Patient Aligned Care Teams- 16 -Department of Veterans Affairs

PACT -051612

**Department of Veterans Affairs**

**PACT (Patient Aligned Care Teams (PACT) Demonstration Labs)**

**Aligning Patient Needs with Self-Management Programs**

**Bree Holtz, Ph.D.**

**Judith A. Long, M.D.**

**May 16, 2012**

Moderator:  In this cyber seminar to PACT investigators presenting samples of supporting behavior change in veterans.  Dr. Holtz will discuss the navigator system, tools for linking patient preferences, goals and needs to enhance care and self management programs.  And Dr. Long will then describe a model of [inaudible] behavior change in veterans using peer mentors to improve diabetes control.  

Bree Holtz is a post doctoral fellow at the VA center for clinical management research located at VA Ann Harbor Healthcare system.  Dr. Holtz is current research interest include provider perceptions of technology, use, strength, patient interactions particularly within a patient centered medical home environment.  She is also interested in using information technology to improve the access to care and patient outcome.

Judith Long is a professor of medicine at University of Pennsylvania Perelman School of medicine and core faculty at Philadelphia PA Center for health equity research and promotion.  Dr. Long is a general internist and health services researcher whose research focuses on health disparity and supporting behavior change and socially vulnerable populations.  

Dr. Holtz, I turn this over to you.

Bree Holtz:  Thank you.  And thank you for having me.  I’m excited to share with you the work that we’ve been doing in our Pact demo lab here in Vision 11, Ann Harbor.  Specifically I’m going to talk about the navigator tool we’ve developed to engage with high risk patients and assess their healthcare priorities to recommend appropriate supplemental or auxiliary self-management or clinical program.  It is our hope that this tool will allow for increased clinic access while providing high quality of care to our patients.

Although navigator programs have been developed over many years in the past there has been no standard definition of core structures or processes.  Navigators have been used in cancer care and pediatrics most commonly. However goals identified as central to most of these programs include coordination of patient care, continuous and proactive patient follow-up and the use of navigator’s specialized knowledge to help patient successfully overcome administrative hurdles and access services.  Navigators have been nurses, social workers and specially trained volunteers.  Prior research suggests that navigators can provide a high quality evidence based care, improve efficiency and patient outcomes.  Within the Vision 11 PACT program we’ve shifted the navigation paradigm slightly.  Our program is being used for proactive outreach by patients identified by registries for conducting a systematic assessment to match patients clinical characteristics need and preferences to available programs.  In this way we hope to improve patient access to services that are tailored not only based on data flags in the EMR but also on patient reported factors that are poorly documented in their medical records such as their social resources.

So we’ve developed a computer based navigator tool in order to allow for standardized patient assessments, noting their healthcare preferences and using shared decision making about enrolment into clinical and self-management programs.

Our navigator objectives include providing patient centered care.  The navigator helps the team led nurse in providing this by assisting them in shared decision making with the patient sought their care by addressing health literacy and other domains which I’ll talk about a little later.  The navigator is also able to identify additional educational needs of the patient.  When using the navigator the nurse is able to focus on what is really important to the patient, such as where is the patient preferences for healthcare.  What are the patient’s priorities for their health related issues?  These type of questions that are not generally asked in office visits.  We hope this tool will bring the patient back into the driver’s seat of their healthcare.

The navigator helps the team improve patient access by using non traditional programs such as non face to face programs and increasing use of expanded team members.  Part of care coordination means the nurse navigator can use expanded team members as identified by PACT such as Social workers, dieticians as well as established self-management support such as mood, inaudible] shared medical appointments, PCHT and newer or local programs as recommended to the patient from the navigator tool.  We have scheduled follow-ups at prescribed intervals at two weeks, three, six, nine and twelve months to make sure the programs have been implemented with the patient and that the patient actually likes the programs and to ensure that they have not fallen through the cracks.

Ultimately the goal of the navigator is to match the patient to programs based on their needs and healthcare preferences.  I’m going to give a top level view of the navigator.  The fist step of the navigator is the registry.  Currently we’re only using a registry of high risk diabetes patients.  This registry is used to populate the navigator tool because the navigator is a standalone application separate from DPRS.  The registry uses a Vista extract and identifies high risk patients and places them into the navigator tool.  When the nurse logs onto the navigator he or she would only see patients that are assigned to their team lets.  The registry has a very focused definition of high risk diabetes and currently the average nurse has sixty seven patients on her panel.  We’ve done pilot work with CHS and hope to roll that out in the next couple of weeks.  In the future we hope this targeted recently discharged patients and patients with depression and pain.

When the nurse logs onto the navigator system, she sees her patient panel and begins to call patients.  She will conduct the initial assessment and this assessment is standardized and is not a full screening tool for programs.  This assessment is a compilation of several validated scales’ to systematically elicit patient preferences and priorities for their healthcare.  We’re asking the same questions of each patient and many questions that are not generally asked in routine care.  I’ll go over some of these a little later.  On average it takes the nurse about twenty to thirty minutes to complete the initial assessment.  During both the assessment and the program recommendation it is important that the nurses use their clinical judgment.  The navigator tool isn’t just meant for then nurse to click some buttons on the assessment.  The need to use critical thinking skills as well.  Once the assessment is completed the navigator will provide a list of recommended programs for the patient and the nurse and the patient discuss these options and the patient decides what program or programs they would like to enroll into.

The navigator provides a system for proactive follow-up for patients and reassesses their stats.  This allows the navigator to be iterative and the needs and preferences of the patient.  If they decide a different program might be a better fit, they can enroll into that program at that time.  The first follow-up occurs at two weeks.  This is just to make sure that the patient has been contacted by the program and is properly enrolled.  This takes about five minutes.

The other follow-ups at three six, nine and twelve months are a little bit more extensive than the two week follow-up and take about ten to fifteen minutes.  Lastly it’s important to note that the navigator is not a traditional case management tool.  Case management is normed up and more clinically focused than the Navigator is.  The navigator helps nurses better understand their patient’s health preferences and priorities and helps them—helps guides the patients into programs.  We would like to think of this as a prelude to case management if the patient needs it.

Case management is actually a program that the navigator can refer patients to.  Here is a list of all the domains in the initial assessment.  The items with an asterisk are places that we specifically encourage the nurse navigator to use their clinical judgment.  I’d also like to mention the living situation, social support and health priorities domains.  It [inaudible] for many of the nurses don’t normally ask their patients and they appreciate knowing the answers to them.  Really that helps the nurses to get to know their patients better.

I’m going to show you some screen shots of the navigator next.  Starting with our depression screener.  Here is the PHQ2.  If everything with the patient is okay we move forward.  And here’s a close-up of the two questions.    If the patient’s score was high enough on the PHQ2, the rest of the PHQ9 will appear.  And at the end a pop up with the score of PHQ9 score and the prompt to complete the clinical reminder is displayed.  Because the patient still had a low score, the navigator process can continue forward.

the last question on the PHQ 9—so this question here over the past two weeks how often have you been bothered by thoughts that you’d be better off dead or hurting yourself in some way if that’s positive, then this last question will appear.  How likely it is that you think that you will harm yourself or end you life over the next few days.  If that is positive then a code orange will be initiated and the navigator tool is stopped.  Luckily we haven’t yet had a code orange in our navigator.  Knock on wood.

Next is a screen shot of some of the questions that we ask about the patient’s living situation?  For example, who they live with and where they’re currently living and additionally we ask about any social support they may receive in their healthcare.  This is how we’re trying to understand what the patient’s most pressing concerns are.  So the nurse calls the patient about their diabetes and she wants to know if it’s something to really focus on right now.  And then we’ll ask—the nurse will ask of all the things going on in your health, what concerns you the most and she’ll type in verbatim in this box what the patient said and read back to the patient what she read and together she’ll categorize it in a list and so this is a drop down box here that has several different categories in it.

Here is a screen shot of some of the technology based questions that we ask the patient.  Many of our nurses and physicians have been surprised about how many of our patients have and are comfortable with technology. I think this is because we’ve never really asked the patient.  

The navigator nurse asks about the patient technology used including their phone, type of phone, computer access that they have and internet access.  And it’s important to note that all of these questions lead to specific referrals, for example if they’re comfortable using a phone for their health, we have a couple of programs called care partners that we can [inaudible] our patient to.  If they’re interested.  If they have a computer you know one of the recommendations might be to [inaudible].  And that goes for all of the questions in our assessment tool.  So after the assessment is complete, the next step is a program recommendation.  As you can see the levels of the recommendations is noted and color coded.  We have red for highly recommended, blue for recommended and black are the does not apply or not appropriate.  And possibly—we have a possible—it’s not showing up here but it’s also in black.

I’d like to draw your attention to the plus, minus sign.  If you click on this you’re taken to our online resource guide, website which is located on the SharePoint.  This is a screenshot of our online resource guide.  Anyone in the VA should be able to access this.  This is not just tied to the navigator tool.  At the beginning of developing the navigator we realized that we needed to create a central information source and [inaudible] our self-management programs and ancillary programs.  This site provides the nurse with standard program recommendations and links to any brochures or websites. So if they have a recommendation to CCHT and the nurse can’t quite think of all the words to describe CCHT, she can come here and then read this description.  Additionally if you click on the link here, the brochure is displayed so the nurse can print and send it to the patient or actually just read directly from there if she wants.

Going back to the navigator, once the nurse has made an action plan with the patient.  She can click on notes.  And a pop up is generated that can be copied and transferred to the patient’s medical record.  This has the information from the navigator assessment.  Now I’m going to provide what our average navigator patient is like.  Keep in mind these are from our high risk diabetes panel from 350 initial assessments that have been completed our average patient is sixty-seven year old male.  Is cognitively healthy, is not depressed—only asked the PHQ-2.  Lives with a spouse or significant other.  Has someone come to an appointment with him and still drives?

Some other information that our providers have found surprising about our patients include many of them, most of them would rather not come to the VA for these programs and this has taken our providers and nurses by surprise.  They think that all of our vets do want to come in but in fact most of them would rather not come into the VA for some of these programs.  The majority of them are comfortable using the phone, in their healthcare and half of them have a computer that they use regularly and of that half, most have access to the internet.  So after the assessment, the navigator would provide recommendations for the program referrals.  As of March 26 the nurses conducted over a 350 assessments and the majority referrals have been to either our technology based programs or enhanced care program.  My healthy vet has been the top referred program followed by Tele-RN Case management CCHT.  We’ve had some referrals to traditional care programs but we found these to be one off visits.  They can go and address immediate problems and then allows the patient to continue to focus on their healthcare through the other self-management programs that we offer.

Approximately 19% of our patients did not want to enroll in a program and this is the patient’s decision.  Hence the patient centered part of this.  And the nurse navigator provides the patient with some health education and will usually send literature of whatever program she thinks is best for the patient and then she’ll follow up with the patient in the next three months to see if the patient has changed his mind.

I want to talk a little bit about what some of our vets have said to a nurse.  So here is an example of a sixty two year old male veteran who was called in the navigator for his high risk diabetes and he ended up being referred to social work because his home was in foreclosure and he had a lot of financial issues and he didn’t know what to do.  He told the nurse, “Thank you for all of your help.  I got the names of agencies that are helping me keep my house; I didn’t think anyone cared.”  Here the navigator process and nurse helped the vet keep his house instead of helping a homeless vet later.  Now the patient is able to focus on his healthcare issues and is in one of our self-management classes.  I just spoke to this nurse about the patient and she reports that he is doing excellent.  And in fact the navigator call helped save another veteran from foreclosure last week.

Here are some additional quotes that the nurses have heard from the veterans by doing the navigator call.  “It is nice that a nurse would take the time out and call me.”  Again these are proactive calls.  The patient is not necessarily expecting them.  “I didn’t know all the different things I can do.”  And repeatedly from many veterans “Thanks for caring.”

Well, everything is going fairly smoothly on the patient side; we’ve experienced some implementation barriers.  For example the navigator tool is a standalone tool.  The nurses have to log in every day and while they’re using it, we ask that they use two screens.  The one screen with CPS open and the one screen with the navigator.  Also the nurses do see the benefits of the navigator and it has been a challenge to implement it given the many changes associated with PACT redesign.  However, the nurses feel that once the teams are fully functioning and have a dedicated space it will be easier to schedule these navigator calls.

However, the nurses do have positive impressions that we were able to find through some initial interviews we did with them.  They do understand that the navigator is a tool that may open up more clinic time for patients.  And that again, they’re surprised that their older veterans use technology more than they thought. 

I would also like to acknowledge the whole Vision 11 Navigator Development team.  Wendy and Diane are nurse navigators.  They’re VA [inaudible] primary care and nurse super trainers.  Jenny Davis is our technical genius in developing the navigator tool.  Liz Masserang created our online resource guide.  Molly and Jess are our qualitative gurus and Sarah is the liaison to the PACT advisor committee and is a [inaudible] on the Vision 11 demo lab.  I’ve included my e-mail so please feel free to e-mail me if you have any further questions that can’t be answered here today and in the next presentation by Judith Long will demonstrate one of these types of programs that the navigator would refer patients to if locally available.  These are the types of programs that we hope the navigator will encourage patients to enroll in.  I’ll turn it over to you, now, Judith.

Judith Long:  Thank you, Bree.  Can everybody see my screen?  Heidi can you?

Heidi:  We certainly can.  Yes.  Perfect.

Judith Long:  Great.  So I’m now going to talk about using peer mentors to improve diabetic outcomes and this is certainly one of those programs that I can imagine a navigator referring a patient to.  However, before I start I think I’m going to ask Heidi to launch the poll since this is somewhat of a research talk and I would like to know the research background of the audience.

Heidi:  We’ve got responses coming in.  If everyone could read through the question and respond.  We’re at about 55% right now, so we’ll give it a few more seconds.  Thank you to everyone who is responding.

Okay it looks like the responses are slowing down a little bit.  Give it just another second or two.  And I will close and share the results.  There we go.

Judith Long:  So it looks like 33% have not done research.  30% have collaborated on research, 22% have conducted research myself, 1% have applied for research funding and 13% have led a funded research grant.  So we’re all over the board, so I will try and aim it at all levels and if people have questions at the end I can go into more details in any direction.

So I just want to am I back to controlling my—okay.

Heidi:  We don’t have your slides up yet.

Judith Long:  You don’t.

Heidi:  [Inaudible] and let me just [inaudible].  If you can click on that popup again.  There you go.  Thank you.

Judith Long:  So I just am going to start with a little bit of background.  And I just want to talk a little bit of providers, since I’m assuming most of us are providers in some manner.  It’s what we are good at as providers and in general we find that we’re very good at approving processes in care.  We’re very good at doing things like checking blood tests if we check our diabetic team and [inaudible] A1c and check the LDL and [inaudible] appropriate care and [inaudible] get the retinal exam done, but we always order it.  We are very good at performing office based care like diabetic foot exams and it’s actually fairly easy to get providers to change their behavior.  When you give a provider a report card or an incentive, sometimes a penalty and you support the process—the new processes, providers change.  So what are we bad at?  What we often find is we’re often bad at and not good at improving intermediate and long term clinical  outcomes and what I mean by this is we often have while we’re good at ordering the HbA1c it is more difficult for us to have our patient improve their A1c.  It’s more difficult to have our patients avoid the micro vascular complications that can come from poor diabetes control.  And we find that this is particularly true for low income and minority patients.  We think that the reasons why we’re good at processes and good at changing our own behavior is it’s a lot more difficult to help somebody change their behavior.  Change somebody else’s behavior.

So this is a diagram that I sometimes like to think about in terms of thinking about the patient, the provider the health care system and everything else that goes around—goes on around that patient and provider.  So as you see we have the patient.  They relate to the provider who’s in the health system.  What happens outside is what I call life and those are everybody.  The patient, the provider, the health system and some of those types of influences are family, our friends, socioeconomic factors, cultural factors, neighborhood environment, community support, access to care, policy and I’m sure the audience can think of other things that are going on that are influencing our patients and influencing ourselves and influencing how VA healthcare works.

One of the things I like to point out is when you think about it an average person is awake 6,000 hours a year.  However they spend with their provider maybe a maximum of three hours a year.  so it’s not very surprising that we’re not always great at influencing patients behaviors because they spend a tiny amount of time with us and our influence cannot be very small compared to the things that are going on around them hour by hour all the time and so I think it’s very important that what we need to do is find interventions that follow-up patients [inaudible] the healthcare system that are supportive of them making choosing healthy behaviors while they’re not in the medical system or talking to their provider.

Which brings me to the concept of using peers to support healthy behaviors on a consistent basis and there are several models out there.  I’m going to get more to our study soon, but I just want to make sure that people have a good background.  So probably the most common model that was used using peer support was group based self-management.  This usually involves some sort of professional support like a nurse—a nurse practitioner, an MD a dietician and is usually conducted within the confines of the healthcare system.  The most common example which is I think at a lot of the VAs is the group health ticket.  So the patient come in they support each other but they’re also supported by the healthcare system.  Another model out there is the community health workers.  Peer health navigators we heard about in most health navigators and these peer health navigators are usually somewhat semi-professional.  They’re usually salaried and what they usually do is they talk regularly with a panel of their own people that they might be working with.  Sometimes they’re supporting healthy behaviors and sometimes they’re helping patients navigate through a complex health system.  These have often been used to help people with cancer navigate a health system.  And then peer coaches or mentors and these might be the most flexible and informal.  They can occur anywhere.  They tend to be done with a one on one paring of patients a mentor and a patient a mentor and a mentee.  And one of the nice things about the peer mentors and often true with peer navigators is they usually have the same cultural language and disease processed as the patients that they’re trying to help.  They often come from the same community in the VA.  We use veterans as a they have that everybody being a veteran and as such I call it innately culturally sensitive.  We don’t need to train cultural sensitivity into peer mentors because of the similarities they have in background between the mentor and the mentee.

So now I’m going to talk a little bit about the modes of delivery—the most common one that is probably being looked at and used is face to face.  What’s growing and we I’m going to talk about a telephone based paper mentoring but there’s other programs.  The most cutting edge, but the least used called the web and e-mail based peer mentoring and there’s not much evaluation of those types of programs.

So I’m now going to talk about our study.  Peer mentoring and financial incentives to improve glucose control in African American veterans.  A randomized, controlled trial.  And this was concluded last year and just recently published in the annals of internal medicine.  And on this slide I just want to recognize my collaborators on this work, Erica Jahnle, Diane Richardson, George Lowenstein and Kevin Volpp.

What did we do?  We performed a randomized controlled trial.  The study was six months long.  The participants were all African American veterans from the Philadelphia VA.  And they were all between the ages of fifty and seventy years old.  The enrollees all had persistently poor diabetes control which we defined as having a hemoglobin A1c of greater than 8% for the last two times it had been measured and we looked at the electronic medical records and they had to have had a recent blood test within three months of enrollment.  The reason we chose this is we were really trying to find those patient s who were struggling a lot with their disease.  They didn’t want somebody who went through the Christmas holidays, splurged a little bit and the hemoglobin A1c went above eight but generally they were fairly well controlled.  We wanted to find those people who everybody feels needed a lot of help.

The mentors all currently had good diabetes control and we chose them they all had to have a recent hemoglobin A1c which was less than 7.5% but they also have had to had a hemoglobin A1c that was poorly controlled, greater than 8% in the last three years and they were the real reason we did this is we had done some qualitative work and we had found that people who were always in good control did not relate well and did not understand what people were struggling with who were not in control.  So we had to find mentors who could relate to the mentee and who could understand perhaps what it was that they were struggling with.  This is a really important part of our design.  Everybody in the study had a hemoglobin A1c drawn at enrollment and in six months.  And they came in—the day they came in and were randomized to either one of three arms.  That was—I’m going to tell you more about that.  They also had a blood test that day.  the next day we would call them and tell them what their starting hemoglobin A1c is and we also did this at the end of the study at six months.  we provided them with the American diabetes associated and the VA recommendations for hemoglobin A1c targets and at that time those recommendations were very closely aligned.  The VA has recently changed its recommendations and has more targeted control for patients who’ve had diabetes for many years.

So that is the current recommendations at that time.  We also called every patient monthly to assess for hypoglycemic syndromes and serious adverse effects.  Anything that was causing their sugar to be low.  We didn’t want to do something that was making people’s sugar to go too low and everybody got $25 to enroll in the study and $25 to complete the final hemoglobin A1c test.

So let me tell you what we did for each of the groups.  We had for the mentor arm; people were matched to a mentor by gender and age and remind you everybody was African American. so they were all matched by race and the age they matched people plus or minus ten years.  We invited the mentor into the VA and we gave them a very straightforward one hour one on one training with our research assistant  and this is very different than what other kinds of mentor trainings are—mentor trainings are often several weeks, several days but they’re usually very long.  The shortest they’re usually sixteen hours at minimum, so the fact that this is only one hour is very minimal and very easy to implement.  We provided the mentor with the mentee’s phone number.  we called the mentor every month to reinforce the training.  Often the calls were very short.  And we also gave the mentors $20 a month if the mentee confirmed that the mentor had called them at least four times during the month.  So we were trying to encourage people to talk at least once a week.

During the training was very much inspired by motivational interviewing techniques and during the training we did a lot of practice with mentor to like we pretended we were the mentee and practice calling us and practice questions that they would ask us and we modeled questions and give them pamphlets to take home about the types of questions they might want to ask but we also told mentors that they should very much rely on their own experience that they were being chosen because they once had poor control and now they had good control and they had managed to get their diabetes in control and they should use that experience to help inform what they were talking about.

And the incentive arm we gave people a lump sum for achieving a goal at six months.  What we did on that second day after they got their blood test, we said we would call them and say your blood test is this and if you drop your hemoglobin A1c by 1 point in six months you’ll get $100 and if you drop it by two points you’ll get $200.  Or depending on their starting value, if you drop it to 6.5% you’ll get $200.  Again, we didn’t want to encourage people to get too low in their sugar.  So for example if a person started with a hemoglobin A1c at 10.  If they got it to nine they got $100 and if they got it to 8, they would get $200.  If a person started with a hemoglobin A1c of 8, we told them if they got it to 7 they would get $100 and to 6.5—if they got it to 6.5 they would get $200.

For the analysis, we did an intention to treat analysis.  That means that anybody who—we didn’t—if they dropped out or they did something different they were still analyzed in the arm that we put them in.  Our main outcome was change in Hemoglobin A1c and we weren’t able to follow everybody perfectly for six months.  we did have a little bit missing and I’ll show you the exact numbers in a second; however if we found that they had seen their provider close to the time that they were supposed to come in for follow-up and we define that as plus or minus four weeks, we used the hemoglobin A1c that was in the medical records.  However, if there was no Hemoglobin A1c in the medical record from around that time, we used a statistical method called multiple imputations which gives you a sort of estimate of what their hemoglobin A1c would likely be at six months based on other characteristics of the patient.  This is a pretty standard approach and we didn’t actually have to do this for too many.  I feel very confident in our results.

And here I’ll go through the specific numbers.  This is our study flow diagram that you use for any randomized control trial that’s standard.  We assessed 642 people to be if they were eligible for the study by looking through their records.  We excluded 525.  366 because they didn’t meet criteria and the most common criteria that they didn’t meet was they weren’t African American.  Our records aren’t perfect.  We looked at all records that said that the person was either African American or race was missing so the race being missing was often why they weren’t African American.  74 people declined to be in the study and 84 people there were other reasons they weren’t in the study.  The most common being that the phone numbers that we had for them weren’t correct so we were never able to contact them.

We then randomized 118 people to the study.  39 people were randomized to the control arm.  39 people were randomized to the peer mentoring arm and 40 people were randomized to the financial incentive arm.

Now one of the people in the peer mentoring arm when they actually got their blood test on the day they were entered into the study had a hemoglobin A1c of less than 7.5%.  And because we were concerned about hyperglycemia, we took that person out of the study.  So that we only analyzed 38.  As you can see we had in the control arm we had three people with missing follow-up data but one of those we were able to get from the chart.  In the peer mentoring arm there were six missing but three were in the chart and the financial incentive arm we had six missing but two were in the chart.

So the characteristics of people in the study and just a few points I’d like to make.  There’s a lot of numbers on the slide.  The first point is our randomization process worked quite well and there was only one difference statistically between the arms and that is the patients in the mentoring arm may have had a few less diabetes co morbidities.  Otherwise they were similar in terms of age and education and marital status and being on insulin and as you can see most—over half the patients had had diabetes for over ten years.  And another thing I really want to point out is we really did well in finding a group of people who really needed to improve their diabetes control.  The mean baseline hemoglobin A1c was above 9.5 for all three arms.  so these were not people who anybody would quibble with us about did they need to get their sugar down.

The final thing to point out in that slide is it took us about ten days to find when somebody was randomized to the mentoring arm it took us about ten days on average to find that person a mentee and this is reflected where it says mean days between tests, as you can see for the control arm and the incentive arm it is about 185 days but for the mentoring arm it was 195 days because that was the ten day lag that it took to find them a mentor.

These are the main results from the study.  The control arm usually what we see in a control arm is some improvement and as you can see our control arm hardly improved the mean starting hemoglobin A1c is 9.9 and the mean end hemoglobin A1c is 9.8.

In the peer mentor arm, the starting hemoglobin A1C is 9.8 and that dropped by almost a full point to 8.7.  Over a full point.  In the financial incentive arm, it went from 9.5 to 9.1.  And the drop in the peer mentoring arm is large and statistically significant and I’ll show you some numbers of how it compares to the control the significant [inaudible].

These slide shows you the actual change for everybody in the study and what you see in the control arm was that some people got better. some people got worse and quite a few people didn’t move a lot—quite a range of what happened to people.  In the peer mentoring arm you can see that the negative—the numbers down below zero show the people who dropped the A1c and most people dropped at least some, a few people dropped a little and one person in the study their hemoglobin A1c got a lot worse but everybody else who did get worse only got worse a small amount.

And the financial incentive arm, we [inaudible] again it’s better than the control arm, but not as good as the peer mentoring arm, but it’s just [inaudible] everybody’s in the study’s results.

This shows us the mean change in hemoglobin A1c level compared to the control.  this is our adjusted analysis and we see that the compared to control the peer mentoring arm in the adjusted analysis dropped their hemoglobin by over a full point and I just want to point out that this, if you think of drug studies a full point change in hemoglobin, mean hemoglobin A1c would be an exciting drug that everybody would be talking about.  So we’re doing as well as a brand new drug that is really effective.  The financial incentive arm, we see compared to control in the adjusted amounts that they dropped hemoglobin A1c by almost half a point.  Now this is a relatively small study and so this was not significant but a lot of the interventions for diabetics are acutely made so you can detect a half a point difference in hemoglobin A1c so what they say about the financial incentives is that we’ve been [inaudible] that will work in this study and I’m not sure that it didn’t work.  That we would need a larger study but I can say confidently is it didn’t work as well as peer mentoring.  Adverse events.  This is important because we’re trying to get people to lower their sugars and we know nowadays that especially people who have had diabetes for many years that sometimes aggressively lowering the sugar can be worse for your health than tolerating a moderate sugar.  we had no deaths in the study.  There were two serious hypoglycemic events which we define as you know being hospitalized, needing to call the paramedics, fainting to the point where you needed help from somebody else and the only two events—none of those events were in the peer mentoring arm as you can see one happened in usual care and one happened in financial incentive.  so there was no difference in serious events.  And mild hypoglycemic events where we asked people how often did they every month we called them and said how often did you have a feeling shaky, feeling like your sugar was low and I don’t remember the [inaudible] the question but most people said none and some people had a few of them, very few felt like their sugar was low frequently.  There were a lot of [inaudible] and these are all minor events that didn’t require assistance in any way.  All the events were unexpected and nobody was removed from the study because of the low sugar.  So in general it was very well tolerated intervention.

We asked people to give us some feedback about what the mentors and the mentees about the experience about being in that arm.  And people—here are some of the common things that people said.  Mentees said it was important that the mentor had diabetes and they appreciated the support that they received from their mentor and they appreciated the education they received from their mentor and a few people were frustrated by difficulty having trouble getting in touch with their mentor and some people said there was a lack of compatibility between them and their mentor.  This was a problem.  And eight people out of twenty eight who responded to our qualitative survey asked said that they had wished that we had given a face to face introduction and they’re going to see the mentors—fifteen out of the twenty four mentors also wished they had received a face to face introductions.  Mentors also appreciated helping other people and they thought it was very important that most of them thought it was important that they had been previously out of control.  They were also frustrated about trouble scheduling calls with their mentees and they didn’t like it when their mentee was disinterested.  Five of them said it was real hard to engage the mentee in the study—in to the process.

I will point out that the fact that people, even though people had wished for face to face introduction it was without face to face introductions making this an appealing intervention for rural populations and populations that might have difficulty coming into the VA and as we pointed out a lot of veterans would prefer programs where they don’t have to come into the VA.

Our study has definitely has limitations and it was one race study and so we don’t know if this would be as effective in [inaudible]. It was a one institution study so that begs the question if you roll it out someplace else, will it work.  That’s an important point to find out.  And the financial incentive were given in a lump sun and they did not really provide an immediate reward for delayed benefits which is the typical way in which you shape financial incentives, they have been done previously.  Successfully often people want a reward once a week or every day so the fact that we had—they had to wait six months to figure out if they were going to get a reward may have limited this why financial incentives didn’t work as well.

And also we weren’t able to follow people for a long time, so we don’t know if the effects will persist.  In weight loss studies we often see that interventions help people lose weight but once you stop it they gain weight again, so we need to figure out if [inaudible]however I will say that the intervention is very easy and easy to implement so it is one that you can easily imagine working well as a revolving door.  You come in you come out.  In and out as you need it.

So what we’re currently launching a PACT peer mentor study and in this study we will include veterans of all races and ethnicities to hopefully show that it was in everybody and I really see—I don’t see any reason why that won’t be the case.  we’re going to follow people for at least six months after they have stopped being getting mentoring and the reason we’re doing that is so that we can see if these results persist.  And also we’re going to have an arm where we’re going to give the mentors who are going to be past mentees, and the reason we’re doing that is we’re really trying to figure out ways to create programs that will be sustainable.  You find a person.  They need help.  They come in.  They get help and then they help somebody else and that will always be leading to renewing the pool of potential mentors.  so that is something that we’re very interested in figuring out because in the end what we’re trying to do is create programs that are very patient centered and can support behavioral change outside of clinical encounters without using a huge amount of additional staff and resources or time.

So we’re trying to make things that would be very easy for PACT teams to implement or to support PACT teams.  You can imagine [inaudible] if the person was a good match for the peer mentoring one person could easily administrate the [inaudible] multiple PACT Teams and they could be something that would be something else for the PACT team could use to help a potential patient.

So in conclusion, peer mentors are the strong effect in improving glucose control in a population with persistently poor diabetes control.  These are people who needed help and improved.  Peer mentor training was extremely short and straightforward making intervention very appealing and very portable, something that would be easy to implement. Peer mentoring may be a powerful tool for reducing disparities and it worked very well in this minority population and improving clinical outcomes in minority population.

But like Bree had pointed out one side is unlikely to fit all and using navigators the nurse navigators to figuring out lots of different programs to help patients you need to find a variety of programs and this is random on many and this can be very helpful and powerful to helping improve chronic disease management.

So thank you.  That’s my e-mail address and you can open it up to questions now.

Heidi:  Great.  thank you.  We actually don’t have any pending questions right now.  I invite our audience if you do have any questions; the Q&A screen is located on the dashboard on the right hand side of your monitor and may have collapsed.  Click that orange arrow at the right hand side of your monitor to open that dashboard back up and type your questions in the question pane that’s here.  We will take those as they come in.  As I was saying we don’t have any questions pending right now.  They should be—hopefully people are typing them in and we’ll be able to get to those.

Here we go.  First question.  Is it known if any of the mentor/mentee dyads continued contact after the study period?

Judith Long:  That’s a good question and actually we do know that a few did continue.  My research assistant said she saw two of them meeting for lunch at the VA canteen.  We are also planning—but we didn’t actually study that.  So we know that anecdotally.  We saw a couple of pairs around the VA meeting after the study so we are doing in the longer study that we’re about to launch is we’re going to evaluate that and we’re going to try to understand what it is about the mentor/mentee relationship that worked as well as whether people continued connecting to their mentor after the formal time of the intervention was stopped.

Heidi:  thank you.  The next question.  I’m not sure if I understand this but I’m going to read it the way it came in.  How do you train a mentor?  What is the SCAT role of mentor plays for example, titrate up insulin?

Judith Long:  Well so our mentor training was I don’t know if people know about motivational interviewing but we tried to give them some very basic motivational interviewing techniques where the idea is you train them to ask the patient, the mentee about their own experiences in diabetes and what they feel that the barriers are and what would motivating them to do well like you know I want to do well because I want to see my grandkids get older and then to help the person find realistic steps that they can take.  it’s really very patient centered and it’s supposed to—you’re not telling the person what to do.  You’re helping the person figure out for themselves what motivates them and what a realistic step they could take to achieving their goals.  And so that’s what we trained, how we trained the mentors and but as I said we also told mentors they can rely on their own experience.  They could tell the person what had worked for them, but we very much told people they were not the doctor and they’re not supposed to tell them to increase their medication.  it was all about more helping people change their behaviors and we didn’t educate mentors and the reason we didn’t do that was that in our qualitative work as I had mentioned during the talk they people knew what they were supposed to be doing.  It’s frequently.  they heard the message.  they knew they were supposed to be taking their medicine and they knew they were supposed to be exercising and knew they were supposed to be watching their diet.  What they had difficulty doing is carrying that out so we didn’t feel—we didn’t call this an educational intervention although people said they liked the education that they got from the program, it was more about helping people do what they already knew that they should be doing.

Heidi:  Great.  Thank you.  I have a question that came in for Bree.  I’m going to try and fit that in quick because I know Bree you have to leave at the top of the hour.  The question what resources were required to start up and maintain the navigator system.  Do you [inaudible] or have you assisted other facilities in establishing something similar.

Bree Holtz:  Hi.  Thank you.  So technical resources, it’s right now an access based, the navigator is an access based database so it’s a little bit clunky but we’re using it right now for pilot testing and we’re hoping to get those turned into a web based application so it would be a little bit easier and I’ll hopefully other facilities could do something similar and I think right now our biggest challenge is the registry is a little harder to do because it is a standalone so we have to manually pull our registry data and put it into the navigator and we do have a data analyst who does that and that can be a little bit tricky.  Some other resources were just making sure that we were getting to the right programs so we do have to talk to the people who ran the programs and making sure we’re appropriately referring patients to them and we have again two nurses who are training the primary care nurses so it is some nurse resources there and then we’re working with other facilities and trying and hoping to help us try to get this navigator tool into a better system that can be used in other facilities.  so that is something that we’re actively working on right now we’re just not quite there yet.  Thank you.

Heidi:  Great.  Thank you.  Okay the next question we received here, do you think the peer mentoring program could be helpful in reducing CHF readmissions?

Judith Long: It would be my hope that this would work in CHF.  CHF is different than diabetes and the patients tend to be generally overall sicker.  And they show [inaudible] although there has been some peer mentoring types of programs in CHF type patients, and they’ve had difficulties.  It hasn’t been as effective as in patients with diabetes.  However [inaudible] programs are restrictive to peer mentoring where they take two people who are struggling with the disease and so maybe if your mentor was in good control that would work better.  it is definitely something, it’s a model that I would think I would hope would work but I can’t tell you for sure and I think that’s what exists in the literature right now is mixed but it’s definitely something that we would like to at some point roll out and test specifically that question.

Heidi:  Great.  Thank you.  The next question how did you find the initial mentors?

Judith Long:  We did that through CPOS.  I think I mentioned we pulled people who were—like Bree does, she creates registries with people who might benefit from programs, so we looked and we found people who had once had poor diabetes control in the last three months based on the hemoglobin A1c and [inaudible] and now were in good control—in the last three years.  Sorry.  And now were in good control in the last three months, had a hemoglobin A1c of less than 7.5 and then we looked for them to be African American and then we would send them a letter and after the letter we would call them and see if they were interested in participating.

Heidi:  Great.  Thank you.

Judith Long:  Can I just—I thought of one last thing that I—there is this [inaudible] be sustaining and that’s why it is interested in testing a model with after you’ve had a mentor you would become a mentor and it’s a very interesting literature that being a mentor is very good for your health and so it might even be a way to help sustain not only the program by finding mentors but help people maintain their glucose control.

[Beeps]

Heidi: Great.  Thank you.  We are at the top of the hour.  Bree.  I know that you have to take off now.  Dr. Long are you able to stay on for—it looks like we’ve got five pending questions here?

Judith Long:  Yes, I can stay on until 1:15.

Heidi:  Sounds good.  We’ll try to get through these then.

Bree Holtz:  Thank you and again if anyone has any questions, please feel free to email me later.

Heidi:  Thank you so much Bree.  We really appreciate the time you put into this.  thank you.

Bree Holtz:  Thank you.

Heidi:  The next question we have one hour seems very brief for motivational interviewing training.  do you have any data regarding whether these techniques were actually use and to [inaudible]?

Judith Long:  No.  we don’t.  It is very brief.  I agree.  And so we have—and it wasn’t a pure motivational interviewing training in that we did tell people to rely on their own experience.  We had no evidence.  We called them to reinforce training every month but we don’t have any evidence as to whether they actually used them.  We don’t tape phone calls at all so I can’t tell you but that again, we would like to—we are planning in this new [inaudible] to really try to figure out how peer mentoring worked so we are going to do a mixed message study with a process evaluation where we are really going to do in depth qualitative very in-depth qualitative interviews with mentors and mentees who really get a clear idea about how the process worked.

Heidi:  Great.  Thank you.  The next question is how do you convince others that a classroom is needed for patient education so these programs can occur and others can occur in a visibly designated space?  That helps market the program to have a designated space for classes, equipped with ipads, laptops for interactive learning and communication.

Judith Long:  That is very much not this intervention.  I was thinking that might be more appropriate for Bree.  In fact what we really were trying to aim for was something that was not VA based and was not visible, but was followed people outside of the VA.  It was very much a program about being able to—being flexible.  If they wanted to talk at 10 o’clock at night because that was the time that worked for both of them, that was fine.  It was very much about creating a very flexible program that worked around people’s lives so I’m not sure if that question might refer to the navigator system a bit more but we’re actually trying to create something that was outside the VA.

Heidi:  Okay.  Great.  thank you.  the next question goes back to the one hour of training.  How did that work?  Was it sufficient?  What experience did the mentors have?  What type of position were they hired into?  [Inaudible] questions about the mentees?

Judith Long:  This is a volunteer program. People weren’t hired.  If you were a mentor you only had one mentee.  It wasn’t—a lot of navigator programs a mentor or navigator might have ten or twelve people that they’re working with at the same time.  This is different.  this is a one on one approach so nobody had more than one person that they were helping at any time and the only financial incentives the mentors got was $20 a month if they talked to their mentee four times.  I can tell you that quite a few people didn’t make that.  they talked two times.  some people made it every month.  so that wasn’t a large sum of money that we were paying.  mentors because we were asking them to be in the study and the studies give a reimbursement, we did give mentors $25 for for [inaudible] and $25 for the follow-up visit.  There is very little money involved in it.  For the mentees they got $25 with the initial visit and $25 at the end visit and that’s all they got so the idea was that this was very much on altruism and I would say that one of the [inaudible] thing about this program was the veterans really wanted to help each other.  it really raises the question to me that these types of programs may be particularly affective in the VA.  They may not work outside the VA, but there’s a really strong cultural camaraderie within the VA and I think you know the veterans want to help each other and they’re excited to be in the program, helping each other.

Heidi:  Great.  Thank you.  And that questioner sent in another—what were the mentees cover for the PACT intervention?

Judith Long:  So the mentees that become mentors.  we will put them through the same training and the idea is that we will give them the same training so that once they complete having six months where they have a mentor, they would then go through a training to become a mentor and what we are actually working on some other work out there.  I think I mentioned Michelle Hideburg who does also peer support type of intervention within the VA .  It’s interesting because she is a [inaudible] peer support for people who are both struggling with their diabetes and they helped each other out.  So what we’re going to try to do is see if it matters whether or not the person got their diabetes in control before they become a mentor.  We will be able to look at that and try to understand do you have to have your sugar under control to become a mentor or can you have that mentoring experience for six months and become a mentor and still be effective.

Heidi:  Great.  Thank you and our last question, what was the source of the funds for the financial incentives?

Judith Long:  I hope I said it up there on one of the slides it was funded by a [Roider] grant and it was Kevin Volpp the senior author on this is the PI on and that grant funded several different small studies looking at different kinds of financial incentives in particular but also different kinds of supports for behavioral change and we received funding for that where that [inaudible] and I believe on that slide the both the funding agency and that was from NIA and the grant number on there.

Heidi:  Fantastic.  Thank you so much Judith for taking the time to answer all these questions.  

Judith Long:  Sure.

Heidi:  We really appreciate them.  On the reporting it’s so much value to have this time for the Q&A.  Let’s wrap up all of the questions we received here.  I really want to thank you so much for taking the time to prepare and present for today’s session.  We really appreciate all of the time and effort that you put into that.

Judith Long:  Thank you.

Heidi:  I also want to thank [inaudible] for sticking with us a little bit past the top of the hour. I hope you guys found some value from it, too.  As you are leaving today’s session you will get a popup on your screen with a form for today’s session.  we hope you take a few seconds to fill that out.  we really do appreciate the feedback that we get from you.  And Dr. Long, do you have any concluding comments that you’d like to make?

Judith Long:  No. None except that I’d be happy to talk to anybody about this share materials.  I think we’re trying to get the word out and if people wanted to try and get a program like this going at their VA we’d be happy to help out.

Heidi:  fantastic, that’s very generous of you to put that forward.  Hopefully someone will take you up on that offer.  And with that concluding remark, I would like to formally end today’s HSR&D  Cyber seminar.  Thank you everyone for joining us today.

**[End of Recording]**

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