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DIABETES SP E C I ALT Y SE RV I C E S P RO GR AMS


It has been an incredible year for healthcare organizations in the U.S. With the passage of the Affordable Care Act and its roadmap for sweeping changes in health care delivery, many physician and hospital organizations have embarked on new strategies to rein in the ever increasing cost of health care while still providing excellent patient care. Diabetes and its complications present a multifaceted challenge as we embark on this new chapter and Joslin Diabetes Center has developed proven strategies to address the growing epidemic of this disease. The news from the International Diabetes Federation’s most recent global data on the diabetes epidemic is stunning: „„ 366 million people globally have diabetes „„ 4.6 million deaths are due to diabetes „„ Health care spending on diabetes has reached the equivalent of $465 billion U.S. dollars „„ In 2011, one person died every 7 seconds from diabetes


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

Joslin Diabetes Center provides programs and consultative capabilities that directly align with this changing healthcare landscape and new direction provided by the Affordable Care Act. We have a comprehensive array of diabetes products and offerings to assist healthcare organizations in addressing the challenges of the disease. These offerings include: „„ Medical model affiliation „„ Network/system affiliation „„ Primary Care Provider Certification program „„ (The above programs include specially developed assessment tools:) „„ JCAT™ (Joslin Clinical Analytic Tool) „„ JARS™ (Joslin Affiliate Reporting System) „„ Inpatient Diabetes program (Inpatient Diabetes Quality Initiative - IDQI™) „„ Pediatric program „„ Skilled Nursing/Long Term Care/Assisted Living program „„ Behavioral Health program „„ Consulting services „„ Community Health programs The Joslin Affiliated Centers network has grown to include more than 40 locations in 17 states and three international locations (Canada, India and Kuwait). The following information overviews our product portfolio.


Medical Model Affiliation Many organizations are not positioned to provide the variety of programs and services needed to meet the complex demands of the patient with diabetes. Through collaboration with Joslin, institutions can replicate the patient centric diabetes care team model pioneered by Dr. Elliott P. Joslin, MD, that has been time proven since the opening of the Joslin Diabetes Center in Boston, MA over 100 years ago. This unique approach, coupled with the continuum of diabetes care programs available through Joslin, are optimally designed to provide diabetes solutions for organizations to offer to patients with diabetes throughout the entire spectrum of patient care. An alliance with Joslin allows organizations to demonstrate to insurers and to self-insured employers that they are qualified to provide leading-edge diabetes management designed to prevent costly short and longterm disease related complications. Joslin Affiliated Centers are well positioned to serve a growing and ethnically diverse population of patients who require new and emerging treatment modalities, specialized services and culturally appropriate care and education. Joslin Affiliated Centers receive many benefits, including: „„ Joslin franchise and protected territory „„ Exclusive territorial use of Joslin brand and institution’s own licensed Joslin mark and logo „„ Rigorous and Joslin validated requirements to maintain minimum standards surrounding „„ Staffing „„ Clinical Care „„ Business and Marketing Operations „„ Connection to the largest center for diabetes treatment and research in the world „„ Intellectual property developed over 25 years of Affiliate operations including operating and clinical manuals along with Joslin protocols and clinical guidelines

„„ Clinical, operational, and marketing support provided by Joslin Diabetes Center experts „„ Comprehensive staff training and education, both on site and twice a year Boston mandatory orientations for MDs, NPs, PAs, Certified Diabetes Educators and Center Administrators every Spring and Fall „„ Joslin developed patient education materials and culturally diverse educator curricula „„ Consultative assistance with application for ADA education programs recognition or AADE accreditation „„ Individual Affiliate site and network outcomes tracking and benchmarking reports produced monthly that track productivity metrics for physicians, nurse practitioners, physician assistants and educators


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

„„ Joslin Affiliates Annual meeting in Boston every October, providing a collegial and networking event for Joslin Affiliate Medical Directors, Education Coordinators and Center Administrators where cutting edge and most recent trends in diabetes care and education are discussed „„ For new Affiliates, implementation visits are conducted that include four visits by a multidisciplinary team (Endocrinologist, Certified Diabetes Educator/CDE and business expert) during the first year „„ Annual site visit and targeted site visit are conducted in each subsequent year of Affiliate operations

„„ Monthly Affiliate conference calls and Affiliate e-Newsletter are offered, along with regular phone and email connections „„ Membership in a network of nationwide Affiliates „„ Support staff assigned to each Affiliate Center include both dietitians and nurses who are certified diabetes educators” „„ Patients have referral access through a service line approach to staff skilled in many disease-related disciplines, including cardiology, endocrinology, mental health, nephrology, ophthalmology, podiatry and vascular medicine.

„„ Networking meetings at national conferences (ADA and AADE) „„ Every Joslin Affiliated Center is assigned a site coordinator who is their liaison with Boston Healthcare facilities today strive to establish and launch Centers of Excellence, a designation for specialized programs that meet specific community needs in cutting-edge treatment modalities and in attracting highly trained and experienced medical staff. Many organizations are interested in a “buy” rather than “build” solution when establishing a diabetes center of excellence. Joslin provides proven and validated diabetes products and services that insure that Joslin excellence in diabetes care and standards are present in your organization.

Network Affiliation

All of the aforementioned benefits available through a medical model Affiliation but offered on a larger scale to a hospital system with multiple locations.


JCAT™ The Joslin Clinical Analytic Tool (JCAT™) was developed by Joslin endocrinologists in response to the need for meaningful quality assessment of complex populations with diabetes. JCAT™ uses easily attainable data and stratifies patient populations using medication regimen as a proxy for disease complexity. Using results from recent clinical trials, biomarker targets are graduated across strata, and when not achieved for a particular subgroup, provide succinct data on which patient to target change in clinical practice. Because of this stratified approach, the tool is applicable to any care setting and any patient mix and will accurately pinpoint subpopulations in need of targeted quality intervention. The abiity to succinctly identify which patients are most in need of intervention means limited time and resources are used more effectively providing higher return on investment (ROI).


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

JCAT Summary Results

The JCAT™ results below summarize the percent of patients at target for glucose, blood pressure, LDL cholesterol, renal and smoking. The summary includes results from Joslin Boston (J1), twenty-one Joslin Affiliated Centers and the network average for these sites. JCAT Summary Results Affiliate Network Average (24 Sites)

Audit Date

Total Charts

Glucose

BP

LDL

Renal

4,983

63.1 %

80.7 %

81.9 %

89.6 %

NonSmoker

82.8 %

1 Joslin

Jan 2011

10,143

72.4 %

82.2 %

83.9 %

90.2 %

74.6 %

Site # 1

Jan 2012

93

73.1 %

57.0 %

79.6 %

93.5 %

88.2 %

Site # 2

Aug 2011

90

66.7 %

92.2 %

86.7 %

87.8 %

80.0 %

Site # 3

Sep 2011

60

66.7 %

91.7 %

83.3 %

86.7 %

88.3 %

Site # 9

Feb 2012

56

53.6 %

83.9 %

76.8 %

91.1 %

83.9 %

Site # 10

Feb 2012

59

69.5 %

86.4 %

83.1 %

94.9 %

89.8 %

Site # 16

May 2012

178

63.5 %

77.0 %

82.0 %

96.6 %

91.0 %

Site # 22

Jun 2012

120

73.3 %

77.5 %

76.7 %

89.2 %

77.5 %

Site # 23

Jan 2012

60

78.3 %

83.3 %

80.0 %

88.3 %

88.3 %

Site # 25

Jul 2011

51

84.3 %

84.3 %

84.3 %

96.1 %

84.3 %

Site # 26

Feb 2012

59

61.0 %

81.4 %

83.1 %

89.8 %

78.0 %

Site # 28

Apr 2012

176

65.9 %

79.5 %

85.2 %

88.1 %

88.6 %

Site # 30

Oct 2012

67

68.7 %

76.1 %

92.5 %

89.6 %

73.1 %

Site # 32

Sep 2012

62

61.3 %

80.6 %

77.4 %

62.9 %

75.8 %

Site # 33

Aug 2011

54

72.2 %

83.3 %

79.6 %

90.7 %

88.9 %

Site # 35

Sep 2011

59

69.5 %

72.9 %

79.7 %

94.9 %

86.4 %

Site # 37

Sep 2011

60

71.7 %

73.3 %

51.7 %

75.0 %

70.0 %

Site # 38

Jan 2011

2,996

67.9 %

78.3 %

79.9 %

86.2 %

82.8 %

Site # 39

Mar 2012

117

49.6 %

83.8 %

86.3 %

93.2 %

84.6 %

Site # 40

Jun 2011

201

65.2 %

88.1 %

91.5 %

92.0 %

70.6 %

Site # 41

Jan 2012

118

39.8 %

78.8 %

78.0 %

89.8 %

93.2 %

Site # 42

Aug 2012

67

41.8 %

85.1 %

91.0 %

94.0 %

73.1 %

Site # 43

May 2012

62

51.6 %

80.6 %

87.1 %

90.3 %

83.9 %

Site # 47

Feb 2012

59

62.7 %

74.6 %

91.5 %

94.9 %

94.9 %

Site # 50

Jul 2012

59

35.6 %

86.4 %

78.0 %

94.9 %

72.9 %


JARS™ JARS™ (Joslin Affiliates Reporting System) is a proprietary data mining tool that Joslin developed to demonstrate to our affiliates the significant value and benefit on both a financial and clinical basis that inures to a host organization through a Joslin affiliation. Through the JARS™ reporting system, the organization’s own billing data is mined to measure downstream net revenue from all Joslin patient services provided at the host institution. „„ JARS™ data validates that during the first year of operations, Affiliate sites derive 13% of total net patient revenue from new or incremental patients (patients who have not presented to the host site for any service whatsoever in the prior 36 months). „„ Association with the Joslin brand and its reputation for excellence offers the opportunity to differentiate your services from the competitive mix of other local hospitals and healthcare facilities with diabetes programs. JARS™ data shows that 44% of new/ incremental patients present from secondary and tertiary service areas defined by the host institution, validating the draw of the Joslin name and approach to diabetes care „„ JARS™ also captures A1C data from hospital patients with diabetes, both Joslin and non-Joslin, to validate the clinical effectiveness of Joslin treatments and interventions on patient outcomes „„ JARS™ report also mines Medicare grouped DRG data, which includes LOS (length of stay) and diagnostic information for clients, crucial data elements in the ACO era. This DRG LOS data contrasts favorably for Joslin patients as compared to the AMLOS (Arithmetic Mean Length of Stay) data that is used by many payors to review LOS results


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

JARS Actual A1C Results

A1C of patients 12 months prior and 12 months post-Joslin Care intervention at Affiliated Joslin Centers (“Joslin”) compared to patients within hospital systems that do not utilize Joslin care (“Non-Joslin”)

A1C%

12

Joslin

Non-Joslin

10.18

10

10.38

9.99

9.63 9.43

9.07

-12 months

9.73

9.16

9.11

9.27 8.97

9.25 8.88

8

10.47

-9 months

-6 months

-3 months

8.76

8.71

3 months

6 months

8.42

9 months

8.19 12 months


Primary Care Provider Certification Program Joslin offers a very robust primary care provider certification product that certifies providers according to Joslin standards around the treatment of diabetes. This certification incorporates the following program components: „„ Provider must achieve passing scores on the Joslin Clinical Analytic Tool (JCAT)™ „„ Complete a PCP Office Assessment „„ Identify and complete Continuous Quality Improvement (CQI) projects „„ Complete 10 diabetes-related CME credit hours annually „„ Participate in an on-site, CME-eligible training course conducted by Joslin clinicians „„ Designate a Joslin-approved diabetes care coordinator at the practice location(s) „„ Participate in clinical conference calls „„ Use Joslin educational materials „„ Establish and maintain a referral network of specialty care providers „„ Complete a patient satisfaction survey The on-site training session includes a detailed review of the JCAT™ and office assessment results. The office assessment was created specifically for this program and is comprised of four high-level categories: Office Systems, Patient Instruction Available in Your Office, Clinical Care and Quality Improvement. The office rates itself on each of the sub-categories that are essential to the delivery of high quality care to patients with diabetes. Gap areas identified in the results of both of these tools will form the basis of the CQI project that the PCP office elects to complete.


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

Pediatric Program The Joslin Pediatric program provides a comprehensive approach to addressing the increasing numbers of children who are being diagnosed with diabetes (particularly Type 1 diabetes). Since diabetes affects all aspects of the child’s life, the support of family and guidance of the healthcare team is required for a successful outcome. Diabetes treatment and self-management education will generally take place during clinic visits. During such visits, a variety of multidisciplinary healthcare team members may be seen. Your pediatric endocrinologist and pediatric diabetes nurse educator will help you and your child recognize when you need the services of each of these team members as well as other specialists identified later. Your primary healthcare team members include: „„ Physicians „„ Nurses/Nurse Practitioners „„ Dietitians „„ Psychologists and Social Workers „„ Child Life Specialists „„ Medical Assistants „„ Pediatric Phlebotomists „„ Exercise Physiologists „„ Office staff The Joslin Pediatric team can be a key resource to your institution as you develop and plan a pediatric diabetes Center of Excellence.


Inpatient Program Research studies support the importance of focusing on diabetes management for hospital inpatients. A study titled “Hospitalizations, Nursing Home Admissions, and Deaths Attributable to Diabetes” shares with us the following: “A simulation model, based on data from the National Health and Nutrition Examination Survey (NHANES) 1 Epidemiologic Follow-up Study, was used to represent the natural history of diabetes and control for a variety of baseline risk factors. The model was applied to 6,265 NHANES III adults aged 45-74 years. For all NHANES III adults aged 4574 years, a diagnosis of diabetes accounted for: „„ 8.6% of hospitalizations „„ 12.3% of nursing home admissions „„ 10.3% of deaths For people with diabetes, diabetes alone was responsible for: „„ 43.4% of hospitalizations „„ 52.1% of nursing home admissions „„ 47% of deaths Adjusting for related cardiovascular conditions, which may provide more accurate estimates of attributable risks for people with diabetes, these estimates increased to 51.4%, 57.1% and 56.8% respectively It is well known that diabetes is a major problem which results in a great deal of human suffering and accounts for a significant part of our unsustainable expenditure on healthcare, It is established that the impact of diabetes can be lessened by bringing about better control of blood sugar levels on a long-term basis. More recently physicians have gained insights into the potential to decrease morbidity and mortality through better control of diabetes in acutely ill patients. We now know that a patient’s blood sugar levels during periods of critical illness, including during heart attacks, strokes, and after surgery can have a significant effect on their clinical outcomes. With this knowledge, it is incumbent upon us to ensure that our patients with diabetes receive the benefits of optimal diabetes care.


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

Our experience clearly shows that even in the best hospitals, optimal diabetes care does not always occur. The challenge we face is how to pursue this goal in the context of a healthcare system that is increasingly stressed and facing competing priorities. The best approach is one that breaks the problem down to its elements with the goal of optimizing performance in each area. A nurse can do an excellent job monitoring blood sugar levels, administering insulin, and providing patient education. She/he, however, cannot formulate the proper meal-plan or order the appropriate insulin regimen and ensure that it is available and dispensed properly. With this in mind, it is clear that only a team approach can be successful: „„ The dietary department devises the meal-plan and distributes it in a consistent way „„ The nurse monitors the blood glucose and administers insulin at the right times „„ The pharmacy makes sure that the insulin is available when needed with minimal cost and risk of errors „„ The doctor devises an insulin regimen that is likely to bring about good control and continuously re-evaluates and modifies it as needed Each of these is essential, but none alone is sufficient. Failure of any one will mean failure of the team and problems for the patient. Joslin has developed an approach to inpatient diabetes management (IDQI™ - Inpatient Diabetes Quality Initiative) that facilitates the optimal performance of each part of the team. While focusing on achieving excellence in its role, each department is also represented in a central steering committee which oversees the effort and monitors performance on an ongoing basis. The program is supported by 9 developed inpatient treatment protocols and care algorithms, a detailed manual as welll as with a focus on evidence-based and proven measures informed by the broad experience and expertise that Joslin offers. Patients benefit directly through better clinical outcomes. Hospitals benefit through provision of more efficient, cost-effective care that results in decreased lengths of stay. Hospitalized patients with diabetes deserve the best care possible. You would have your patients receive nothing less. The Joslin Inpatient Diabetes Quality Initiative (IDQI™) provides a clear pathway to this worthy end result.

“Hospitalizations, Nursing Home Admissions, and Deaths Attributable to Diabetes”; Russell LB, Valiyeva E, Roman SH, Pogach LM, Suh DC, and Safford MM, Diabetes Care 2005; 28: 1611


SNF/LTC Program Diabetes Specialty Services, a program of Joslin Diabetes Center, was designed to meet the needs of skilled nursing facilities to improve the care of residents with diabetes and to provide optimal diabetes care for rehab and frail elder patients as they transition from an acute, inpatient setting to a home or long term care setting. Our goal is prevention or early recognition and treatment of hypoglycemia and hyperglycemia in skilled nursing facilities and long term care settings. The program requires a commitment of time and financial support by the facility. Key components of the program include: „„ Specialized training for nurses and certified nursing assistants to insure that clinical staff prevent and recognize diabetes complications early and treat appropriately „„ Collaboration with providers to assure that standards of diabetes care for medical management are met „„ Provision of developed clinical protocols to guide practice „„ implementation of a comprehensive patient assessment for diabetes risk factors at time of admission with immediate changes made in at-risk patients „„ Appropriate frequency of blood glucose monitoring to evaluate diabetes control „„ Diabetes Care Coordinator, a nurse focused on blood glucose analysis and communication to medical staff for medication adjustments in a timely manner „„ Patient and family education in diabetes management in preparation for discharge to optimize home management „„ Focus on eliminating hypoglycemia before treating hyperglycemia „„ Outcomes data is mined and tracked to review outcomes


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

Results 443 diabetes patients from 3 Skilled Nursing Facilities 53% of patients were treated with insulin at time of admission Hypoglycemia „„ 28% of patients had a hypoglycemic event (Blood glucose < 70 mg/dL) „„ 66% had only 1 event „„ 90% of hypoglycemic events were resolved (no further episodes in 7 days) Hyperglycemia „„ 26% of patients had a hyperglycemic event (Blood glucose > 200 mg/dL for 3 days) „„ 59% had only 1 event „„ 70% of hyperglycemic events were resolved or decreased High A1C (>8%) does not protect patients from hypoglycemia We identified commonality in patients experiencing hypoglycemia and hyperglycemia „„ On Insulin „„ Dialysis/renal disease „„ Recurrent hypoglycemia „„ History of Diabetes Ketoacidosis or Hyperosmolar Hyperglycemic Syndrome „„ In some patients decreasing hyperglycemia results in increased risk for hypoglycemia Identifying risk factors for hypoglycemia and hyperglycemia at admission and a well trained staff can prevent future episodes!


Behavioral Health Program In the United States up to 24 million people of all ages and genders suffer from an eating disorder (anorexia, bulimia and binge eating). Adolescent girls and young women with type 1 diabetes have an increased risk for eating disorders, with the incidence of type 1 diabetes (ED-DMT1) ranging up to 11% in this population. Eating disorders in individuals with type 1 (ED-DMT1) are clinically concerning because of the increased risk of diabetic ketoacidosis (DKA) and diabetes related complications (particularly retinopathy and neuropathy) for these patients. To address diabetes in this population, Joslin has developed a Behavioral Health Care program focused on: „„ Training all clinical staff to prevent and recognize diabetes complications early and to treat them appropriately „„ Collaborating with physicians, nurse practitioners and physician assistants to assure standards of diabetes medical care are met „„ Developing protocols to guide practice for patients with eating disorders and diabetes admitted to a specialized behavioral health facility or program focusing on eating disorders „„ Training a diabetes care coordinator (who is trained to monitor continuous quality care through management, teaching and evaluation), and clinical staff to educate patients and families to understand how to self- manage diabetes „„ Insuring staff commitment to exceptional care of the person with diabetes „„ Data collection to evaluate the impact of the program „„ Regular communications with the Joslin team to assure continuous quality improvement „„ Quarterly case study conference calls presented by behavioral health center staff to address difficult patient scenarios „„ Training nurse practitioner to better manage diabetes in the presence for patients with eating disorders


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S

Consulting Services

The Joslin team is available to conduct comprehensive consulting engagements on any and all aspects of diabetes. We are often engaged by clients to come in and lead an assessment of the organizationâ&#x20AC;&#x2122;s state of diabetes clinical and education care and to make recommendations regarding all aspects of implementing a diabetes Center of Excellence. Very often, after we conduct our assessment and deliver a comprehensive report with our recommendations, the client makes the decision to become a Joslin Affiliated partner.


Community Health Programs With the advent of the Affordable Care Act (ACA), one of the key focuses of health care delivery is to provide care to patients “at the right time, with the right provider, in the right setting”. Joslin has excellent programs such as “On The Road™” to provide comprehensive training and guidance to non-clinicians who are trained to provide diabetes education in community settings. The On the Road program was developed in 2000 as a diabetes pre-education program targeting information to a less-educated population that was not regularly accessing health care. Program sessions are delivered in a local community setting by any level of educator, from lay health workers with basic knowledge about diabetes and a positive attitude, to clinicians using the program to supplement a more comprehensive diabetes education program. The program uses point-of-care (POC) testing with results immediately provided to participants and their families, so that they have their individual results available during discussion of the tests. There are many benefits that flow directly from this program: „„ Joslin trained staff educates underserved populations about diabetes care: awareness, knowledge and management of important clinical tests „„ Joslin staff trains health advocates to implement the program „„ Program materials are available in English and Spanish „„ To date 18,000+ people in five states have been through the program (Pennsylvania, Hawaii, New Mexico, Washington and West Virginia) „„ Classes target people with diabetes, but caregivers and people “interested in diabetes” are strongly encouraged to attend since this group is enriched for pre-diabetes and cardiovascular risk factors

„„ Program enables us to show impact potential of delaying progression from pre-diabetes to diabetes „„ Patient blood pressure decreases are the most insightful measure „„ Unintended consequence: 40 – 50% of participants who “don’t have diabetes” (spouses, family members) are found to have pre-diabetes” „„ Program has demonstrated improved outcomes in people with pre-diabetes that may prevent or delay progression to diabetes „„ Joslin received $5 million CMS grant to to demonstrate the cost effectiveness and impact of this program


JOSL I N D IABET ES CENT ER DI A BETE S S PECIALTY SERVI C E S PR OGR A M S


About Joslin Diabetes Center

Joslin Diabetes Center is the world’s preeminent diabetes clinic, diabetes research center, and provider of diabetes education. Joslin is dedicated to ensuring people with diabetes live long, healthy lives and offers real hope and progress toward diabetes prevention and a cure for the disease. Founded in 1898 by Elliott P. Joslin, MD, Joslin is an independent nonprofit institution affiliated with Harvard Medical School. For more information about Joslin, call 1-800-JOSLIN-1 or visit www.joslin.org. In 2006, Joslin was re-accredited by the Accreditation Council for Continuing Medical Education (ACCME) and received “Accreditation with Commendation” status, the highest rating achievable by a provider of CME.

D I A BET E S I S E V E RYW H E R E . . . SO A R E WE

Joslin Diabetes Center One Joslin Place Boston, MA 02215 www.joslin.org/bp/affiliated_centers.html


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