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Self Management Activation with Outcomes

Athena Philis-Tsimikas, MD Corporate Vice President Scripps Whittier Diabetes Institute La Jolla, CA. Self Management Activation with Outcomes. Trends in Risk Factors. S. H. Saydah; et al. JAMA, January 21, 2004; 291: 335 - 342.

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Self Management Activation with Outcomes

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  1. Athena Philis-Tsimikas, MD Corporate Vice President Scripps Whittier Diabetes Institute La Jolla, CA Self Management Activation with Outcomes

  2. Trends in Risk Factors S. H. Saydah; et al. JAMA, January 21, 2004; 291: 335 - 342

  3. Diabetes Excellence Across Communities:Nurse Case Management and Peer Educator Models for Improving Diabetes Care Established 1997 Primary Care setting Centralized registry and quality management Partnership between CHCs and diabetes experts

  4. Peer Education and Support Electronic Registry Improved Health Status and Quality of Life Standards of Care; Algorithms Nurse-led Team Four Pillars of Chronic Care

  5. Project Dulce Model Multidisciplinary Team Approach Nurse-led Peer education (Promotoras) Key Elements Empowered Patients

  6. Pilot Program 1997 1/3 MediCal, 1/3 County, 1/3 uninsured Female (73%) Latino (72%) Type 2 DM (82%) Annual income below $10,000 (68%) 8th grade education or lower (51%) January 2004 Philis-Tsimikas et al. Diabetes Care 2004:27;110-115 Philis-Tsimikas et al. Diabetes Care 2004:27;110-115

  7. Philis-Tsimikas et al. Diabetes Care 2004:27;110-115 Gilmer T, Philis-Tsimikas A, Walker C. Ann Pharmacother 2005;39;817-22

  8. Group Medical Visits Achieve Improvements of Clinical Outcomes in Diverse Ethnic, Underinsured Populations: A Project Dulce™ Disease Management Intervention 38 patients, enrolled in monthly, structured GMV, 8 – 12 patients scheduled for 2 hours 15-30 minutes-medication lists reviewed, blood sugars checked, weights and vital signs are measured, 45 minute educational session conducted by the RN/CDE, dietitian, or an invited guest. 10-15 min-primary care provider reviews the education topic for with the group, answers questions, then conducts brief individual visits with each patient. Results: Patients expressed acceptance and enthusiasm for this method 2009 ADA Abrstract presentation-Lisa Rivard, RN, CDE, Chris Walker, MPH, Adelle Arias, MPH, Athena Philis-Tsimikas, MD

  9. Rapid Achievement of Blood Pressure and Lipid Lowering Goals in Latino Diabetic Populations: A Project Dulce™ CVD Risk Reduction Study 70 Latinos, with type 2 DM, ages 18-75, with LDL>70mg/dl, and SBP>130mmHg treated with an ACE inhibitor or ARB Randomly assigned to enter treatment of hypertension and lipid management with either a traditional stepped therapy protocol (n=36) or simultaneous therapy with Caduet (n=34), over 24 weeks Results: 65% Female, mean age 53.7 years, with baseline mean LDL of 126 mg/dl and SBP of 139 mmHg Change in LDL-C Change in SBP ADA 2009

  10. Promotoras – Peer Educators • Competency-based training program • Stipends and/or reimbursement • Continuing education • Supervision and support • Standardized curriculum • Support of the health care team

  11. Cultural Divide: Providers and Patients Providers: Science is the only truth Stereotyping Cultural myths need to be discarded People will do what I tell them Non-compliance – patient’s problem Patients: Severity of disease not understood Fatalismo – Act of God Stories from family or friends Fear Language Insurance Immigration status

  12. Peer Educators and Cultural Competence Recognize that culture influences health practices Meet patient in the middle—accommodate their beliefs Respect and learn from our patients

  13. What do Diabetes Peer Educators do? Teach diabetes education Facilitate behavior change Encourage interaction Solve problems Support gains Empower

  14. Peer Education Clinical Outcomes No Nurse Management N = 133 (July, 2000) (HbA1c 9.11  8.06); classes only Data on file Dulce DEMS registry 2005

  15. NIDDK funded Study-2006 Randomized to Project Dulce Peer Education Program versus Standard Care Clinical Outcomes HbA1c, Cholesterol and BP Behavioral Outcomes Exercise/Diet/PHQ9/Self Care/Medication Adherence/EQOL Assessment of Intervention Fidelity

  16. 2009 ADA abstract presentation

  17. Horton Hawks Stay Healthy Program • Peer-led multi-level ecological intervention for the prevention of adolescent and adult chronic diseases such as obesity and type 2 diabetes Chris Walker, TheWhittier Institute for Diabetes Rosemary Jaworski, Horton Elementary School Nurse Robin McCulloch, Horton Elementary School Principal Funded by the California Endowment, the Legler Benbough Foundation, and the Alliance Healthcare Foundation

  18. Program Components Awareness Screening and Referral Behavior Change Intervention Teen Peer Advocate Training Environmental Change Physical Education Physical Activity (Adults and Children) Professional Education

  19. Percent of 5th Grade Girls in Healthy Aerobic Fitness Zone Karen Coleman, PhD, 2010

  20. Percent of 5th Grade Boys in Healthy Aerobic Fitness Zone HHSH program began fall 2005 Karen Coleman, PhD, 2010

  21. ARRA funded DM Prevention Study in Latino women with GDM-2009 Based on Diabetes Prevention Program curriculum Conducted by Project Dulce peer educators alone Adapted and tested in Mexican-American women Pilot study for clinical and behavioral outcomes in 70 women

  22. San Diego County’s ProgramFinance Model Reimbursement for services provided by RN/CDEs, RDs, and peer educators Maximum service/year (for high risk): 1 RN/CDE initial and 8 follow-up visits; 1 RD initial assessment and 1 follow-up; 12 hours group education by peer educators Peer Education and Support Electronic Registry Improved Health Status and Quality of Life Standards of Care; Algorithms Nurse-led Team

  23. HEDIS Results-Project Dulce 2009

  24. Standardized Diabetes Education Materials Diabetes Education Handbook Multilingual Handouts

  25. Screening • Health Fairs • Community Education • Research

  26. VITAL SIGNS Prognosis: Numbers Rise in a Diabetes Forecast By RONI CARYN RABIN Published: November 30, 2009 The number of Americans with diabetes will nearly double over the next 25 years, while the cost of care will almost triple, as patients live longer and develop more of the disease’s long-term complications, a new analysis said. The projections estimate that the population will rise to 44.1 million in 2034, from 23.7 million now, with medical spending increasing to $336 billion from $113 billion. The calculations were published in the December issue of the journal Diabetes Care.

  27. SEARCH For Diabetes in Youth Study Observational study Physician-diagnosed diabetes in youth ages 0-19 Data will help researchers better understand and treat diabetes in young people (SEARCH). Diabetes Care 2006 29(8): 1891-6.

  28. SEARCH Findings • Determine prevalence and correlates of selected CVD risk factors among youth with diabetes • 21% of young people with diabetes had at least two CVD risk factors • Prevalence of CVD risk factors was higher among youth aged 10-19 years and among girls (SEARCH). Diabetes Care 2006 29(8): 1891-6.

  29. SEARCH Findings • In young people with type 2 diabetes: • 92% had at least two CVD risk factors In young people with type 1 diabetes: • 14% had at least two CVD risk factors (SEARCH). Diabetes Care 2006 29(8): 1891-6.

  30. Prevention of Diabetes by Ethnicity The DPP Research Group, NEJM 346:393-403, 2002

  31. Global Projection for Type 2 DM Islet transplantation 250 DPP IV I Exenatide Exubera 200 Nateglinide PPARγ/α agonists? Glucovance Millions of people Repaglinide Pramlintide Glimepiride 150 Metformin since 1957 Miglitol Rosiglitazone, Pioglitazone Sulfonylureas since 1957 Troglitazone 100 Metformin (US) Acarbose Insulin since 1922 1992 2000 2004 2006 1990 1994 1996 1998 2002 2008 YEAR

  32. Scripps Whittier Diabetes Institute Team-2010

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