Improving Diabetes Awareness, Education and Disease Management among Patients at Diabetes mellitus is a chronic disease characterized by persistent hyperglycemia. …
Improving Diabetes Awareness, Education and Disease Management among
Patients at the
Anthony L Jordan Health Center
CHIC Block 1
August 30, 2006
Background/Literature review
Diabetes mellitus is a chronic disease characterized by persistent
hyperglycemia It is the 6th leading cause of death in America and is among
the most disabling and costly diseases in the United States[i] Worldwide,
diabetes has soared to epidemic proportions and is at the forefront of
public and community health in the United States and abroad
Diabetes is found in approximately one in ten individuals, but by the time
a person reaches 65 years of age, the incidence rises to one in five Type
2 diabetes accounts for up to 95 of all diabetes cases, affecting 8 of
the population age 20 and older[ii] Worldwide, 135 million people were
diagnosed with diabetes in 1995 The World Health Organization estimates
that this number is expected to increase to at least 300 million by
2025[iii] The increasing incidence of Type 2 diabetes
is thought to be
correlated with the aging population, a dramatic rise in the prevalence of
obesity, and a more sedentary lifestyle[iv],[v]
Diabetes that is uncontrolled, characterized by consistently high levels of
blood glucose 200, leads to micro and macro vascular disease
complications, such as blindness, lower extremity amputations, end-stage
renal disease, coronary artery disease, and stroke Consequently, it also
creates a significant clinical and economic burden on
society[vi],[vii],[viii] In 1998, direct and indirect costs of diabetes
mellitus and its complications in the United States were estimated at 982
billion[ix],[x] The annual cost of diabetes in medical expenditures and
lost productivity escalated from 98 billion in 1997 to 132 billion in
2002 Improving care for diabetic patients is a priority
Standards of care for diabetes mellitus have been broadly disseminated
since the 1980s in the belief that improved processes of care can improve
patient outcomes [xi],[xii] However, a significant gap exists in diabetic
research: the issue of replication[xiii] Although there are few studies
that
fully describe the number, applicability and availability of
successful interventions, diabetic education is as essential component of
managing diabetes Further studies need to be done to determine the number
of existing interventions and which of them are best at modifying patient
behavior
The number and complexity of services required to manage patients in accord
with accepted guidelines have made Type 2 diabetes the target of multiple
disease management efforts, as well as targeted efforts involving
professional education and case management As health resources continue
to shrink, however, healthcare providers are being forced to provide more
services with decreasing resources They are unable to implement ideal
patient care and education as per national guidelines and
recommendations[xiv],[xv] Additional barriers to guideline adherence and
implementation include: patient perception that type 2 diabetes is not
serious; that aggressive treatment cannot forestall complications; that
guidelines are not flexible enough to be useful in patient care and that
patients with diabetes mellitus are
unwilling to make needed lifestyle
changes[xvi],[xvii],[xviii],[xix],[xx],[xxi],[xxii]
Diabetes in Monroe County: needs assessment
According to the Monroe County Adult Health Survey Report 2000, the
prevalence of diabetes is lower in Monroe County than in the nation, 55
versus 96 However, according to the 1998 Health Action Priorities for
Monroe County Adult Health Report Card, 36 of African Americans in
Rochester had diabetes, compared to 14 of Caucasians There is a normative
need for diabetes intervention within the Monroe community due to its
significant morbidity, mortality and economic burden, particularly among
minorities
Estimated Diabetes Prevalence Rates by Age and Race/Ethnicity
in New York State 1997-1999[xxiii]
Diabetes Mortality Rates by Age and Race/Ethnicity for New York State in
1998[xxiv]
Impact on Minority Populations
Diabetes occurs across all racial and ethnic and socioeconomic groups, but
is two to five times more common in African Americans, Hispanics, and
Native
Americans[xxv] African Americans are 17 times more likely to have
Type 2 diabetes than the general population with an estimated 23 million,
or 108 having diabetes Hispanics are almost twice as likely to have
type 2 diabetes The overall prevalence of type 2 diabetes in Native
Americans is 122 vs 52 of the general population In some tribes, as
many as 50 of individuals have the disease
Age-Adjusted Prevalence of Diagnosed Diabetes by Race/Ethnicity and Sex in
the United States, 1980-2003[xxvi]
Consequently, the burden of diabetes is much greater for minority
populations than the Caucasian population When compared with non-Hispanic
whites, minorities also have much higher rates of diabetes-related
complications, hospitalizations, and death, in some instances by as much as
50 percent more than the total population[xxvii],[xxviii],[xxix],[xxx]
Minorities are also at higher risk of developing diabetes due to social,
cultural, and economic trends[xxxi] They are more likely to: live in
poverty, work for companies that provide little or no benefits,
be
uninsured and/or lack access to healthcare, be overweight, and have
difficulty managing diabetes due to conflicts with culture
Our target community, therefore, was the diabetic patients of the Anthony
L Jordan Health Center AJHC Approximately 300 of the 500 patients seen
at the center are diabetic The majority of these patients are African-
American and Hispanic the primary populations who are at increased risk of
developing diabetic complications Currently, patients receive standard
primary healthcare services along with specialized services dentists,
optometrists, and podiatrists are on site Barriers to implementing
additional services include: patient work schedule, transportation and
childcare services The most significant difference among specific
subpopulations regarding health needs and access is language A number of
patients are Spanish speaking and we wish to extend support services to
them as well, but are not currently equipped to do so
This Community Health Improvement Clerkship project is threefold and will
eventually undertake a Population Health Approach Our goal is to reduce
the disease and
economic burden of diabetes by reducing the knowledge
disparity of the patients who receive their care at the Anthony L Jordan
Health Center Ultimately, we hope to maintain a program in which we:
Increase the proportion of patients who receive formal diabetes
education
Encourage AJHC healthcare providers to promote risk assessment and
self-management for diabetics in their practice settings by utilizing
the patient electronic care system
Empower patients to be partners in their healthcare
Educate community leaders about diabetes and its management
Reduce the complications of diabetes: coronary artery disease, limb
loss, renal disease, and vision loss
Reduce the rate of diabetes related deaths
Implementation
Diabetes Support Group
Understanding that training in self-management is integral to the treatment
of diabetes, we sought to address psychosocial and lifestyle issues that
may have been hindering glucose control We decided to promote patients
becoming involved in managing their diabetes by initiating a peer/focus
group at AJHC This will, hopefully, motivate patients to improve
their
glucose control and, in turn, prevent chronic disease via healthy
behaviors: increasing physical activity, weight loss, making healthy eating
decisions and taking anti-glycemic medication regularly as necessary
The support group was scheduled for August 28th at the Anthony L Jordan
Health Center since that date would permit adequate time to plan and
execute the meeting I contacted Susan Calcagno, a certified diabetes
educator who had attempted to conduct a similar group on diabetic
nutritional needs two months prior, but had poor attendance no one came to
the meeting After extensive discussion with Dr Kennedy and Trish Harren,
it was determined that there had not been enough advertising or personal
contact prior to the meeting In order to prevent a similar recurrence, I
composed and mailed flyers to diabetic AJHC patients Posters were also
placed throughout the center Phone calls were made the Wednesday through
Friday prior to the meeting to encourage attendance Unfortunately, during
the course of attempting to phone patients, I discovered that 29 out of the
147 phone numbers listed in the charts were either no
longer in service or
wrong numbers It was hoped that addresses listed for these patients were
current so that their phone numbers could be obtained upon their attendance
at the meeting I also contacted Marion Walker President of JOSANA who
agreed that the support group is necessary and asserted that he would
assist us in encouraging attendance
In preparation for the support group, I requested a donation of a 25 gift
card from the manager of the local TOPS market The card was awarded as a
door prize at the end of the meeting in order to provide incentive for
attendance at future sessions I also spoke at length with the local
pharmacist to ascertain what he thought the needs of the community were and
he suggested that although the support group was a good idea, we should
arrange to have an interpreter present at future meetings due to the large
Spanish-speaking population at AJHC Unfortunately, no interpreter was
available for the meeting
Diabetes Educational Kiosk
I obtained the majority of diabetes themed handouts and flyers from
reputable online sites American Diabetes Association, National Diabetes
Education
Program, National Institute of Diabetes and Digestive and Kidney
Diseases These materials were organized into labeled sections so that
providers could have ready access Information on topics such as: the
overview of diabetes, nutrition, foot care, and eye care was acquired in
both English and Spanish I also ordered a DVD offered on Ministry Healths
website[xxxii]
Diabetes Report Card
I designed a diabetes report card that will help both patients and their
providers keep track of predictors of future complications such as
glycosylated hemoglobin HgBA1C, blood pressure, cholesterol level,
weight/ body mass index BMI and urine microalbumin I have also included
reminders for yearly dental, eye and foot exams as well as healthy eating
tips Along with the help of Gabrielle Kapsack, I was able to develop an
automatic graphing feature within the Word Excel program that will enable
providers to track each patients HgBA1C, blood pressure, weight, and BMI
values over time Establishing this system program is essential in
permitting patients to see a longitudinal record of modifiable health
risks
Community Impact/
Results
The diabetes support group was a success and I think that the most
important component of this project was phoning patients rather than simply
mailing flyers In all, 10 patients attended the meeting one Spanish-
speaking patient came with an aide who translated for her The individuals
who came to the meeting were very interested in learning more about how
diabetes is caused and the various methods of managing it diet, exercise,
oral agents, and insulin During the session, participants were given a
copy of the report card I had designed and counseled about their most
recent values We were also able to convey the importance of partnering
with physicians and seeking regular medical attention Attendees expressed
excitement about having a support group that would address topics that they
wished to discuss and I hope that this session will be the first of many
monthly meetings
After the session, everyone expressed that they had enjoyed the session
Some individuals stated that they were looking forward to future meetings
and would bring a loved one to the next support group On a community wide-
level, the support group
provided AJHC patients the opportunity to obtain
vital information about diabetic nutritional needs and the importance of
maintaining healthy blood pressure, cholesterol and blood sugar
Barriers
It was difficult selecting material that was comprehensive yet easy to
understand/not overwhelming Furthermore, there seems to be a limited
amount of diabetes themed DVD or VHS media Although Susan Calcagno had
provided me with the contact information of two diabetic outreach liaisons
who may have been able to assist me with the search for diabetic themed
resources, neither responded to my inquiries
Process Outcome Evaluation
Our initial endeavors to improve diabetes awareness, education and disease
management among patients at the Anthony L Jordan Health Center were
successful and are ongoing
In addition to achieving the primary goal of establishing a support group
for diabetic patients, I was able to obtain diabetes themed materials for
the Diabetes Educational Kiosk as well as design both a diabetes report
card and Word Excel program
Sustainability
My partnerships enabled me to initiate and implement a
sustainable
community project that targeted diabetic patients at AJHC The long-term
success of this project, although enriched by the participation of future
CHIC students, can continue with the effort of AJHC providers and
community leaders If successful, we may consider submitting our findings
for additional funding and possible extension of services Future potential
projects include:
Establishing AJHC monthly support group as a community program of the
Students of Rochester Outreach
Organizing a tour of the local TOPS with a certified diabetic educator
Arranging the donation of pedometers to AJHC in order to increase
physical activity
Phone outreach to AJHC diabetic patients
Assessing the effectiveness of our interventions and completing a
program evaluation
Analyzing the effects of non-medical determinants of health cultural
foods, access to recreation center on glucose control
Personal Impact
I realize the importance of contributing to my surrounding community and
have therefore participated in outreach programs prior to and throughout
medical school Students of Rochester Saturday
School Program and Student
National Medical Association Health fairs My aim for this Community
Health Improvement Clerkship was to initiate a sustainable project that
empowers diabetics because there is an undeniable need for furthering
diabetes education among Anthony L Jordan Health Center patients
During our session, I witnessed participants share their personal and
family experiences and noted how important it was for these patients to be
among those who understood what they were undergoing and to share problem-
solving strategies I wanted to provide participants with the knowledge and
confidence necessary for allowing them to be their own health advocates
Establishing the support group was an essential component of my project
task since it played a crucial part in reassuring patients that they are
not alone, and that help is available Ideally, the support group at AJHC
will be a place where feelings of demoralization, depression and isolation
can be shared as peers
As a future healthcare provider, it will be important to assess the needs
of my community so that I can better understand and support my patients I
intend
on having an active social role and I will engage in partnerships to
strengthen the prevention, detection and management of disease,
particularly of the pediatric population I will also use the skills I
learned designing the diabetes report card and Word excel automatic
graphing program in caring for my future patients
Appendix 1: Partnerships
Dr Richard Kennedy
Anthony L Jordan Health Center
82 Holland Street
Rochester, New York 14606
423-5800
RKennedy@rochesterrrcom
Trish Harren
Diabetes Collaborative
Anthony L Jordan Health Center
Woodward Health Center
734-9091
tharren@westsidehealthnet
Susan Calcagno
Certified Diabetic Educator
Innovex/sanofi-aventis
737-3939
SusanCalcagno@Innovexcom]
Marion Walker
President of JOSANA
967-5403
Maurice
Tops Friendly Markets
285 Upper Falls Blvd
Rochester, NY 14605
423-0789
Appendix 2: Flyer page 1
Appendix 2: Flyer page 2
Appendix 3: Letter to TOPS
August 17, 2006
Tops Friendly Markets
285 Upper Falls Blvd
Rochester, NY 14605
Dear Mr Thomas:
My name is Joanne Moreau and I
am a fourth year medical student at the
University of Rochester I am currently organizing a Diabetic Resource
Center at the Anthony L Jordan Health as part of the University of
Rochesters Community Health Improvement Clerkship which is sponsored by
the Department of Community and Preventive Medicine
Currently Anthony L Jordan Health Center has approximately 300 diabetic
patients and, given the devastating complications of the disease, our goal
is to improve patients understanding of diabetes and its associated co-
morbidities To this end, we are establishing a Diabetes Support Group
The first meeting is scheduled for Monday August 28th 2006 I am writing
this letter to request a donation of a 25 gift card from Tops Friendly
Markets for door prize/incentive to encourage attendance at the meeting
Your assistance with our endeavors would be greatly appreciated
If you have any questions, I can be reached by phone at 585 506-6849 or
at the above address
Sincerely,
University of Rochester
School of Medicine and Dentistry
Appendix 4: Word Excel Graphs
|Name | | | | | |
|
|DOB | | | | | | |
| | | | | | | |
|Date |Systoli|Diastol|Weight|Height |BMI |HgbA1C |
| |c blood|ic | |inches| | |
| |pressur|blood | | | | |
| |e |pressur| | | | |
| | |e | | | | |
|10/2/2006|214 |98 |325 |70 |466|10 |
|10/4/2006|190 |87 |299 |70 |429|6 |
|10/6/2006|201 |95 |290 |70 |416|9 |
|10/8/2006|168 |75 |287 |70 |412|14 |
|10/10/200|175 |81 |275 |70 |395|8 |
|6 | | | | | | |
|10/12/200|182 |86 |256 |70 |367|7 |
|6 | | | | | | |
|10/14/200|150 |79 |235 |70 |337|11 |
|6 | | | | | | |
|10/16/200|194 |93 |236 |70 |339|9 |
|6 | | | | | | |
|10/18/200|163 |92 |278 |70 |399|8 |
|6 | | | | | | |
Appendix 4: Word Excel Graphs continued
ANTHONY L JORDAN HEALTH CENTER
DIABETES REPORT CARD
Name:
|Date: |Measure |1st |2nd |3rd |4th |
| | |Visit |Visit |Visit |Visit |
| |HgBA1C | | | | |
| |Goal: 70 | | | | |
| |Fasting blood sugar | | | | |
| |level | | | | |
| |Goal: 100 | | | | |
| |Blood Pressure | | | | |
| |Goal: 130/80 | | | | |
| |LDL Cholesterol | | | | |
| |Goal: 100 | | | | |
| |HDL Cholesterol | | | | |
| |Goal: 40 | | | | |
|
|Current Weight | | | | |
| |BMI | | | | |
| |Goal: 25 | | | | |
| |Urine Microalbumin | | | | |
| |measures kidney | | | | |
| |function | | | | |
| |Goal: Ratio less | | | | |
| |than 30 | | | | |
| |Dental Exam | | | | |
| |Dilated Eye Exam | | | | |
| |yearly | | | | |
| |Foot exam yearly | | | | |
| |Flu Shot yearly | | | | |
Take control of the ABCs of diabetes and live a long healthy life
A is for A1C A1C measures your average blood sugar levels over the
last 3 months
B is for blood pressure High blood pressure makes your heart work too
hard
C is for cholesterol Bad cholesterol LDL builds up and clogs
your
arteries
|A1C |Average |
| |Blood |
| |Glucose |
| 4|60 |
|5 |90 |
|6 |120 |
|7 |150 |
|8 |180 |
|9 |210 |
|10 |240 |
|11 |270 |
|12 |300 |
|13 |330 |
|14 |360 |
Healthy Eating Tips:
V Eat three meals at regular times Do not skip meals
V Decrease saturated fat intake red meat, cheese, whole milk, butter,
ice cream, etc
V Eat less trans fat stick margarine, shortening, cakes, pies, french
fries, snack chips
V Reduce cholesterol no more than 4 egg yolks per week/limit meat,
poultry to less than 6 ounces a day
V Reduce salt intake canned and dried soups, fast food, frozen dinners,
pizza
V Eat more fruits, vegetables, beans, whole grain breads, and cereals
V Maintain a healthy weight
V Eat 20-35 grams/day of dietary fiber
V Be careful when using special diet or dietetic foods such as dietetic
cake, cookies, candy and ice cream These foods contain some form of
sweetener and, therefore, calories
V Use the sweet spices-cinnamon cloves ginger or nutmeg-to bring out
sweetness in baked
goods
References
———————–
[i] Alliance for Aging Research A Call to Action: How the 107th Congress
Can Achieve Health and Independence for Americans as They Age, April 2001
[ii] US Department of Health and Human Services One-Third of Adults with
Diabetes Still Dont Know They Have It NIH News, May 2006
[iii] King H, Aubert RE, Herman WH Global burden of diabetes, 1995-2025:
prevalence, numerical estimates, and projections Diabetes Care 1998;
219:1414-1431
[iv] Tuomilehto J, Knowler WC, Zimmet P Primary prevention of non-insulin-
dependent diabetes mellitus Diabetes/ Metabolism Reviews 1992; 84:339-
353
[v] Glasgow RE, Wagner EH, Kaplan RM, Vinicor F, Smith L, Norman J If
diabetes is a public health problem, why not treat it as one? A population-
based approach to chronic illness Annals of behavioral medicine 1999;
212:159-170
[vi] Songer TJ, Ettaro L; Economics of Diabetes Project Panel Studies on
the Costs of Diabetes Centers for Disease Control and Prevention; 1998
[vii] American Diabetes Association Economic consequences of diabetes
mellitus in the US in 1997 Diabetes Care 1998; 21:296-309
[viii] Rubin RJ, Altman WM, Mendelson DN Health care expenditures
for
people with diabetes mellitus, 1992 The Journal of clinical endocrinology
and metabolism 1994; 78:809A-809F
[ix] Songer TJ, Ettaro L; Economics of Diabetes Project Panel Studies on
the Costs of Diabetes Centers for Disease Control and Prevention; 1998
[x] American Diabetes Association Economic consequences of diabetes
mellitus in the US in 1997 Diabetes Care 1998; 21:296-309
[xi] Alberti KG, Zimmet PZ Definition, diagnosis and classification of
diabetes mellitus and its complications: part 1: diagnosis and
classification of diabetes mellitus provisional report of a WHO
consultation Diabetic Medicine 1998;15:539-553
[xii] Conseil Superieur du Diabete Diabetes care and research in Europe:
the St Vincent Declaration Action Program [in French] Diabetes Metab
1992; 18:334-377
[xiii] Fain JA et al Diabetes patient education research: An Integrative
Literature The Diabetes Educator, 25 6: 7-15
[xiv] Kenny SJ, Smith PJ, Goldschmid MG, Newman JM, Herman WH Survey of
physician practice behaviors related to diabetes mellitus in the US:
physician adherence to consensus recommendations Diabetes Care 1993;
16:1507-1510
[xv] Stolar MW; Endocrine Fellows Foundation Study Group
Clinical
management of the NIDDM patient: impact of the American Diabetes
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707
[xvi] Helseth LD, Susman JL, Crabtree BF, OConnor PJ Primary care
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[xvii] OConnor PJ From blame to understanding: moving diabetes care
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[xviii] Anderson RM, Donnelly MB, Dedrick RF, Gressard CP The attitudes of
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[xix] Anderson RM, Donnelly MB, Davis WK Controversial beliefs about
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[xx] Golin CE, DiMatteo MR, Gelberg L The role of patient participation in
the doctor visit: implications for adherence to diabetes care Diabetes
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[xxi] Wing RR, Epstein LH, Nowalk MP, Scott N, Koeske R Compliance to self
monitoring of blood glucose: a marked-item technique compared with self-
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[xxii] Christensen NK, Terry RD, Wyatt S, Pichert JW, Lorenz RA
Quantitative assessment of dietary adherence in patients with insulin-
dependent
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[xxiii] New York State Department of Health, Diabetes Surveillance and
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1999
[xxiv] New York State Department of Health, Diabetes Surveillance and
Evaluation Unit Vital Records 1998, US Census Population Estimates 1997-
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[xxv] Mokdad AH, et al Diabetes trends in the US: 1990-1998 Diabetes
Care 2000;239:1278-83
[xxvi] CDC National Center for Chronic Disease Prevention and Health
Promotion
[xxvii] Carter JS, Pugh JA, Monterrosa A Non-insulin-dependent diabetes
mellitus in minorities in the United States Annals of Internal Medicine
1996;1253:221-32 AHRQ Grant HS07397
[xxviii] King, H et al Global burden of diabetes, 1995-2025 diabetes care
219: 14141-1431, 1998
[xxix] Harris, MI Diabetes in America: epidemiology and scope of the
problem Diabetes care 21 supplement 3: c11-c14, 1998
[xxx] Sundquist J, Winkleby MA and Pudaric S Cardiovascular Disease Risk
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[xxxi] Carter, JS Pugh JA, and
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[xxxii]
http://wwwministryhealthorg/healthconnection/Spring2006/diabeteshtm
———————–
Meet other people who are living with diabetes
Please join us for the next meeting:
Topic: Nutrition
Speaker: Susan Calcagno, MS, RD, CDE
Certified Diabetic Educator
Affiliated with sanofi-aventis
Date: Monday, August 28th, 2006
Time: 6:30 - 7:30pm
Location: Anthony L Jordan Health Center
82 Holland Street
An open discussion will follow
Bring your ideas and questions
Family members and friends are welcome
If you have diabetes, you are at high risk for heart attack and stroke
Take control of the ABCs of diabetes and live a long healthy life
A is for A1C A1C which measures your average blood sugar levels
over the last 3 months
Suggested A1C target: below 7
B is for blood pressure High blood pressure makes your heart
work too hard
Suggested BP
target: below 120/80
C is for cholesterol Bad cholesterol LDL builds up and clogs
your arteries
Suggested LDL target: below 100
We Look Forward to Seeing You at the Meeting
Hemoglobin A1C Glycosylated Hemoglobin - The amount of sugar attached to
your hemoglobin
The higher the A1C, the higher the risk of future diabetic complications of
Diabetes:
Loss of vision: which can lead to blindness
Loss of kidney function: which can lead to dialysis
Diabetic neuropathy: chronic nerve pain in the legs
Narrowing of blood vessels: which can lead to higher risk of stroke or
heart attack, or amputation
