In this year’s evaluation, CMS considered the COVID-19 pandemic and its impact on hospitals, excluding data for the first half of 2020 and Medicare patients readmitted with pneumonia, according to a report in Kaiser Health News.
Nationally, Medicare is penalizing 2,273 hospitals, the fewest since 2014, with an average payment reduction of 0.43%, Kaiser reported.
Hartford Health Care Photo.
CMS fined William Backus Hospital 1.42%.
In Connecticut, 69% of all hospitals in the program face fines, but most are under 1%.
Six hospitals saw significant drops in penalties, including Rockville Hospital, from 2.3% last year to 0.45% this year, and Bridgeport Hospital, from 2.15% to 0.7%.
The others are Bristol Hospital, from 1.34% to 0.28%; Manchester Memorial Hospital, from 1.8% to 0.74%; Middlesex Hospital, from 1.67% to 0.97%; and Waterbury Hospital, from 1.13% to 0.51%.
William Backus Hospital received the highest penalty this year among facilities in the state, at 1.42%, which is slightly lower than last year’s 1.56%.
“We are encouraged that many hospitals in our state showed improvement from last year or sustained past gains,” Alison Vail, RN, vice president of quality and patient safety, Connecticut Hospital Association, said in an email. “Through the Connecticut Hospital Association, hospitals are working collaboratively and transparently to improve the quality of care delivered at hospitals and to focus on patient care needs outside the hospital walls.
“This ongoing collaboration is having a positive effect on patient care,” Vail said. “These efforts to support patients through programs that address social and health care needs will improve patients’ quality of life and minimize the need for hospital readmissions. Hospitals and health systems are committed to continuous quality improvement and will continue working together to achieve even better outcomes for patients.”
Lisa Freeman
Lisa Freeman, executive director of the Connecticut Center for Patient Safety, said, “It is important to move the focus from the monetary consequence of readmissions to the causal reason for them. While I commend our hospitals for much of the good work that was done, COVID or not, readmissions can and should be greatly reduced with well-coordinated hospital care, discharge planning, and aftercare.
“COVID provided a stress test for our health care system, and that provided a window through which the weaknesses that showed up should be identified and addressed,” Freeman said. “As much as hospitals don’t want to be penalized, for many reasons, patients don’t want to be readmitted either. Effective communication among all members of the patient care team, including the patient and home caregiver, coupled with consideration of discharge readiness and medication reconciliation as well as the other related factors must always be addressed—COVID or not.
The hospitals losing less than 1% reimbursement are Charlotte Hungerford, .38%; Danbury, .23%; Day Kimball, .77%; Greenwich, .24%; Hartford, 0.71%; John Dempsey, .58%; Johnson Memorial, .27%; and Lawrence + Memorial, .18%.
Also losing less than 1% reimbursement are MidState Medical, 0.62%; Norwalk, 0.09%; St. Mary’s, 0.6%; Sharon, 0.11%; St. Francis, 0.33%; St. Vincent’s, 0.54%; Stamford, 0.04%; Hospital of Central Connecticut, 0.08%; Windham Memorial, 0.15%; and Yale New Haven, 0.41%.
Griffin Hospital in Derby, Masonicare Health Center in Wallingford, Hebrew Home and Hospital Inc. in West Hartford and Connecticut Hospice Inc., Branford, were not penalized.
Connecticut hospitals exempt from the program include Connecticut Children’s in Hartford, Connecticut Valley Hospital in Middletown, Natchaug Hospital in Mansfield, Connecticut Mental Health Center in New Haven, Southwest Connecticut Mental Health in Bridgeport, Silver Hill Hospital Inc. in New Canaan and Albert J. Solnit Children’s Center in Middletown.
This is the 11th year for CMS penalties, enacted under the Affordable Care Act. The maximum penalty is 3%. The penalties take effect as of Oct. 1.
]]>The new reports cover state inspections that were completed in 2021 with approved hospital corrective action plans.
At William Backus Hospital, a pregnant woman suffering from drug abuse disorder delivered a baby who tested positive for fentanyl and buprenorphine. During the time that the baby was under observation for neonatal abstinence syndrome (drug withdrawal), a parent holding the infant fell and reported “that the infant’s head may have touched the ground a little,” the report said. Following the incident, staff determined that the baby suffered a head injury and was transferred to a higher-level hospital. The state inspector said that the hospital “failed to develop a safe plan of care for the infant to prevent a fall with injury.”
The Hospital for Central Connecticut was cited for failing to identify that an infant was assessed when forceps were used in labor and delivery, which resulted in head injuries to the infant. During delivery, forceps were used unsuccessfully to rotate the baby’s head, so the baby was delivered by cesarean section, the report said. Hours after delivery, the infant was transferred to the neonatal intensive care unit and was later transferred to another hospital for neurosurgical evaluation.
In six instances, Hartford Hospital was cited for failing to follow surgical and invasive procedures which resulted in a wrong-site surgery and objects retained after surgery. In two of the cases, a lumpectomy was performed on the wrong area of a woman’s breast and in another a doctor failed to remove the entire gastric lap band during a removal procedure.
At Lawrence + Memorial Hospital, a nurse punched an unruly patient in the stomach and was later disciplined and suspended for a week, an inspection report said.
Hartford Hospital was also cited for not following a patient’s dysphagia diet of puree consistency. The patient was given a tuna sandwich and apple juice. The patient began to choke, a medical code was called, and the patient was revived using CPR, state records said.
MidState Medical Center was cited for not having a policy or guidance for use of a stabilization method after a photo was posted on social media, according to the state report. A child was treated in the hospital’s satellite emergency department for an injury, accompanied by a parent. The child was wrapped in a blanket on a stretcher, secured by gauze tied underneath the stretcher. The hospital was cited for not having a policy or procedure for this type of immobilization.
Several hospitals were cited for dust build-up in operating rooms and torn operating table pads.
Inspectors from DPH generally survey Connecticut hospitals in unannounced visits every two to four years. They tour facilities, observe staff in action and examine documents. Though hospitals are surveyed every several years, DPH usually inspects them more often in response to complaints and investigations, according to DPH.
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Nationally, Medicare is reducing payments to 2,499 hospitals, about 47% of all facilities, with the average penalty being 0.64%, according to a report by Kaiser Health News (KHN).
Rockville General Hospital Photo.
Rockville General Hospital received the largest penalty from CMS for readmissions.
This year’s penalties were based on tracking patients from July 1, 2017 through Dec. 1, 2019, so the influx of patient care during the pandemic is not included, CMS said.
In Connecticut, 72 % of all hospitals in the program will face a loss in CMS payments, beginning October 2021 through September 2022.
No Connecticut hospital received the maximum penalty of 3%. But Rockville General Hospital will lose 2.3%, the highest penalty of any Connecticut facility; and Bridgeport Hospital will lose 2.15%.
Five hospitals will lose more than 1% of their funds, 19 others less than 1%.
“Connecticut’s hospitals share a strong commitment to the quality of care they provide and to patient safety. Through the Connecticut Hospital Association, hospitals drive quality improvement through a shared commitment to best practice and clinical collaboration and we are always striving to do better,” said the CHA in a statement.
“Hospitals have been operating under tremendous strain in response to the COVID-19 pandemic while continuing to focus on quality improvement. We are encouraged that many hospitals showed improvement and we will maintain our focus on the quality of care delivered at hospitals across the state,” CHA said.
“This measure, and the results among Connecticut hospitals, demonstrate the need for a higher degree of coordinated care after hospitalization. This is a time when a discharged patient is particularly vulnerable to complications related to their recent hospitalization and when thorough, accurate, and understandable care instructions, new supplies, clarity and access to all medications and oversight of care are particularly important to their continued recovery.”
— Lisa Freeman, executive director
Connecticut Center for Patient Safety
Freeman said that while readmission measures have “the potential to slightly mislead patients because the readmission that is being counted can be for any reason, not only the reason for the initial hospitalization, it still addresses the wellness, or un-wellness of the patient at discharge.”
CHA has launched Unite Connecticut to improve hospital readmission rates. Under the program, “hospitals now have direct referral and communication loops, through a shared digital platform, to refer and support patients in need of community-based social services to help stabilize their living conditions and optimize their health. “
This year, the program has served more than 3,600 patients through referrals to about 280 community-based organizations. “We expect these robust support channels will help patients to realize better health outcomes, by addressing the social drivers of health. Over time, taking down those social barriers supports a patient’s ability to fully follow a course of treatment or make a necessary lifestyle change, reducing the need for readmission and also improving the patient’s health outcomes,” the CHA said. There are 11 hospitals participating and CHA said five more are in the process of joining.
The hospitals receiving penalties of over 1% are: Manchester Memorial, 1.8%; Middlesex, 1.67%; William Backus, 1.56%; Bristol, 1.34%; and Waterbury, 1.13%.
The 19 hospitals losing less than 1% reimbursement are: Charlotte Hungerford, .38%; Danbury, .31%; Day Kimball, .27%; Greenwich, .53%; Griffin, .02%; Hartford, 0.57%; John Dempsey, .78%; Johnson Memorial, .67%; and Lawrence + Memorial, .08%;
Also, Mid-State Medical, 0.45%; Norwalk, 0.74%; St. Mary’s 0.62%; Sharon, 0.02%; St. Francis, 0.56%; St. Vincent’s, 0.41%; Stamford, 0.22%; Hospital of Central Connecticut, 0.64%; Windham Memorial, 0.08%; and Yale New Haven, 0.76%.
Only two facilities received no penalty: Masonicare Health Center in Wallingford and Hebrew Home and Hospital Inc. in West Hartford.
Eight Connecticut hospitals are exempt from the program. They are: Connecticut Children’s Medical Center in Hartford, Connecticut Valley Hospital in Middletown, Natchaug Hospital in Mansfield, Connecticut Mental Health Center in New Haven, Southwest Connecticut Mental Health in Bridgeport, Silver Hill Hospital Inc. in New Canaan, the Connecticut Hospice Inc. in Branford, and Albert J. Solnit Children’s Center in Middletown.
This is the 10th year for CMS penalties, enacted under the Affordable Care Act (ACA).
To review Kaiser Health News’ data on hospital penalties over several years go here.
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Statewide, 25 of the hospitals evaluated – or 89% – will have reimbursements reduced, to varying degrees, in the 2021 fiscal year that started Oct. 1, according to a Kaiser Health News analysis of CMS data.
Nationwide, almost half of hospitals, or 2,545 of them, will have their Medicare reimbursements cut, according to Kaiser Health News. The latest penalties were calculated using data from June 2016 through June 2019, meaning the influx of patients to hospitals seen amid the pandemic didn’t factor in.
iStock Photo.
Twenty-five hospitals are being penalized for high rates of patients who are readmitted within one month of discharge.
CMS has been imposing reimbursement reductions since the 2013 fiscal year, to penalize hospitals that have high rates of patients who are readmitted within one month of being discharged. The penalties were enacted under the Affordable Care Act.
This year’s penalties come as many hospitals already face financial hardship from the pandemic.
“We’re not really sure why they (CMS) chose to still go through with the readmission criteria,” said Dr. Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association (CHA). Levying penalties at this time “feels insensitive” as hospitals continue to be front-line responders to the COVID-19 crisis, she said.
But hospitals continuously are working to improve readmissions rates, Cooper said.
“We always want to make it better,” she said.
In partnership with Unite Us and United Way’s 2-1-1 information line, the hospital association this year began rolling out programs that connect hospitals with community-based organizations, with the goal of improving care coordination, Cooper said. Hospitals are being given tools that help them assess “other factors that may be affecting their [patients’] health outcomes,” she said, such as social, economic and genetic factors.
The program makes it easier to refer patients to organizations such as food pantries, housing agencies, transportation authorities and other services that can affect patients’ health outcomes once they leave the hospital, Cooper said. Those agencies also can report back to the hospitals.
“This year, more than ever, there’s been such a need for [coordinated care]. The hospitals were just so happy to implement that; we have tremendous buy-in. We’ve never had access to that kind of closed-loop referral before.”
— Dr. Mary Cooper
So far, about one third of hospitals statewide are part of the program, and it is slated to be implemented at all hospitals by the end of 2021, Cooper said. These efforts, though, likely won’t be reflected in readmissions data for a few years, she added.
This year, no Connecticut hospitals received the maximum penalty rate of 3%, but three will lose more than 2% of their Medicare reimbursements. They are: Manchester Memorial Hospital, at 2.89%; Bridgeport Hospital, at 2.62%; and Rockville General Hospital, at 2.02%.
Most hospitals in the state – 20 of them – are losing less than 1% of their reimbursements. They include: Danbury Hospital at 0.39%, Norwalk Hospital at 0.92%, Greenwich Hospital at 0.79%, St. Vincent’s Medical Center in Bridgeport at 0.72%, Griffin Hospital in Derby at 0.33%, Middlesex Hospital at 0.88%, and Charlotte Hungerford Hospital in Torrington at 0.36%.
Stamford Hospital, which for two years in a row was not penalized, will see a 0.07% reduction.
Among the state’s largest hospitals, Hartford Hospital is losing 0.90% of its reimbursement, Yale New Haven Hospital, 0.70% and St. Francis Hospital and Medical Center, 0.50%.
Three hospitals received no penalty: Hebrew Home and Hospital Inc. in West Hartford, Masonicare Health Center in Wallingford, and Sharon Hospital.
Since the program’s inception, most Connecticut hospitals have gotten penalties each year.
“It always concerns me when we have a situation where it’s same story, different year; and that’s what’s we’re having here,” said Lisa Freeman, executive director of the Connecticut Center for Patient Safety.
That shows, she said, that the penalties aren’t having the intended effect of reducing admissions in a meaningful way. Many hospitals are likely just budgeting the penalties into their cost of doing business, she said.
Some hospitals are making strides, but others have a long way to go, Freeman said. A big part of the problem, she said, is poor coordination of care once patients leave the hospital. Ensuring patients have access to doctors for follow-up visits, can get to a pharmacy to fill prescriptions, and are connected to other services they need, for instance, should be considered upon discharge, she said.
“It really does concern me. It’s something that we absolutely have to attend to. Right now, the system is not set up to support the kind of coordination that’s needed. We’re just not thinking the process through, and therefore we’re setting it up to fail.”
— Lisa Freeman
Eight Connecticut hospitals are exempt from the program. They are: Connecticut Children’s Medical Center in Hartford, Connecticut Valley Hospital in Middletown, Natchaug Hospital in Mansfield, Connecticut Mental Health Center in New Haven, Southwest Connecticut Mental Health in Bridgeport, Silver Hill Hospital Inc. in New Canaan, the Connecticut Hospice Inc. in Branford, and Albert J. Solnit Children’s Center in Middletown.
]]>Two hospitals, Yale New Haven Hospital’s main campus and Hartford Hospital, are nationally certified as Comprehensive Stroke Care Centers, providing the highest level of stroke care available, which includes 24-hour access to neurological practitioners and the ability to perform complex endovascular therapies, including thrombectomies and endovascular coiling of an aneurysm, among other surgeries.
Yale and Hartford hospitals are two of only 178 certified nationally as comprehensive stroke centers, according to The Joint Commission, which certifies hospitals.
But when time is critical, traveling to New Haven or Hartford can be a risky commute from the northwestern and northeastern parts and other parts of the state, where hospitals certified in stroke care are sparse.
In all, the state has 23 hospitals that are certified in some level of stroke care, up from 16 in 2013.
Melanie Stengel Photo.
Dr. Joseph L. Schindler heads Yale’s Acute Stroke and TeleStroke Services.
Nineteen hospitals—including Norwalk Hospital, Stamford Hospital, St. Vincent’s Medical Center in Bridgeport, Bridgeport Hospital, Danbury Hospital, Greenwich Hospital, Middlesex Hospital in Middletown —are certified as primary stroke centers, and are equipped to do brain scans, administer clot-busting drugs (IV-tPA) and provide neurosurgical services.
In addition to Yale and Hartford Hospital, UConn Health John Dempsey Hospital in Farmington, St. Francis Hospital & Medical Center in Hartford, Stamford Hospital, Danbury Hospital are among the facilities that perform thrombectomies, according to a member of the state’s Stroke Advisory Committee. A complete list was not available. The Joint Commission does not require primary stroke centers to perform thrombectomies.
Griffin Hospital in Derby and Johnson Memorial Hospital in Stafford Springs are certified as acute stroke-ready hospitals, providing basic care, including administering drugs to break up a clot and evaluating whether a patient needs to be transferred to a primary or comprehensive stroke center.
Seven facilities — Charlotte Hungerford Hospital in Torrington, Bristol Hospital, Waterbury Hospital, Milford Hospital, New Milford Hospital, Windham Hospital in Willimantic, and the West Haven VA — have no stroke certification.
Even with more hospitals nationally certified, Connecticut is lagging in some areas of care, said Dr. Joseph Schindler, an associate professor neurology and neurosurgery, director of Acute Stroke and TeleStroke Services and director of the Vascular Neurology Fellowship Program at Yale New Haven.
“It’s left up to the hospitals to make investment in providing stroke care,” Schindler said. “Connecticut is a couple of states behind more progressive states like Rhode Island or Massachusetts when it comes to stroke care.”
Connecticut’s EMS protocols, updated in 2017, delineate the steps emergency responders should take to transport a stroke patient to a hospital quickly. The steps include notifying a hospital immediately that a stroke patient is on the way and getting witness information on when symptoms started. But the protocols don’t specify where EMTs should transport a stroke patient.
Rhode Island, Virginia and Colorado are among a handful of states that require EMTs to transport a person suffering from a stroke to a hospital designated as a comprehensive stroke center. Massachusetts legislators are considering implementing similar protocols. Current Massachusetts law requires EMTs to take patients directly to a primary stroke center.
Nationally, about 140,000 people die of a stroke annually, and more than 795,000 people will have a stroke, the Centers for Disease Control and Prevention (CDC) reports.
In 2017, 1,403 people died in Connecticut from strokes, a death rate of 27.8 per 100,000 residents — the third lowest rate in the country, the CDC reports. Connecticut’s stroke death rate has remained below the national average of 37.3 per 100,000 people since 2015, the CDC said.
By comparison, states in the “stroke belt”— such as Kentucky, Mississippi and Tennessee — have a death rate 10% higher than the national average, according to the National Heart, Lung and Blood Institute.
Stroke Care
In addition to providing top-level stroke care, Yale and Hartford offer telestroke services to some hospitals, which provides quick access to neurological experts by video screen.
Lisa Backus Photo.
Dr. Richard Kamin, EMS director and associate professor at UConn Health.
Yale’s telestroke services are provided to nearly a dozen hospitals, including Sharon Hospital, St. Francis Hospital & Medical Center, Griffin Hospital, and Yale’s St. Raphael’s campus, Schindler said. Greenwich Hospital is expected to join the telestroke program with Yale in the coming months.
Hartford Hospital’s Telehealth Network includes Windham Hospital, Charlotte Hungerford Hospital, MidState Medical Center in Meriden and Backus Hospital in Norwich, all of which are under the umbrella of Hartford Healthcare.
The immediate video conferences allow physicians to receive expert consultations on the appropriate use of an intravenous drug to break up clots. The drug must be administered within 4½ hours of the onset of stroke symptoms. The video conferencing assists in patient evaluation to determine if a transfer to a higher level of stroke care facility is needed.
“An acute stroke-ready hospital is probably not going to have all the fancy tools, but they do have a team trained to immediately deal with stroke patients and get them where they need to go,” said Rommie Duckworth, an emergency responder in Ridgefield and the founder of the New England Center for Rescue and Emergency Medicine.
Stroke Policy Changes Under Review
Connecticut officials are continually reviewing stroke care through the state Stroke Advisory Committee, which is working with EMS officials to examine protocols for emergency responders.
One concept being discussed is whether it’s quicker and more effective to bring patients to the closest hospital, no matter what the certification level, to have the patient evaluated to see if they are a candidate for a thrombectomy, said Raffaella Coler, the director of the Office of Emergency Medical Services at the state Department of Public Health (DPH).
“The need for interventional treatment (thrombectomy) is what would prompt transfer to a higher level of care,” Coler said. “This way the patient would get the treatment needed if appropriate in the shortest amount of time but still have the needed evaluation to see if they would benefit from transfer.”
About 80 percent of stroke victims have ischemic strokes, which are caused by blockages in the arteries leading to the brain, according to Dr. Richard Kamin, the EMS director and an associate professor at UConn Health, who is also an advisory committee member.
Another 10-15% have hemorrhagic strokes, which are caused by aneurisms or bleeding on the brain. Both types of strokes can cause death or severe disability if not treated quickly and properly. About 10% of ischemic stroke victims are appropriate for evaluation for a thrombectomy, with about 5% of those receiving the procedure, Kamin said.
Kamin said that bypassing a hospital that is close in order to transport a patient directly to a comprehensive stroke center could also have negative impact. “There is a sacrifice you make when you go past one hospital to another,” he said. “We know that if you have certain types of injuries you are taken to trauma center. Patients who are taken there have a better survival rate with less complications. It’s also true with certain types of heart attacks. We’re in the process of trying to figure that out for stroke.”
Officials have been working since 2014 to make legislators aware that the state needs updated stroke policies after funding for a DPH state stroke care hospital designation program ran out.
In a medical crisis where “time is brain,” every minute counts, which is why the state needed a system of care after the state’s designation program expired, said Dawn Beland, a registered nurse and coordinator of Hartford Hospital’s stroke center, who sits on the advisory committee.
“It helps us make sure that we are being the most efficient in passing that patient from EMS to the emergency department to the next level of care,” Beland said.
As part of the advisory committee’s continued work, every hospital in the state is now being assessed for its stroke care capabilities, Kamin and Coler said. Hospitals that don’t have the capability for stroke treatment should be transparent about what they can and can’t do, Kamin said.
“I think we owe the people of Connecticut, regardless of where they live, an understanding of what’s available to them in their local community,” Kamin said.
At the same time, the committee is trying to determine how to make sure everyone in the state has access to timely and effective stroke care, Kamin said.
“We have gaps,” Kamin said. “Those gaps are being looked at and hopefully we’re coming up with ways to address them.”
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The app told him that in the past when he’d eaten that particular sandwich from the same deli, he hadn’t experienced glucose spikes. “So I decided to stick with it,” Berger said. “An hour later when ezbds reminded me to check, my glucose was 123.” That’s a good number according to the American Diabetes Association (ADA), which suggests a target of less than 180 mg/dL an hour or two after beginning a meal for adults with diabetes.
“By tracking what they eat, people can identify how certain foods affect their blood sugar,” said Nancy Salem, coordinator of the Diabetes Education Program at Danbury Hospital. “Apps have made it a lot easier for patients to make better choices.”
Berger’s ezbds LLC is among a handful of Connecticut startups with diabetes apps competing in a market cluttered with more than 165,000 health apps, according to the Danbury-based IMS Institute for Healthcare Informatics.
Photo Courtesy of Adam Berger.
Diabetes apps can help people track their numbers.
But adaptation remains a challenge. The September 2015 IMS study found that 40 percent of apps had less than 5,000 downloads.
“It’s very difficult,” Berger said. “There’s resistance to new technology.” Even though ezbds is downloadable for free, it has just 1,200 users to date.
The new players have limited product differentiation and are vying for marketshare with established apps such as dLife’s Diabetes Companion, Glucose Buddy from SkyHealth, iDiabetes from iHealth Ventures, Track3 from Coheso, GoMeals from Sanofi-Aventis, and One Drop from Informed Data Systems. Some apps are downloadable at no cost, but others are priced from $2.99 for iDiabetes to $5.99 for Track3.
The use of smartphone apps to manage diabetes is part of the conversation that many doctors are having with their patients. Doctors say that self-management drives better health outcomes and apps enable accountability.
“A good diabetes app helps patients track their numbers—blood glucose readings, carbs, calories and weight. Some even let you map your emotions, stress, and sleep,” said Dr. Yi-Hao Yu, director of endocrinology at Greenwich Hospital’s Center for Behavioral and Nutritional Health.
Bunny Kasper, 73, of Hamden credits the Dexcom’s Share app with saving her life. She was asleep when the app notified her son in Massachusetts in the middle of the night that she was experiencing a hypoglycemic episode.
“I was almost semiconscious when my son got the alert,” Kasper said.
At Saint Francis Hospital and Medical Center in Hartford, health care providers help patients chose the best app. “The average patient doesn’t have the know-how to find the right app,” said Dr. Latha Dulipsingh, director of the Center for Diabetes and Metabolic Care at Saint Francis. “Most of my patients’ app data is reviewed by the diabetes educator. We [doctors] make a lot of medication changes based on patterns we see.”
Educators at Dulipsingh’s center, one of 11 facilities statewide to offer the Centers for Disease Control and Prevention-recognized National Diabetes Prevention Program, suggest apps as an additional tool.
About 250,000 adults (8.9 percent) in Connecticut have been diagnosed with diabetes, according to the state Department of Public Health’s 2016 report. More than 83,000 adults have prediabetes.
And diabetes is an expensive disease to treat. According to latest data from the ADA, diabetes cost Connecticut an estimated $2.92 billion in 2012. A single injectable drug, Lantus Solostar, priced at $395 for a five-pack, is among the 10 most prescribed drugs in the HUSKY Health program.
Companies claim apps enable better self-management and thereby help lower health care costs through reduced hospitalization and emergency care.
According to a February 2014 study published in US Endocrinology, just one smartphone app alone, from Massachusetts-based Telcare Inc., helped drive a reduction of $3,300 in annual health care costs among employees with diabetes.
Despite opportunities, app makers are struggling. New Haven-based Applivate LLC has exited the business after turning over to Tolland-based Loon Medical Inc. the ShugaTrak app, which transfers blood glucose measurements from the glucose meter to a secure database for review by medical professionals. Plans are underway to expand the rebranded SensaCare’s connectivity with a wider range of glucometers, and link it to other parameters that impact diabetes, such as weight.
“We’re starting our first clinical study to track blood glucose levels,” said Joel Douglas, chief technology officer for Loon Medical. “Hospitals want data to prevent readmissions as they get penalized by Medicare for too many readmissions within 30 days. We’ll provide them with graphs and hundreds of readings.”
This fall BetweenMD LLC in Farmington is set to launch its diabetes app that can be connected to any Bluetooth-enabled device. The market? Self-insured employers seeking to cut medical costs for their diabetic employees. “Costs [of employee medical expenses to a company] can run on average about $10,000 a year,” said Andy Quinn, co-founder. “I’m also to looking to partner with companies that have connections with doctors.”
Biorasis Inc. of Storrs is developing an app to run its grain-sized implantable glucose sensor wirelessly and to collect and store data. “Biorasis is testing the system on the International Space Station, where the absence of gravity allows us to study sensor accuracy,” said Ilze Krisst, chief operating officer.
C-HIT is hosting a free community forum on diabetes from 5 to 7:30 p.m., Thursday, at the Lyceum, 227 Lawrence St., Hartford. The event includes a cooking demonstration and sampling of health food choices by Becky Stevens-McGuigan, executive chef at The Kitchen at Billings Forge, followed by a panel discussion with top doctors and dietitians. Live Spanish translation will be available. For information and to register click here.
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The Centers for Medicare & Medicaid Services (CMS) announced this month that 758 of the nation’s hospitals – about 23 percent of all eligible hospitals — would be penalized for patient safety lapses in the second year of the Hospital-Acquired Condition Reduction Program, which was mandated by federal health care reform. The penalties are based on rates of infections and other complications that occurred in hospitals between 2012 and 2014.
Yale New-Haven is being penalized for the second year in a row.
The 18 hospitals in Connecticut include larger urban institutions, such as Yale-New Haven, Hartford and Bridgeport hospitals, and smaller hospitals, such as Manchester Memorial and Windham. They are among hospitals in the worst performing quartile nationally on patient-safety measures including the frequency of central-line and catheter-related infections, post-operative sepsis and accidental laceration.
Twelve of the 18 Connecticut hospitals are being penalized for the second year in a row. They are: Bridgeport, Danbury, John Dempsey, Hartford, Manchester Memorial, Hospital of Central Connecticut, Yale-New Haven, Norwalk, Stamford, Waterbury, Windham and Connecticut Hospice. The six hospitals penalized for the first time are: Greenwich, St. Francis Hospital & Medical Center, Middlesex, Lawrence + Memorial, Charlotte Hungerford and Saint Mary’s.
While nearly a quarter of all eligible hospitals nationally are subject to penalties, a higher proportion – close to 60 percent — of Connecticut’s hospitals are facing penalties.
In total, Medicare expects the penalties will cost hospitals $364 million in fiscal year 2016. About half of the hospitals cited this year were also penalized in 2015.
In releasing the 2016 penalties, Medicare said that the average hospital performance improved for central line-associated blood stream infections and composite safety measures since 2015. Rates of catheter-associated urinary tract infections increased slightly.
The patient safety sanctions are among several programs that Medicare uses to penalize underperforming hospitals. Hospitals also are penalized for high rates of readmitting discharged patients, and for poor performance on certain clinical and mortality-rate measures.
Greenwich Hospital is being penalized for the first time.
In Connecticut, 28 hospitals will lose Medicare reimbursement in 2016 for relatively high 30-day readmissions of patients with heart failure and other conditions.
Lisa Freeman, director of the Connecticut Center for Patient Safety, said that while the state’s hospitals have made progress through a statewide initiative to eliminate preventable harm, they “need to be doing much better in terms of advancing their cultures of patient safety . . .
“Each avoidable complication leading to patient harm is happening to a person – a mother or a father, sister, brother or a child,” she added. “It is not only a statistic.”
Dr. Mary Cooper, vice president and chief quality officer of the Connecticut Hospital Association (CHA) – noting that the data for the 2016 penalties date back to 2013 and 2014 — said hospitals have made progress in the last several years in reducing blood stream and catheter-related infections.
“We do see a fairly significant reduction in preventable infections, blood clots and pressure ulcers in the last few years,” she said. “Everyone is improving, everyone is working hard, but we have to do better . . . One preventable complication is one too many.”
Some hospital officials have criticized the penalty program as misguided, noting that Medicare is required to punish a quarter of hospitals nationwide each year, regardless of whether individual hospitals have shown significant improvements over time.
Cooper said that hospital leaders in Connecticut are committed to moving towards “zero harm” to patients. Connecticut hospitals have been recognized nationally for 100 percent participation in a statewide initiative to become “high reliability organizations,” a program focused on patient safety that has trained more than 10,000 staff and physicians.
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The report by the Department of Public Health (DPH) shows that the total number of hospital adverse events, or errors, dropped by 12 percent — from 534 in 2013, to 471 last year. Deaths or serious injuries from falls declined from 90 to 78; perforations during surgical procedures fell from 79 to 70; and life-threatening medication errors fell from six to one. The number of patients with serious pressure ulcers dropped from 277 to 245.
iStock Photo.
Surgeries on wrong body parts increased from 13 to 15 in 2014.
Rates of all four of those incidents had climbed in 2013, in part because of an expansion of required reporting on pressure sores to include “unstageable” ulcers. While the 2014 counts – overall, and for the individual categories — are lower than in 2013, they remain higher than in 2012.
Other categories of errors increased in 2014. They include surgeries performed on the wrong body part (15 in 2014, up from 13 in 2013); wrong surgical procedures performed on a patient (four, up from one); deaths or serious injuries of a neonate during labor or delivery in a low-risk pregnancy (four, up from one); and reported sexual abuse or assault on patients or staff members (nine, up from four). There were 24 reports of foreign objects, such as sponges or towels, left in patients after procedures — down by one from last year, but double the number reported in 2012.
As expected, some of the state’s largest hospitals reported the highest numbers of adverse events: Yale-New Haven Hospital, with 80; Saint Francis Hospital, with 52; and Hartford Hospital, with 36. In terms of rates per patient days, which adjusts for patient volume, the hospitals with the highest rates were: Bristol, at 42.5 per 100,000 patient days; Danbury, at 41.3; Manchester Memorial, at 36.4; Saint Francis, at 34.5; and Griffin, at 33.
Hospitals with the lowest rates of reported adverse events were: Day Kimball Healthcare, with zero; Waterbury Hospital, with 3.4 per 100,000 patient days; Charlotte Hungerford, with 3.9; and Greenwich Hospital, with 7.5 The statewide average was 21 errors per 100,000 patient days.
Officials of the Connecticut Hospital Association said the reduction in adverse events is a sign that statewide efforts to reduce preventable harm, including a “high reliability” initiative that involves extensive training in patient safety, are working.
“I think we’re starting to see the decrease we were hoping for, with all the work we’ve been doing,” said Dr. Mary Cooper, vice president and chief quality officer of the association. She said some of the increases in surgical-related and other adverse events could stem from more “transparency in reporting” by hospitals.
While Cooper said she was pleased that the numbers of the most common harms, such as pressure ulcers and falls, had declined, she added, “Our goal is zero preventable harm – not reducing these things by 10 percent. We need to keep going.”
In comments included with the report, officials of most hospitals said they were taking myriad steps to reduce preventable harm. For example, Saint Francis said it had made reduction of pressure ulcers a priority for 2015, while the Western Connecticut Health Network, which includes Danbury Hospital, said it had implemented daily “safety huddles” and “safety coach” programs, as well as internal systems to detect and treat early-stage pressure ulcers.
Lisa Freeman, director of the non-profit Connecticut Center for Patient Safety, said that while hospitals had made progress in some areas, “Unfortunately, there are still too many events that should not be occurring, and too many patients and their families suffering the consequences. Our state still has work to do to move closer to eliminating harm to patients.
“Adverse events are not just statistics, but involve real people,” she said. “It is important to determine why these events are continuing, in spite of all of the efforts being made.” She said hospitals should do more to treat families and patients as “equal members of the care team” and involve them in discussions of safety.
The DPH report is careful not to draw conclusions about the state of patient safety in Connecticut hospitals, mainly because the incidents are self-reported. Also, the majority of adverse reports involve patients over the age of 65, so hospitals with more elderly patients may report higher rates of adverse events.
“We cannot say whether a high reporting rate reflects highly complete reporting in a facility with good quality of care, or perhaps modestly complete reporting in a facility with poor care, or neither better nor worse quality care,” the DPH says.
Yale-New Haven and Saint Francis each reported three incidents of surgery on the wrong body part, while Yale also had six cases of foreign objects left in patients. Of the 12 deaths or serious injuries reported as a result of surgery, two were at Bristol Hospital and four at Yale. The Hospital of Central Connecticut reported eight life-threatening perforations during surgery, while Saint Francis had seven.
Of the 70 perforations reported in 2014, 27 occurred during colonoscopy and six others during unspecified colon procedures.
The DPH does not investigate all adverse events. Instead, the agency focuses on incidents that may indicate “a systems issue or issues related to inadequate standards of care,” the report says.
The full report is available here.
]]>Sixty-four percent of Connecticut’s youth who use Emergency Mobile Psychiatric Services (EMPS), the state’s mobile crisis intervention team, have experienced one or more traumatic incidents, such as domestic violence, cyber-bullying, physical assaults, or gang warfare, experts report.
Research shows childhood exposure to violence, physical or sexual abuse, and other traumatic events can cause chronic health and behavioral health problems, and such exposure is associated with increased involvement with the child welfare and criminal justice systems.
“The number of children who have been exposed to trauma is a significant concern. It’s a common occurrence among young people,” said Jeffrey Vanderploeg, vice president for mental health initiatives for the Child Health and Development Institute of Connecticut (CHDI). He is director of the EMPS Performance Improvement Center, which is housed at CHDI.
Expanded Role For Crisis Intervention
EMPS is a crisis intervention program with a statewide network of about 150 mobile mental health professionals who assist children up to age 18 with behavioral or mental health emergencies. When a call is placed to 2-1-1 from any Connecticut town, clinicians respond within 45 minutes, either by telephone or at a face-to-face crisis assessment and intervention at home, at school or in the community. They can remain involved for up to 45 days, creating care plans, coordinating services and following up.
Last fiscal year, EMPS provided 12,376 instances of care – up 11.4 percent from the previous fiscal year – and some worry that demand will soon exceed the program’s capacity.
State lawmakers are currently considering future funding for EMPS and other mental health initiatives. In October, Gov. Dannel Malloy issued an “action plan” for children’s behavioral health that called for using $160,000 to post a full-time EMPS crisis-intervention worker in the emergency department of Connecticut Children’s Medical Center and a part-time worker in another hospital. The plan also said the governor was “considering” enhancing the EMPS network by increasing the hours of service from 11 hours a day to 18 hours a day, at an expected cost of $3 million. Current EMPS costs are about $10.5 million this year.
EMPS was created to assist children in their homes and communities, reduce emergency department visits, and divert youth from more restrictive and costly interventions, such as hospitalizations, residential care settings or arrest. Funded by the state Department of Children and Families in partnership with United Way of Connecticut, the program serves all youth regardless of health insurance status.
Heightened awareness about behavioral health issues and the EMPS program accounts for some of the increased demand for services, experts said. But clinicians also report an increase in the severity of cases, compounded by the shortage of outpatient and residential treatment placements and the inability of many families to afford the behavioral health care their children need.
“We’re seeing kids who require an intense level of services that might not be available right away. We’re being called in to provide treatment in the interim so their situation does not escalate. Some children need a high level of care. But others can step down from the crisis,” said Jessica Welt, director of crisis services at the Child Guidance Center of Southern Connecticut. The center is one of six agencies that provide crisis intervention services from 15 satellite sites statewide.
“EMPS clinicians are doing a tremendous job of responding to crisis, but their ability to follow up with clients is being stretched,” Vanderploeg said.
More Youth At Risk
Twenty percent of Connecticut youth – that’s 156,000 children under age 18 – could benefit from behavioral health treatment, but many can’t access services, according to the Connecticut Children’s Behavioral Health Plan. The plan was developed after the Sandy Hook Elementary School shooting that killed 20 students and six adults in 2012.
But more Connecticut children and young people with mental health problems are being hospitalized. Mental disorders surpassed respiratory problems and all other ailments as the leading cause of hospitalization in Connecticut in 2012 for children ages 5 to 14, teenagers and younger adults, according to a new state Department of Public Health report. Common conditions among children include mood disorders, depression, attention deficit disorder and disruptive behaviors.
Youths 13 to 15 years old (37.6 percent) and 9 to 12 years old (24.5 percent) accounted for most EMPS clients. Harm or risk of harm to self or others (36 percent) is the most common reason parents, school staff and police call EMPS, followed by disruptive behavior (22 percent), depression (15 percent), family conflict (6 percent) and anxiety (6 percent).
Elizabeth Peralta, a social worker and manager of crisis intervention at Danbury Hospital, assists children and adolescents who come to the emergency department. Volume has remained steady, she said, “but the cases are very much more involved and intense.” She steers youth who do not require hospitalization to EMPS to connect with community behavioral health services.
“There is a huge need for mental health services for children and adolescents,” said Peralta. “They and their families are struggling. It’s heartbreaking.”
Stressors On Multiple Fronts
“We’re seeing more kids who are traumatized by problems at home and at school. Their actions and behaviors are more understandable when you view them in the context of what is happening in their environment,” said Amy Evison, senior program director for Community Health Resources in Middletown, which handled more than 1,200 crisis calls last year.
Social media is a major source of angst. “We see lots of kids who are struggling with how to manage social media,” said Evison. “They have contact with people in the community and the world that they don’t even know, yet they’re immediately impacted by what they say. Kids are saying very violent and threatening things over social media.”
Christine Mullin, one of five social workers serving 2,600 students at New Britain High School, contacts EMPS clinicians at the Wheeler Clinic in Plainville about four times a month and sometimes twice in a week.
“The number of kids who need help keeps increasing each year,” said Mullin. “It’s hard to keep up with demand.”
Mullin sees students who are experiencing trauma, anxiety, panic attacks and depression, with some teens threatening to harm themselves and others. Students face multiple stressors, ranging from academic pressure to succeed to concerns about unemployment and hunger at home.
“What is wonderful about EMPS is that they come out to the school for all forms of crisis, not just when a student is suicidal,” said Mullin. “They can help students who are in a state of serious duress that could worsen without early intervention. It’s a preventative measure.”
With assistance from EMPS, Mullin has been able to keep students from inappropriately using the emergency department. EMPS clinicians also “bridge the gap” by following clients for up to 45 days until children and families are connected to home- and community-based services.
“I know our families and kids are in good hands when EMPS is involved,” she said.
Latin America children traumatized by their journey to the United States and their experiences back home represent a growing portion of youth accessing crisis services, said Welt, of the Child Guidance Center. The agency – which saw a 33 percent increase in crisis calls last fiscal year – serves Stamford, New Canaan, Greenwich and Darien.
“Fairfield County has a large immigrant population. We’re seeing an increasing number of children and young adolescents who have been exposed to horrific traumas en route to the United States or in their country of origin,” she said. These include youths who have experienced or witnessed physical or sexual abuse, assault, homicides, separation from loved ones, gang violence and more.
For some youths, the trauma of witnessing the arrest of a parent or caregiver can have long-lasting implications, said Lt. Sean Grant of the Manchester Police Department. Grant is the liaison for REACT (Responding to Children of Arrested Caregivers Together), which brings police and EMPS clinicians together to support traumatized children.
“We understand kids are seeing a lot of traumatic events in the world and in our community,” said Grant. “As much as we are called up at times to be social workers, we don’t have expertise in this area. It’s nice to be able to call EMPS professionals when we don’t have all the answers.”
Limited Access And Affordability
Experts don’t expect demand for crisis services to lessen anytime soon, given the shift from congregate to community-based treatment settings, a shortage of child psychiatrists, and the lack of sufficient inpatient and outpatient treatment placements.
Families with health insurance plans that have high co-payments and deductibles are struggling to find affordable behavioral health services. Some child psychiatrists don’t accept commercial insurance at all.
“We see many families who may have insurance, but they still can’t afford the services their children need, such as medication, partial hospital programs or an intensive in-home program,” said Evison. “Health care is out of reach for many working poor families.”
Disparities in access to care among children with private insurance and those enrolled in HUSKY, the state’s health insurance program for the poor, exacerbate the situation.
“People in the child welfare and court systems have access to a more robust range of evidenced-based mental health services at home and in the community than what is available to people with commercial insurance,” said Vanderploeg. “Access to services even differs for children (covered by the state) depending on whether they entered through the child welfare or court system. These are all issues that were struggling with and need to change.”
For now, advocates are calling for increased funding from private and public insurers to support mental health services for children, including the EMPS program. “There are many kids out there facing mental health problems that need to be addressed,” said Welt.
For a partial list of mental health services offered in Connecticut click here.
On May 7, C-HIT will host a community forum on teen mental health at The Lyceum, 227 Lawrence St., in Hartford. The event, which features an expert panel, is being held in collaboration with ConnectiCare and Hartford Hospital’s Institute of Living. For information and to purchase a ticket, go here.
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Approximately 250,000 Connecticut adults (8 percent) have been diagnosed with Type 2 diabetes and an estimated 83,000 state residents don’t realize they have the disease, according to 2011-13 data from the U.S. Centers for Disease Control and Prevention (CDC). Nationally, 29.1 million people (9.3 percent) have diabetes and 8.1 million people don’t know they have the disease, reports the CDC.
Connecticut’s Hispanics (14.6 percent) and African-Americans (14.1 percent) have significantly higher rates of diabetes than whites (6.7 percent). In addition, adults with annual household incomes below $25,000 are 2.3 times more likely to have diagnosed diabetes compared with adults with household incomes over $75,000, according to the CDC.
Health experts cite multiple barriers to comprehensive diabetes care, including inadequate prescription coverage for costly medications and testing supplies; a shortage of Spanish-speaking medical specialists and community health workers; insensitivity among health care providers to cultural food preferences; a lack of neighborhood markets offering healthy foods; and a dearth of safe recreational opportunities.
“We need a more comprehensive set of solutions that happen at the neighborhood level to get at the root causes of diabetes,” said Dr. Mehul Dalal, chronic disease director for the state Department of Public Health. He said the data show “shocking disparities.”
The “Silent Killer”
Diabetes occurs when blood sugar (also known as glucose) levels remain abnormally high because the body doesn’t produce insulin (Type 1 diabetes) or doesn’t use insulin properly (Type 2 diabetes). About 95 percent of people with the disease have Type 2 diabetes, reports the American Diabetes Association (ADA).
Health experts often call diabetes the “silent killer” because people do not experience symptoms during the early years of the disease. But the long-term complications of diabetes can be deadly and costly. Diabetes can lead to serious health issues such as blindness, kidney failure, lower extremity amputations, stroke and heart disease. One report estimates the total cost of diabetes in Connecticut at $2.43 billion annually, reports the ADA.
Research shows some ethnic and racial groups are genetically predisposed to developing diabetes, including Hispanics, African-Americans, Asians and Native Americans.
In Connecticut, blacks and Hispanics are more likely to die from diabetes and experience higher rates of diabetes-related hospitalizations and amputations than whites, according to data from DPH.
• Black adults had 4.2 times the rate of hospitalizations for diabetes and four times the rate of diabetes-related lower extremity amputations compared with white adults.
• Hispanic adults had 2.2 times the rate of hospitalizations for diabetes and nearly twice the rate of diabetes-related lower extremity amputations compared with white adults.
• Black adults had the highest diabetes and diabetes-related mortality rates, followed by Hispanic residents.
“Diabetes is one of the most serious health problems that African-Americans and Hispanics face today,” said Lindsay Scheinblum, manager for fundraising and special events with the Connecticut chapter of the American Diabetes Association. The ADA offers outreach programs to increase awareness among Hispanics and blacks.
While genetics play a role in the onset of diabetes, lifestyle issues such as obesity and physical inactivity are the main culprits behind the increased prevalence of Type 2 diabetes among people of all ages, said Dr. Raul Arguello, chairman of the Pediatric Department at Danbury Hospital and chief of the Pediatric Endocrine and Diabetes Program.
Danbury Hospital Photo
Dr. Raul Arguello
“There has been an explosion of Type 2 diabetes in teenagers nationwide,” said Arguello, a pediatric endocrinologist who noted that diabetes in children was “practically nonexistent” two decades ago. “Now it is a fact of life for many families.”
Expensive Medications
Dr. Bismruta Misra, an endocrinologist at Stamford Hospital, sees some “positive trends” in her medical practice, where up to 60 percent of all patients have diabetes. More people are seeking medical care after gaining health insurance with passage of the Affordable Care Act. Primary care physicians are actively working to identify patients with pre-diabetes — those with high blood sugar levels at risk of becoming diabetic.
But many patients can’t afford the expensive medications and blood sugar testing supplies that are crucial for managing the disease. People with diabetes spend an estimated $7,900 a year on medication and supplies, reports the ADA.
“People living on a fixed income may have to choose between paying for their insulin or paying their rent,” Misra said. “They have health insurance to see a doctor. But their prescription coverage is terrible or they don’t have any at all.”
Other challenges include “structural barriers” that make it difficult for urban and rural residents to manage diabetes, Dalal said. These hurdles include a shortage of neighborhood markets that carry fresh produce and few recreational options in communities that lack sidewalks or aren’t safe.
“For a while, we thought we weren’t getting the right messages across,” he said. “But telling people to eat healthy food and stay active only goes so far. Many patients at higher risk for diabetes live in neighborhoods where that simply is not an option.”
Cultural Barriers
A shortage of medical providers who understand the cultural and language preferences of their patients can create barriers to care, said Arguello, a native of El Salvador who speaks English with his pediatric patients and Spanish with their parents. “People feel more comfortable when they can communicate in their own language,” he said.
Understanding cultural food preferences is also key. For example, white rice — which the body metabolizes as sugar — is the basis of many meals for Hispanics and Asians. Fried foods enjoyed by African-Americans and other ethnic groups increase the risk for obesity. Even Sunday dinners that bring Italian families together can pose a health threat because pasta is a carbohydrate that acts like sugar in the body.
“Certain cultural food staples are not always ideal,” Misra said. “But asking people to stop eating a food that has been a part of their family traditions for years doesn’t work.” Educating patients about portion control, nutrition labels and ways they can limit — not eliminate — certain foods from their diets are more effective strategies, she said.
Home-based Interventions
Home-based interventions with specially trained bilingual community health workers can help low-income residents achieve their Type 2 diabetes goals, said Sofia Segura-Perez, associate director of the Center for Community Nutrition at the Hispanic Health Council in Hartford.
In a recent study, patients who were linked to community health workers successfully attained better blood glucose control. The workers provided education about nutrition, grocery shopping, medications, exercise and diabetes medical management, in addition to assisting with translation services and transportation to doctor visits. The HHC study was conducted in conjunction with the University of Connecticut and Hartford Hospital.
“Community workers can identify things at home that make it difficult for people to adhere to a regimen,” said Segura-Perez. These include “social stressors” such as lacking money to buy food, worrying about eviction, or raising grandchildren because the parents are absent. “These are things that the doctor doesn’t see during an office visit.”
Other studies show that Hispanics who immigrated to the United States are at a greater risk of developing diabetes the longer they live in America. “Acculturation seems to be another factor among Latinos that may impact their risk for diabetes,” she said.
Looking Ahead
Experts point to prevention and self-management initiatives underway to help stem the prevalence of diabetes. State health officials are working with the state Department on Aging to increase the use of diabetes self-management programs in community settings and to offer programs in Spanish and English.
Local organizations, such as YMCAs, are offering evidence-based intervention programs to reach at-risk residents. More health care systems are using health information technology to identify and track patients who would benefit from diabetes prevention and self-management education programs.
Segura-Perez looks forward to a time when insurers cover home-based strategies that help diabetics avoid more costly complications such as hospitalizations and amputations.
“My hope is that people will recognize the value of home-based interventions to the individual and society,” she said.
Information on diabetes is available at these websites:
Connecticut Department of Public Health (diabetes prevention and control program)
American Diabetes Association, Connecticut Chapter
Centers for Disease Control and Prevention (Diabetes Home page)
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