What is your practice's configuration?

Employed, hospital based clinic

Does your practice have a care manager that works with type 2 diabetes patients?

Yes

Does your practice have an embedded pharmacist that treats type 2 diabetes patients?

Yes

Does your practice have a dietitian that treats type 2 diabetes patients?

Yes

Does your practice have advanced practice providers?

Yes

Estimate the percentage of your type 2 diabetes patients who are on Medicaid.

0-25%

To what extent do you have patients who have type 2 diabetes and do not speak English?

To a very limited extent

What percent of clinic patients are impacted by technological limitations, specifically related to CGM use?

41-50%

What percent of clinic patients are impacted by food insecurity?

0-10%

Please restate the problem that your clinic was trying to solve/improve.

We identified that providers with our clinic had a lack of knowledge regarding low carbohydrate diet for type 2 diabetes. Most providers were aware that a lower carb diet is effective for type 2 diabetes but very few providers had specific knowledge regarding the grams of carbs per day, also we did not have any resources for implementation (nutrition support, patient information, etc). We have a clinic dietician, but access is limited, it typically takes a minimum 3 months for an initial appointment and often 3-5 months. We thought sending general nutrition referrals for MCT2D Low Carb, which would be mixed in with all the other general/misc referrals from providers, would be a dissatisfier for the patient and provider. It may not be clear to the RDN provider that they were sent for low carb (if the referral wasn’t clear) and the RDN provider wouldn’t be as ‘expert level’ on low carb approach.

Describe how your clinic operated before implementing this new change.

Providers and PharmDs would variably discuss low carbohydrate diets with patients at appointments and would refer to diabetes education and/or nutrition. Access for a new referral to general nutrition was typically approximately 3 months, and access for diabetes education was 6 weeks to 12 weeks. We did not have standardized patient information to provide to patients with low carb background information, implementation, etc

Who championed this change and how did they get others on board or involved?

This problem was identified at our Michigan Medicine MCT2D group. Katy Harmes (former PO lead) met with primary care and nutrition leadership (Emily Collins). A dedicated dietician (Stacey Pilarz) was hired with dedicated clinical time (24 hours per week) for low carbohydrate diet nutrition counseling for patients with type 2 diabetes. RDN leadership developed the plan to carve out a RDN resource to train specifically on the low carb approach to be a dedicated referral source and resource for the MD providers and the patients.

What changes did you make to improve this process? Tell us in enough detail that another practice could replicate this process in their clinic.

A new nutrition referral was developed for Epic. This specifically indicated that the referral was for low carbohydrate diet counseling in patients at participating MCT2D clinics with type 2 diabetes. We also indicated in the referral that the low carbohydrate diet may not be appropriate for patients on SGLT-2s following a very low carbohydrate diet. The dedicated dietician has both virtual group class options as well as 1:1 visits. Based on competing demands for the incremental RDN resource, it was estimated that 0.6 FTE (three days a week) was a reasonable amount of time to dedicate to the program. The general goal for RDN productivity is 4 billable units/4-hour session. Our dedicated Low Carb RDN is now so busy she is achieving an average of 6 billable units/4-hour session in the last 3 months. She still has some access despite her high productivity. Her productivity numbers are so high as she is hosting frequent groups as part of her care model, which accommodates up to 8 patients per hour in a group care setting versus only 1-2 patients per hour in a 1:1 care model. Patients start seeing the Low Carb RDN in a group video visit setting “Intro to low carb” class. Following that, our RDN and the patient identify if they wish to continue with low carb. If they do, they can proceed to 4 more groups or can work 1:1. Or, if the patients prefer a more general lifestyle-based change approach without following low carb, they route back to the primary care RDN.

Which staff take on the primary additional responsibility of this process change?

The dedicated dietician for low carb diet counseling has primary responsibility for the patient interactions. The clinical champions at each clinic also help to encourage referrals from their individual clinics. This has been done in a variety of ways. Our dedicated dietician periodically attends each clinic’s monthly provider meetings with additional educational information for the providers as well as to encourage referrals. RDN leadership is also involved in troubleshooting the Epic referral, helping to increase referral numbers, etc.

Were any other tasks taken off their plate to allow for this additional process?

Not in this case, a dietician with dedicated time for low carb nutrition counseling for patients with DM2 was hired.

List all the staff whose standard workflow changed with this new process. Please list their role and any new tasks that they completed related to the change.

Each clinical champion helped to educate the providers at their clinics regarding implementation information (new referral, reminders, etc.). Clinical champions worked within their own clinics to distribute information and encourage referrals. The primary care RDN lead was also involved in diabetes care model workflow and list refining.

Please list any costs to this change, which could include additional patient time, staff time, financial costs, or other.

Our model is that RDN costs are funded through a central RDN budget. It is coming from our RDN department budget (through the Care Connect Department of UMMG – University of Michigan Medical Group) and not from MCT2D funding. Stacey (dedicated Low Carb RDN) was trained by an online competency, an “Intro to Team Based Care” training on our billing codes, and by RDN leadership. The codes used are “provider delivered care management” codes. They are not unique codes to low carb diet counseling. They are the codes used for all RD visits overall. For FY23 Q1, Q2, she has billed out $45,662 in charges and we’ve received $9672 of that as revenue (the actual revenue received is based on payor mix. Patients who have Medicare coverage we do not receive revenue for, this revenue comes only from people with BCBS/Commercial coverage). The actual revenue received is covering ~50% of the dedicated Low Carb RDN salary cost. This does not include benefit cost. Computer equipment was provided upon hire, otherwise, our dedicated Low Carb RDN works fully virtually so there is no overhead “space” cost for her joining our team.

What advice would you have for other practices looking to implement the process change that you implemented?

Initially referrals were low as below. More lead time education to providers who would refer to low carb nutrition would likely have been helpful to increase initial referrals. It was also very helpful to build a dedicated referral in Epic. This also included criteria for referral and is easily searchable in the EMR. It was also very important to have buy in and support from leadership (both primary care leadership and RD leadership). Having one dedicated RDN keeps the process streamlined and the patient education consistent. We have also found that increasing RDN visibility is important. Our dedicated RDN comes to clinical champion meetings monthly as well as the primary care RDN lead. This especially helped early on to brainstorm solutions to barriers. It has also been very morale boosting to hear patient stories and “wins” from our dedicated low carb RDN.

What challenges did you face implementing these changes?

The biggest initial barriers were lack of knowledge on the provider end as well as lack of time during clinic visits to dedicate to low carb counseling, as clinics are busy and there are many competing priorities. This led to an initial lack of referrals. There is still some access available, but referrals have improved.

What has your practice learned through making these changes?

Making implementation very easy for the providers (referral in Epic) is important. Individual providers have much more buy in once they have had experience with the new referral. Once providers participate and see patient success, they are much more likely to referral for future patients. We also have the benefit of working in the same health system, all clinics have the same EMR, same resources, etc. The referral is also very low cost to patients, which encourages further engagement.

Are you going to continue this change, adapt it, or discard it?

Adapt the change

What other changes are you going to make?

We are continuing this dedicated low carb nutrition referral, but we are working to increase referrals as well as increase provider knowledge regarding low carb diet.