Diabetes Prevention Program at Thundermist Health Center

1. Diabetes Prevention Program atThundermist Health Center

2. THUNDERMIST HEALTH CENTER Located in underserved areas throughout the state of Rhode Island, THC has three main clinics serving 21, 000 adult, pediatric and women’s health patients with 80,000 encounters. In addition, THC has four school-based health centers, two WIC offices, and three dental offices, including a dental screening and treatment program in two of our school sites. THC’s also has a pharmacy, the first 340B pharmacy in the state of Rhode Island, with telepharmacy links to other sites. To date, at our main Woonsocket site, one hundred and forty two pre-DM patients have been identified.

3. Team Members Cynthia Buckley, RNP-Team Leader School Based HC Provider Susanne Campbell, RN Vice President of Clinical Affairs Estelle Ducharme, RN Director of Nursing Dianne Therrieau, Registered Dietitian Carol Walsh MA, Adult Medicine Patty Kelly-Flis RN, RI DCPC

4. Thundermistutilizes the Chronic Care Model so that community-based identification and intervention is implemented based upon evidence from the Finnish Diabetes Prevention Study and the American Diabetes Prevention Program (DPP) using the key measures and goals. Key Measures and Goals: • % follow-up recommendation to get HbA1c twice per year > 90% • % documentation of self-management goal setting > 70 % • Average % weight loss > 7 % • Exercise, 150 minutes > 60 % • % with HbA1c>7.0 or FBS>126 mg/dl < 1 % • % yield pre- diabetic 10 %

5. The population of focus are Tanner 4 adolescents and adults with an impaired fasting glucose and/or an impaired glucose tolerance test that are routinely seen by us at our Woonsocket sites.

6. What Are the High Risk Factors? History of gestational diabetes History of a first degree relative with diabetes Patients identified with impaired fasting blood sugar >100-125 (as of November 2003) and/or impaired glucose tolerance of 140-199. Ethnicity BMI>30 Age >45 History of altered random glucose History of CVD Hypertension Dyslipidemia

7. WHAT GAVE US THE BEST YIELD At the point of care at our Woonsocket site, patients are asked to complete an at riskscreening tool that is based upon the identified risk factors. Then, it is reviewed by the provider who sends the patient for a FBS and OGTT. • 8 patients were identified through our billing system with Gestational DM. • 200 patients with elevated random BS were identified through our hospital laboratory system. Chart audits were performed. Subsequent telephone follow-up to these patients was labor intensive and found not productive. • Information about the project was given to existing diabetic patients, as well as their relatives, when they picked up their medication from our pharmacy. • Outreach into churches and Head Start health fairs.

8. Organization of Health Care • Chronic Care Model is part of our strategic plan • Senior Leadership support • Risk management • Quarterly updates to the Board • Orientation package for all employees on collaboratives and chronic care model

9. Decision Support Implemented by: • Orientation to all staff about Diabetes prevention project • Orientation to all providers about the project and the NDEP packet • Monthly progress reports to providers • Storyboards and NDEP posters in all waiting rooms

10. Decision Support Implemented by (cont): • Orientation to all providers about latest changes (November 2003) • Nutrition classes modeled after the DPP project curriculum • Development of clinical practice guidelines for pre-DM/DM. • Decision to utilize ADA Risk Factor Sheet as Screening Tool

11. Community Implementation: • BE FIT program • Landmark Medical Center agreement to provide OGTT screening at a reduced rate for the uninsured • Partnership with DFRII • Partnership with Diabetes Control Program at DOH • $2500 grant from Aventis for purchase of pedometers

12. Community Implementation (cont): • Toolbox of local supports: videos, exercise options, NIA video, Moviemiento CD • Support from Johnson & Wales student in nutrition and culinary arts through the DOH. • Partnership with Family Medicine Dept. Memorial Hospital • Staff education assistance from Novo-nordisk

13. How is it implemented into the Delivery System : • Laminated sheets with ADA risk criteria in all clinical areas, WIC, dental • Screening tools in English and Spanish • Provider referral for pre-diabetes screening at the patient visit • Lab drawing incentives • NDEP information

14. The tools we use • Guidelines for pre-DM/DM care/Standing orders • Combined Clinic Visit sheet for chronic disease management/Summary of Care • Screening Tool • Lab Letter/Lab ordering sheet • Nutrition referral • Self management form • Script for exercise clearance • Pedometer diary

15. Self management skills implemented : • NDEP “Small Steps Big Rewards Patient Package” • Pedometers and diaries to students, patients, providers and staff • Prescriptions developed for exercise clearance before starting the program • Ongoing drop in weight loss support group at WIC every Wednesday afternoon

16. Self management skills implemented (cont) : • Our RD offers classes in diet management and one on one counseling • Visit with CDOE nurse to review NDEP information, set self management goals and assesses readiness for behavior change • Behavior health clinicians available to help with pt. problem areas in the clinic-2 clinicians available-grant through mental health team

17. Clinical Information Systems Implementation: • Excel spreadsheet designed to help track pre-diabetics and patients at risk; • Utilization of PECS (Patient Electronic Care System)2.2 for communicating, tracking and running of reports; • Data and senior leader reports submitted to national site for viewing. • All pre-DM and DM pts entered in PECS • In addition, report run monthly on billing system of all pre- DM pts that had appointment that month

18. Challenges that we have overcome: • Negotiating with Landmark Medical Center for lab services at a low cost • Provider, staff and patient buy-in

19. Barriers • Patient priority may not be their health • Time • Monies • Changes in key personnel/staff turnover • As time passes, the increasing number of pre-DM pts has and will increase the challenges arising in order to keep track of them and note their progress

20. How Do We Measure Up • Number of people eligible for OGTT…630 • Number of pts screened……………. 328 • 142 pre-diabetic…...……………. 43% yield • 60 diabetics….... ………………..18% yield • 3.6% weight loss; 30pts reporting exercise>150 min /week • 62 % documented self management goals • 85 pts with HgbA1C after diagnosis • 8 pts converted to DM

21. Conclusions

22. QuestionsEmail : CynthiaB@thundermisthealth.org