Transcript An Innovative Approach to Managing Diabetes in a Large Public Health System Donna J.

An Innovative Approach to
Managing Diabetes in a Large
Public Health System
Donna J. Calvin,
PhD, FNP-BC, CNN
Post Doctoral Research Associate
University of Illinois at Chicago
College of Nursing
Department of Health Systems Science
October 29, 2012
Oak Forest Hospital
Englewood Health Center
Fantus Clinic
Woodlawn Health Center
Background
Disparity in the Prevalence
of Diabetes in Chicago
US
Whites
Hispanics
African Americans
0%
5%
10%
15%
20%
Background
Chicago
Diabetes Death Rates
per 100,000
CDPH, 2004
Background
Diabetes
Hospitalizations
by Chicago Zip
Codes, 2007
Chicago Plan for Public Health System Improvement, 2012-2016
Background
 Access
 Cultural incongruence
 Lack of knowledge
- Provider
- Patient
United States
Chicago-County Clinics
 13 million
 Mean A1C 7.6%
 50% < 7
 25% > 9.0




40,000
Mean A1C 8.8%
18% < 7.0%
60% > 9.5%
2001 data
Purpose
To determine the impact of a system-level quality
assurance program aimed to improve diabetes
outcomes among an urban minority population.
Goal
Reduce the average blood
glucose level (A1C) among a
low income, predominately
African American and
Hispanic population.
Optimal HbA1c (A1C) <7.0 %
A measure of chronic glucose
control, and reflects the
prevailing level of glycemia over
the past three months.
Significance
Cost of managing diabetes:
$174 billion total
 $116 billion medical
expenditures
 $58 billion in reduced
national productivity
Significance
Benefits of Decreasing A1C by 1%
14%
40%
Decrease in risk of all
Diabetes
complications
Decrease in risk of
microvascular
diseases
Significance
Decreasing A1C Prevents:
 Blindness
 Kidney Failure
 Amputation
What Should We Do?
Our Evidence-Based Program
Network Diabetes Program
Our Evidence-Based Program
Providers
Physician/NURSE
Social Worker &
Pharmacists
Psychologist
Patient
Ophthalmologists
Podiatrists
.
Dieticians
Family/Friends
Our Evidence-Based Program
Provider-Level Strategies: Nurses receive
three days of intensive education
 Motivational interviewing
 Apply multidisciplinary approach
 ABC goals
 Signs, symptoms and treatment of hyper/
hypoglycemia self-management of hypo and
hyperglycemia
 Glucometer (prepare for testing and action if meter
breaks or not functioning)
Our Evidence-Based Program
Provider-Level Strategies: Physicians
receive two days of intensive education
 Motivational interviewing
- self management
 The use of insulin in diabetes management
- “Clinical inertia”
 Treat to target
- Implementing the ABCs of Diabetes
 Foot exams
Our Evidence-Based Program
Patient-Level Strategies
Multicultural staff provide one-on-one encounters:
 Knowledge Test
 Basic discussion of diabetes
 Review of lab results
 Assessment of: dietary habits, lifestyle,
psychosocial problems
Our Evidence-Based Program
Patient-Level Strategies
 Adjustment of diabetes
medication
 Referral to: PCP,
ophthalmology, podiatry,
social worker and/or
psychologist as needed
 Appointment to attend
diabetes class
Our Evidence-Based Program
Diabetes Class (Spanish & English)
 Overview of diabetes
 Basic self-management skills
 Glucose monitoring
 A personal consultation after
the group class to discuss
concerns and misperceptions
Our Evidence-Based Program
System-Wide Activities
 Nurses
 Physicians
 ABC goals implementations throughout system
 Annual Update
 “Sugar Beat,” a quarterly diabetes publications with
updates in diabetes management
Results
System-Level Data
2001
18.1
81.9
Mean A1C:
8.8%
< 7%
> 7%
2008
A1C
48.2
51.8
Mean A1C:
7.8%
Results
System-Level Data
A1C over 9.5%
2008
2001
69%
< 9.5
> 9.5
31%
78%
22%
Results
NDP Data - More Complex Patients
Crossectional Analysis 2001-2012
10
9.84
9.81
A1C
9.5
9
8.71
8.5
8.54
8
7.5
12 Wk N=5,922
A1c_first
26 Wk N=4,589
A1c_last
Summary of QA Program
Our Evidence-based Program is Effective:
 Meeting national goals
 American Diabetes
Association (ADA)
recognition
 Continuity of care
Future Directions
 Lifestyle Center
 Last chance clinic
 Diabetes Group visits
 Collect and analyze
data to determine what
aspect of our program
has the greatest impact
Elements of the Program
 Treating difficult patients
 Enhancing provider’s skills
 Uniform management in the system (ABC)
Thank You!
Model for other publicly
financed primary health
care systems
Thank You!
Questions?