AJN, American Journal of Nursing:
Linda M. Siminerio is director of the University of Pittsburgh Diabetes Institute in Pittsburgh, PA. Laurie Lewis is a freelance medical writer and editor in New York City.
Contact author: siminerioL@upmc.edu.
The diabetes education program at the University of Pittsburgh Medical Center (UPMC) is the first reported program in the country to use all key elements of the Chronic Care Model in support of diabetes self-management education (see Figure 1, "the Chronic Care Model," in "Diabetes Care: The Need for Change," page 14).1 Collaboration among UPMC partners, including 19 hospitals and more than 200 primary care providers, has been instrumental to the success of this program. Not only have patients' glycosylated hemoglobin (HbAIc) levels decreased significantly, but also the costs of the program have been supported through increased reimbursement.
This financial success is a result of the systems approach of the Chronic Care Model. With the support of the health system, educators were able to access services in administration, finance, billing, insurer contracting, and information technology. Tapping into these resources, educators identified gaps and problems in reimbursement. They relied on administrative support to work with the insurers, and they tracked payment through the computer and data systems.
The key to profitability of a diabetes education program is adequate reimbursement. Medicare and other third-party payors reimburse for such programs if they meet the requirements for the American Diabetes Association (ADA) Education Recognition Program.2 Diabetes education programs pay a $1,100 ADA recognition application fee. Use of the same forms, curricula, and educational materials to assure a consistent approach to diabetes self-management education enabled the entire UPMC system (and, later, smaller facilities in western Pennsylvania that partnered with the program) to apply for ADA recognition as a group for an additional fee of only $100 per site.
Support of administrators was critical to the success of the program. The administration was so impressed with the early results, including lower HbAIc levels and increased access to education, that it made diabetes a quality improvement initiative for the entire health system. This provided diabetes educators with access to many areas in the health system, including financial departments. Thus, the educators became aware of problems related to reimbursement in some of the diabetes education programs. For example, some departments weren't filing for reimbursement if they deemed it insignificant. In others, the accounting department was treating reimbursement for diabetes education as a low priority.
Once these problems became apparent, administrators and educators joined with insurers. Administrators made sure to meet that staff prioritized reimbursement for diabetes education. Now diabetes education is a break-even operation and is close to becoming profitable.
PRIMARY CARE OFFICES
For the most part, the diabetes self-management education program at UPMC did not add new services; rather, it brought together existing services as part of an integrated health system. The exception was the addition of diabetes educators to primary care offices.
Rather than travel to a hospital outpatient clinic for diabetes education, patients received their education in the more convenient, familiar setting of their physician's office. In response to this change, the program leaders received positive feedback from both patients and providers. Primary care physicians were relieved to have skilled professionals on site who could focus on the often time-consuming task of diabetes education. And they liked having direct communication with a trusted educator who saw their patients in their office. Physicians who had experienced the advantages of having diabetes educators in their office encouraged other physicians to participate in the program. The services provided by these educators were billed through the physician; by contractual agreement, a percentage goes back to the educator.
This is in contrast to other situations, in which educators only have access to information regarding charges for their services. They often don't know how much revenue is actually being collected. With our systems approach, however, diabetes educators are part of the team and included in the financial operation. Moreover, they don't have to work with large systems or insurers on their own.
1. Siminerio LM, et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. Diabetes Educ