All Hands Meeting

1. September 30, 2010 All Hands Meeting

2. Agenda • Medicaid Formulary • IMC Diabetes Program update • Flu vaccine • Carolina Care review • Pass the Pickle • IMC Depression Care

3. Changes in Prescription Drug Coverage, 2010 NC-Medicaid Preferred Drug List (PDL)

4. Background • Updated Preferred Drug List (PDL) became effective 9/15/10 • New restrictions on prescription drug coverage for a number of commonly used medications • Medicaid patients need to be transitioned to preferred drugs in order to preserve Rx coverage • Otherwise, prior authorization (PA) must be documented to ensure continued coverage of non-preferred agents • Future prescriptions will need to keep formulary restrictions in mind

5. Drug Classes Involved • Inhaled Corticosteroids & Combo therapies • Short-acting Inhaled Beta agonists (SABAs) • Leukotriene Modifiers (Singulair®) • Statins (Lipitor®) • Smoking Cessation Agents • Topical Anesthetics (Lidoderm® patch) • Triptans • Insulins

6. Prior Authorizations • Failure of the preferred drug or intolerance of the preferred drug will justify the use of a more expensive alternatives

7. Inhaled Corticosteroids & Combos • Preferred IH steroid: QVAR (beclomethasone) • All steroid/LABA combo agents require PA based on clinical criteria • PA Criteria • Disease severe enough to warrant steroid/LABA combo agent for symptom control • Patients diagnosed w/ COPD

8. Leukotriene Modifiers • Covered only if patient meets clinical criteria: • Asthma • Inhaled steroids not working • Allergic Rhinitis • Antihistamine and nasal steroid combination not working • Exercise-induced Bronchoconstriction (EIB) • SABA not working

9. Statins • Preferred: lovastatin, pravastatin, simvastatin • PA criteria • Simvastatin not effective • Patients with CAD or DM on Lipitor® 80mg, or Crestor® 20-40mg • Patients on lower doses of lipitor will be switched to an equivalent dose of simvastatin.

10. Smoking Cessation Agents • No longer covered • Commit® lozenges, Nicoderm CQ® patch, Nicotrol® inhaler, Zyban® (brand bupropion) • PA criteria • Try and fail at least 2 preferred agents • CI or intolerance to preferred agents • Also… • Chantix® quantity limit to 6-month supply/yr

11. Topical Anesthetics • Preferred: Voltaren® gel • PA criteria (for Lidoderm® patch) • Available only for patients with postherpetic neuralgia

12. Triptans • Preferred: sumatriptan, Maxalt MLT® • PA criteria: quantity limit (must meet ALL criteria) • Diagnosis of migraine or cluster HA • > 6 moderate-severe HA days/mo • Tried and failed NSAIDs (or CI to NSAIDS) • Concurrently using migraine prevention medication • No h/o ischemic cardiac, cerebrovascular, or peripheral vascular syndromes, etc. • PA criteria: non-preferred agent • Try and fail or CI/intolerance to at least 2 preferred agents

13. Insulins • Coverage no longer provided for: • Humalog® pens • Levemir® Flexpen • Apidra® Solostar • PA criteria • Try and fail at least 2 preferred agents • CI or intolerance to preferred agents

14. Notification Process • Prescribers will be notified by WebCIS “phone message” regarding patients affected by new PDL • Message may include: • Request for approval of switch to preferred agent • Request for information regarding potential PA criteria • Notification of automatic conversion to preferred agent • Patients will be notified by mail of any changes made to their medication regimen

15. Documentation • If applicable, PA criteria will be documented as a WebCIS general note • Subject: “Prior Authorization – (Drug name)” • Patient medication profiles will be updated to reflect new drug regimen • If changes are made, new prescriptions will be prepared and sent (eRx when possible) to the patient’s pharmacy

16. For More Information… • Internal Medicine website - Clinic • Announcements

17. Victoria Hawk GIM Enhanced CareDiabetes Program update

18. Diabetes Program Staff Shaun McDonald IT/Database Specialist (3-1350) Maria Walker Administrative Assistant (ext 290) Victoria Hawk, RD Manager (ext 259) Carlie BlakeCare Assistant (ext 275) Natalie Phillips Care Assistant (ext 244) Will GarneauCare Assistant (ext 245)

19. Diabetes Practitioners Betsy Shilliday, PharmD, CDE Robb Malone, PharmD, CDE Brittain Fish, PA-C Carrie Palmer, ANP, CDE Victoria Hawk, RD Bart Scott, PA-C

20. Diabetes Services • Education • Individual sessions and group classes • Medication education and adjustments • Insulin teaching • Glucose meter • Teaching, troubleshooting • Download in clinic • Retinal Camera • Patient Follow-up • Visits • Phone calls

21. Visit Planner • Specific prompts to assess needs • Improve patient care • Help patients access clinic services

22. Case Management Care Assistants assigned to group of patients: • Improved, personalized communication to create partnership • Enhanced patient monitoring Patients that need extra help: • Proactive phone follow-up (before/after visit) • Improved visit coordination • Improved utilization of clinic services

23. Case Management Model Natalie Patients A-L Side 2 Room 3117 Carlie Patients M-Z Side 1 Room 3217

24. 2578 Total Diabetes Patients Patients per Care Assistant 1289 1289 Risk Zone 731 357 201 715 344 230 GIM Diabetes Patients A-L M-Z • Risk Zone calculation: • A1c • Blood Pressure • Key medication use • Depression assessment • Smoking assessment

25. Diabetes Patient Zones 25

26. High Risk Zone • Call 2 weeks before visit • Care Assistant follow-up in clinic • Call on same day if no-show • Call within 2 weeks after visit • Visit coordination for other clinic services

27. Case Management of High Risk Patients

28. Case Study • Mr. Baker • 63 year old man • Last HgA1c: 11% • Blood Pressure: 140/90 • Classified as High Risk Zone

29. Pre-clinic call: Not checking blood sugar Eye exam out-of-date No-show for last appointment Intervention: Assessed appropriate use of medication Plan for glucose monitoring Confirmed upcoming clinic visit Scheduled retinal camera appointment at upcoming visit Reminded to bring meter and medicines

30. In clinic visit: Stamped provider schedule On arrival, meter downloaded, medication assessed and CA identified that patient had not been taking Metformin Communication with provider – plan to restart Metformin and begin daily walking routine Provided summary sheet with goal, medication changes, follow-up plan and contact information Patient taken to retinal camera

31. 2 week post-clinic call: Medication compliance Blood sugar monitoring Goal to start daily walking routine Patient reported GI distress Intervention: Precepted with Diabetes Practitioner Adjusted Metformin dose Phone follow-up in 1 week

32. Care Assistant Follow-up • Care Assistants are available in clinic for ALLpatients that need diabetes care including: • New diagnosis • Basic diabetes education • Glucose meter training or questions • Insulin teaching Please call or come find us, we are here to help!

33. Janie Dail Flu vaccine update

34. 2010 – 2011Influenza Information Sheet • Vaccine availability • Friday, September 24, 2010 • Product Information • The cap on the single dose syringe may contain latex so use the multi-dose vial for those patients who have a latex allergy. • CDC Information • Yearly flu vaccination should begin in September or as soon as vaccine is available and continue throughout the influenza season, into December, January, and beyond. This is because the timing and duration of influenza seasons vary. While influenza outbreaks can happen as early as October, most of the time influenza activity peaks in January or later. • http://www.cdc.gov/flu/protect/keyfacts.htm

35. 2010 – 2011Influenza Information Sheet • Who Should Get Vaccinated • Everyone 6 months and older should get a flu vaccine each year starting with the 2010-2011 influenza season. The "universal" flu vaccination available in the U.S. will expand protection against the flu to more people. • While everyone should get a flu vaccine each flu season, it’s especially important that the following groups get vaccinated either because they are at high risk of having serious flu-related complications or because they live with or care for people at high risk for developing flu-related complications:  • Pregnant women • People 50 years of age and older • People of any age with certain chronic medical conditions • People who live in nursing homes and other long-term care facilities • People who live with or care for those at high risk for complications from flu, including: • Health care workers • Household contacts of persons at high risk for complications from the flu • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

37. Scheduled appointments • During flu season, vaccines are offered to all patients during clinic visit. • Patients with a clinic appointment before December 1 can receive their flu vaccine at their scheduled visit. • Patients can also be encouraged to make an appointment for a nurse visit to receive their flu vaccine and avoid long waits. The following schedule is available for receiving flu shots: • Thursday: 9am – 12pm • Friday: 1:30pm – 4:30pm • Walk-ins will be worked in (walk-in patients will be informed that they may experience a wait, or given the option to schedule a nurse visit for their flu shot)

38. Janie Dail Carolina Care review

39. What Is Carolina Care? A program to improve patient satisfaction & staff work experience, as measured by Press Ganey scores Defined set of service behaviors patients can expect at UNC Health Care Clinics and Practices A tool kit of processes and words developed to convey Carolina Care is consistently demonstrated

40. Who will attend the Carolina Care meetings and distribute the information to clinic staff? Janie Dail & Lisa Beaver

41. Janie Dail Pass the Pickle

42. Diane Dolan-Soto IMC: Depression Care

43. Depression Care at IMC • Coordinated care involves all levels of staff trained to identify and treat depression • Regular use of PHQ9 = A1c of Depression • Screen = identify; Retest = track & manage • Follow up phone calls at 2 weeks • Standardized treatment and medication management • On-site counseling: Internal Medicine Counseling Program (IMCP)

44. Evidence Based Program Model. Results for patients: • Doubled the effectiveness of usual care – JAMA 2002; 288:2836-2845 • Patients experienced better physical function – Callahan et al, JAGS 2005 • Care was shown to benefit diverse populations – Arean et al. Medical Care 2005 • Effects persisted one year after IMPACT – Hunkeler, et al 2004 – unpublished data

45. How does counseling help? • Teaches patients a structured approach to problem solving. • Increases patients’ ability to clearly define their problems and set concrete & realistic goals. • Increases patients’ understanding of the link between their current symptoms & current problems in living. • Emphasizes the need to increase pleasant, social and physical activity.

46. Who does counseling help? • Adults diagnosed with depression • Patients with active substance abuse, personality disorder, mental illness, complications from pain or long-term depression will need other services (e.g. specialized treatment program, psychiatric services, etc.) • Case example: Ms. W is a 57 year old woman with diabetes & depression. Unemployed. Hx of DV. Severe depression; crying daily, unable to sleep, unable to concentrate. Difficulty functioning in all usual activities.

47. Functioning Before & With PST Before With Established sleep routine Set reasonable expectations of self & training Reality test w/ trainers Re-claim home; engaged in pleasant and physical activity PHQ9 = 1 (at 2 mo, sess 6 of 12) • Not sleeping well • Learning insecurities • Fears of failing • Not caring for home; emotionally shut down • PHQ9 = 21

48. IMCP: Overview of Service Activity • Internal Medicine Counseling Program started May 2010

49. Things we’re doing well: • Following the given protocol • 2 week follow up calls = 90% of the time • Pt seen within 4 weeks (for any reason) = 76% of the time • Medication = 53% of the time initiated/changed; 37% no change= outside treatment; 10% Unknown • Providing education for mild/moderate depression = good/uneven • New system offer Depression Decision Aid • Identifying potentially suicidal patients and further investigating, documenting this in notes • 40% positive screen for all June PHQ9s • Providers documented majority of instances • Providers did additional assessment & documentation beyond PHQ9

50. Depression Screening: Visit Planner Prompts • Depression Screening Prompts are paired so both the Nurse and Provider are prompted Nurse Prompt Provider Prompt