 13% to over 34%, demonstrating a wide variation in the quality of care received by Veterans nationwide. Current care structure for DM-2 is fragmented between specialty care- endocrine services (SCS) and PCS with no cohesive ownership, and this system-related factor in DM-2 care worsens clinical therapy inertia (CTI). Limited access to SCS to manage the complex diabetes further increases this burden resulting in CTI, i.e. delay in optimizing care for diabetes. Whether the factor relates to an overburdened PC provider (PCP) or lack of timely access to SCS for advanced care, it is the Veteran with DM-2 who pays the price of CTI.
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A quick look at the burden of diabetes within the VA.
- VHA wide Diabetes data burden as of 09/05/2023 extracted from corporate data warehouse Diabetes Data Burden_2023.pdf
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Solution
The ecosystem of VA healthcare contains every tool that can provide proactive, timely, goal driven care to Veterans with equal access for all. These tools are: dashboards to identify gaps in the care, virtual modalities of care delivery, and a mission towards value driven care. These were put together to create a three pronged ELEGANT-DM2 solution where: 1)
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The ecosystem of VA healthcare contains every tool that can provide proactive, timely, goal driven care to Veterans with equal access for all. These tools are: dashboards to identify gaps in the care, virtual modalities of care delivery, and a mission towards value driven care. These were put together to create a three pronged ELEGANT-DM2 solution where: 1) Veterans in need of care are identified via diabetes dashboard and corporate data warehouse (CDW), 2) clinical pharmacist practitioners (CPP), and clinical pharmacy technicians (CPT), in sync with PCP, initiate the care that is goal driven and allows for higher and more frequent engagement with Veterans, and 3) partner with endocrinology via weekly virtual group huddles for case discussions that obviate the need for traditional consult mechanisms yet bring specialty endocrine skills into primary care of DM-2. To redesign the systems of care for DM-2, previous elements of care and traditional flow of services were realigned so that Veterans' care remains within PCS and team members actively engage with Veterans, while fully supported by endocrine, to augment the quality of care in Vets who have complicated DM-2.
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Patient Centric ELEGANT-DM2 approach
The ELEGANT-DM2 workflow process .
- A process cycle showing system redesign of the patient centric care using various tools for collaboration. Structure of the ELEGANT solution
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Results
Since the inception in 9/2020, the CPP from every PACT team at station 646/ VA Pittsburgh HCS (VAPHS) participate in weekly virtual huddles to present, discuss, and accelerate the care optimization for Vets with DM-2 in their panels. To date, over 700 unique Vets have been presented and followed in ELEGANT-DM2 model. This has allowed to improve the state of
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Since the inception in 9/2020, the CPP from every PACT team at station 646/ VA Pittsburgh HCS (VAPHS) participate in weekly virtual huddles to present, discuss, and accelerate the care optimization for Vets with DM-2 in their panels. To date, over 700 unique Vets have been presented and followed in ELEGANT-DM2 model. This has allowed to improve the state of diabetes care within VAPHS without a need for endocrine consultative services for all DM-2 patients. As noted in the link, when followed over a period of one year during the initial phase of implementation, a successful and sustained improvement of A1c, reflecting better diabetes control, was achieved. Of much importance was the quality of optimization, where therapy choices were concordant with associated co-morbid diseases with benefits beyond diabetes, i.e. a statistically significant number of Veterans were initiated on newer drugs for diabetes such as SGLT-2I (Jardiance- Empagliflozin) and GLP-1RA (Ozempic - Semaglutide/Dulaglutide/Liraglutide) that are now proven to provide the cardiovascular and reno-protective benefits. This also allowed for an expedited and state-of-art care for Vets without a need for “transfer” of care to SCS as traditional referral-based mechanisms would have required. Easy access to a specialist also provided support and avoided ER visits and admission for certain patients (anecdotal experience).
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Images
The A1c results before the intervention and after the intervention for all Veteran seen during the pilot stage.
The A1c results before the intervention and after the interventions for those defined as poorly controlled.
A secondary measure shows improvement of the prescriptive rates of SGLT2i and GLP1-RA in applicable patients.
- A file showing outcome data from ELEGANT-DM2 pilot. Results Summary 1
Files
Metrics
- HbA1c Improvement
- Reduced gap in the care for rural Veterans reflected by DM23h_ec matrix
- Increased prescription rate of concentrated insulins by clinical pharmacist practitioners
- Increased prescription rate of continuous glucose monitors by clinical pharmacist practitioners
- Improved rate of the prescription of new glucose lowering agents in patients with CHF, CKD, and cardiovascular diseases
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Timeline
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Phase one: 0-3 months
Diabetes focused population needs assessment:• Train the nurse care manager (NCM)/program support analyst (PSA) to use primary care equity dashboard (PCED), academic detailing diabetes dashboard (ADDD), and corporate data warehouse (CDW).• Use the PCED and CDW to identify the gaps in the care.• Using the tools, NCM and PSA identify the sites and the resources at the sites in need:• Availability of CPP, CPT, medical support assistant (MSA), and endocrinologist.• CPPs to review training, competency requirements, and scopes of practice. -
Phase two: 6 weeks to 3 months (in tandem with later half of phase one)
Planning phase:• Review the established grids for CPPs and endocrinologist.• Identify CPP leads and champions in the system.• Collaboration planning meetings between home telehealth (HT), CPP, NCM, CPT and endocrinologists.• Assess or redesign the calendar for collaborative processes.• Work with CPRS support team to create CPRS tools: templates, clinic locations, encounters, and parent-child notes for workload capture.• Set the go-live date.• Education and information materials to be sent out to all primary care providers, such as email communication and chief’s weekly newsletter. -
Phase three: 3rd month and continuing
Implementation phase• CPPs/CPTs start engaging with Vets who are identified in need of care collaboration.• MSAs/licensed practical nurse (LPN) if available, start with scheduling process.• CPTs complete the scripted intakes for CPP.• CPPs schedule patients in the clinics (any).• Weekly huddles start a week after go-live date.• CPPs start implementing the action plan for individual Veterans. Care collaboration continues guided by patients' needs. -
Phase four: 6 months from the go-live date
Program assessment: 3 months after phase 3 implementation (6 months from the go-live date)• Reassess eQM matrices for A1c for each provider.• Reassess eQM matrices for A1c each sites.• Each FY-Q reassess delta in the PCED data from baseline.• Conduct the surveys, if interested, from Veterans, PCP, and CPP about the process.• Cost saving can be extrapolated for CPP and Endocrinologist using existing formulae. -
Phase five: 9 months from the go live date
Program expansion:• Care expansion to include Diabetes technology. Includes training, software and hardware procurement.• Consider creating CVT/VVC clinics for Endocrinologist, if not already in existent.• Consider revising scopes for prescription practices, if already not done.• Consider expanding to all PACT teams, if not already established.
Departments
- Endocrinology
- Pharmacy
- Administration
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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PROCESSES |
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Optional Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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TOOLS |
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Support Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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PROCESSES |
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Risks and mitigations
| Risk | Mitigation |
|---|---|
| Risks during assessment phase | A well coordinated effort is needed to identify and design a collaborative program. Risk of excess burden may arise from non-engagement or lack of a NCM or program manager to assist with this step. Mitigation measures may include reserving time for the lead clinical pharmacist/s and /or endocrinologist providing support and oversight for the program. |
| Larger than expected burden of care |
While the state of the diabetes care at their specific sites may already be well known to the sharks, actual burden of care may be out of proportion based on the resources available, namely clinical providers: PCPs and CPPs. Mitigation measures: A realignment of case load, a review of current panels and bookability for CPPs may need to be revisited to improve the care quality provided by the PACT teams. |
| Non-availability of Endocrinologist/Endocrine Service |
Lack of endocrinologist to engage in the care collaboration or lack of available time when endocrine services do exist. Given that Endocrinologists actually provide the backbone for complicated care in this program, the program will not be successful to its fullest. Mitigation: VA Pittsburgh HCS/VISN4 will be willing to provide clinical support/program oversight to the site in need. Under well specified MOUs, VAPHS may provide an interim endocrine support, while the facility considers either future hiring or developing a long term relation with VAPHS/VISN4 based programs. |
Contact
Comment
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Email archana.bandi@va.gov with questions about this innovation.
About
Origin story
VAPHS endocrine division has been at the forefront of modernizing care access and delivery. While our division led the forefront as the pioneers first with the E-consults, then expanded to CVT and VVC in the decade of 2010, truly improving the care of Veterans under our own care, diabetes care for larger population still remained an enigma. The work of our D
...
VAPHS endocrine division has been at the forefront of modernizing care access and delivery. While our division led the forefront as the pioneers first with the E-consults, then expanded to CVT and VVC in the decade of 2010, truly improving the care of Veterans under our own care, diabetes care for larger population still remained an enigma. The work of our Diabetes Care Network (DCN) pilot that attempted to address these silos was highlighted in the Shark Tank competition of 2018 as a semifinalist, yet the silo of diabetes care would not break. Hence, learning the lessons from DCN, a conversation started in mid-winter 2019 between the outpatient clinical pharmacy supervisor Dr. Amy Plumley and the endocrinologist, Dr. Archana Bandi. Their vision was to create a program with a seamless patient-centric approach, where a team works together to optimize the care for a larger population without Veterans having to transfer their care from one silo, i.e. primary care environment, to another silo, i.e. endocrine division. A program that elevates the care using the existing resources, allowing all to work at their top dollar value, eventually helps a larger body of Veterans as it improves the quality of care for all. After designing the early framework of collaboration, they started to lay down the elements of this program, such as getting the buy-in of stakeholders, which includes administration, primary care providers, clinical pharmacy services, to assess sites that would benefit most from this program, identify clinical champions willing to adopt this new care approach, establish CPRS tools, etc. The timing could not have been more perfect. Within a few weeks, arrival of the COVID pandemic was announced!! Access to care was initially shut down systematically until VHA got its bearing together, but ELEGANT-DM2 had already been at work, as if ready for this timing to allow care to continue without a complex system getting in the way! And, that’s what we did. We started with the weekly collaboration huddle for one site, quickly expanded to 3 sites by the end of the year 2020, and by our first year anniversary, all PACT team clinical pharmacist practitioners were joining the huddle to seek expertise of our endocrinologist without having to go the traditional consultative route. This not only expedited the care, it also removed every administrative and delayed care barrier that a Veteran meets during specialty consultation. It also kept their care within the primary care environment, a place that they rely the most. As a team lead, I am proud to say, we have saved lives. For example, a Veteran who had an MVA due to unrecognized hypoglycemia, his family now can be in comfort that he has the tools, not only for an optimal diabetes control with minimal to no hypoglycemia but more importantly to save him from life threatening hypoglycemia. Another young Veteran, who works 60 hours a week as a nurse, now is on an insulin pump without having to travel even once to endocrine services, and all the while, finally for the first time, enjoying excellent control with the QOL that he desires. Also, another Veteran who was relocating to Pennsylvania, didn’t have means of transportation, ran out of insulin, and needed to go to ER due to severe hyperglycemia but avoided the ER because the ELEGANT-DM2 team engaged with him, sought endocrine guidance, and managed him at home while initiating him on a complex regimen of insulin U500. He now enjoys excellent control on a complex regimen and has never “seen” or traveled to an endocrinologist office. Hence, as you can see, our work for Veterans with diabetes who receive their care in primary care services but need endocrine expertise, can finally have a seamless, collaborative care team that truly operates in a patient centric way, in an ELEGANT way!
Original team
Archana Bandi, MD
Endocrinologist responsible for the oversight
Amy Plumley, PharmD, BCACP, CDCE
PACT Clinical Pharmacy Supervisor
Jessica Anderson, PharmD
Clinical Pharmacist Practitioner
Danya Becker, PharmD
Clinical Pharmacist Practitioner
Stephanie Sodders, PharmD, BCPS
Clinical Pharmacist Practitioner
Amazing work again by VAPHS highlighting the power of teamwork to improve the health of veterans some of which are in rural locations!
I am PACT CPP at VA Pittsburgh and I have had the pleasure to work with Dr. Bandi and my CPP colleagues in our Endocrine-PharmD Collaboration Group. I completed my PGY1 in 2022 and began working in the PACT setting immediately after. The Endocrine-PharmD meetings have been a major benefit for me at VAPHS, especially in my first year as a PACT PharmD. I have brought many difficult and/or interesting cases to our meetings and always leave with a great plan. I have learned a lot from our meetings by discussing cases and reviewing literature/guideline resources. It is great to know that when I am facing a difficult to manage case, I can bring the patients needs to the group to collaborate on an effective and safe plan.
- Albert Allard, PharmD