MAKING THE CHANGE!

An Evaluation of the control of diabetes at the Sojourner Free Health Clinic Apurva Bhatt

1

, Peter Lazarz

1

, Angela Barnett

1,2

, Miranda Huffman

1,2

1

UMKC School of Medicine,

2

Truman Medical Center

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Introduction

The Sojourner Free Health Clinic (SFHC) is a service-based, student operated clinic located at Grand Avenue United Methodist Temple in downtown Kansas City, MO.

Results

• 25 HbA1C tests were run in 2013, with 15 patients being tested.

• SFHC operates on Sunday afternoons and provides free outpatient medical services to the homeless and underserved population of Greater Kansas City. • • In 2012, SFHC opened up a new laboratory which allowed the clinic to run point of care HbA1C tests free of charge for patients. This has been an initial step in helping improve the control of diabetes at the SFHC.

• To date, there have been no studies evaluating the control of type 2 diabetes at SFHC. Quantification of control by measuring baseline hemoglobin A1C levels in patients with type 2 diabetes is a necessary first step in the implementation of quality improvement processes.

The purpose of this study is to evaluate the control of hyperglycemia in SFHC’s diabetic patient populations by measuring A1C values and to propose quality improvement measures to enhance patient compliance and understanding of diabetes management.

• • • • 5 of the 15 patients had labs drawn more than once throughout the year, and their trends are shown below. The average A1C of all patients (taking into account only most recent values for patients tested repeatedly) was 9.08%. The average A1C of patients seen regularly for health maintenance was 8.88%.

The data showed a 0.20% decrease in A1C levels in patients treated regularly compared to those treated once. This decrease is less than optimal and warrants several changes.

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Methods

We evaluated HbA1C lab values that were gathered from SFHC patients from January 2013 to December 2013.

• We viewed A1C trends from patients who received more than one A1C test in 2013.

• We calculated the average numeric change in A1C by comparing the first A1C value to the most recent A1C value.

• We evaluated how well patients met HbA1C goals as specified by the ADA 1 . • We proposed ideas that would help improve control of diabetes at SFHC .

• • The average change in A1C for patients with repeat values: 0.22% decrease in A1C.

Patient B showed a 3.2% drop in A1C, from almost 11% to the desired 7%. This drop is demonstrates the success in treatment involving intensive patient education on a weekly basis, lifestyle changes, and medication.

• Number of patients who met/did not meet ADA goals for A1C<7%: Number of patients who met ADA guidelines of A1C<7% 6/15 Number of patients who did NOT meet ADA guidelines of A1C<7% 9/15 •

HEALTH EDUCATION and LITERACY

: Patient health education and literacy is another factor which affects control of diabetes at SFHC. Some patients do not understand how to appropriately take their medications/insulin which affects their control of diabetes. • • These values reflect the most recent A1C value recorded in our patients.

40.0% pf patients tested met goals; 60.0% did not meet goals.

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ACCESS

: Many patients lack adequate access to medical care and often visit local emergency departments for care.

CONTINUITY

: Minimal follow-up with patients with uncontrolled diabetes is due to the transiency of the patient population. • • • •

LIMITATIONS

Retrospective study with small sample size and small number of patients who received repeat A1C testing at SFHC, likely due to the transiency of the population seen at the clinic.

We did not evaluate fasting blood sugars, cholesterol or blood pressures, all of which are important factors to evaluate in patients with diabetes. Most patients are not fasting as they eat the free lunch provided to them by the church prior to attending clinic.

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Recommendations

SFHC should implement quality improvement measures to improve diabetes control in its patient population.

• Next steps as indicated by this project include:

ECONOMIC:

Partner with other interprofessional learners to develop compassionate care programs and with other foundations to provide a broader spectrum of medications for improving control of hyperglycemia.

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NUTRITION:

Provide handouts to patients and partner with interprofessional learners to provide education.

This review did not reflect whether the patient was currently compliant with medication recommendations or if a patient was currently out of their medications.

We did not evaluate patients’ current eating habits or diabetic education.

•

HEALTH EDUCATION and LITERACY:

Complete a patient Health Literacy study to evaluate health literacy in patients at the clinic. Implement a Patient Discharge Summary Sheet to enhance patient understanding and compliance to their therapy regimen.

• We did not evaluate patients weight for this study.

Summary

• With this data, we were able to conclude that control of diabetes at SFHC is suboptimal, with 60.0% of patients not meeting A1C goals set by the ADA.

• There are many factors which contribute to poor control of diabetes in the SFHC patient population: • •

ACCESS

: Implement a discharge process that includes a discharge summary sheet, education, and pre-visit planning for follow-up. Also change lab processes so that patients obtain labs before eating lunch.

CONTINUITY

: Placement of lab testing reminders in patient charts to remind SFHC personnel about lab work that needs to be completed at next visit. Educate patients on proper follow-up and giving priority for follow-up.

•

ECONOMIC

: the majority of patients that come to the clinic are homeless and unemployed. They lack resources and support towards care. •

NUTRITION

: Barriers to adequate nutrition also exist.

1.

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Further Research:

Implement measures then perform a follow up study to evaluate effectiveness of new measures.

References

"Standards of Medical Care in Diabetes-2014."

American Diabetes Association

37.S1 (2014): S14-80.

Standards of Medical Care in Diabetes 2014

. American Diabetes Association. Web. 05 Feb. 2014. Accessed: 01 March 2014. .