Anna Marshall, BSN, MSN candidate December 10, 2012

1. Implementing Best Practice in Diabetes Care: An Intervention to Improve Practice in the Community Health Care Setting Anna Marshall, BSN, MSN candidate December 10, 2012

2. Overview of Presentation • Background • Problem Statement • Theoretical Framework • Critical Appraisal of the Evidence • Purpose • Project Implementation • Project Outputs • Discussion • Implications for Advanced Practice Nursing

3. Background of the Problem • Chronic disease • Annually, 7 out of 10 deaths among Americans from chronic disease • Long-term management is challenging and requires an organized, integrated approach • Diabetes • Common, costly & preventable • 346 million people worldwide with diabetes (WHO, 2012) • On the rise worldwide, projected to increase 165% between 2000-2050 • Fastest increases occurring in older and minority subpopulations (Venkat Narayan, Boyle, Thompson, Sorenson, & Williamson, 2003)

4. Background of the Project • Community Health Centers (CHCs) • Deliver care to some of the most vulnerable populations • Improve access to screening & preventative services • Role of AmeriCorps staff • As community health workers (CHW) to improve functional capacity of CHCs

5. Background of the Project • Heartland Community Health Center • Kansas Safety Net Clinic • Primary care services • Specialty services • Case management • Diabetes Care & Prevention Program (DCPP) • Wellness program (smoking cessation exercise, nutrition) 8.3% (103) of total patients served in 2011 were diabetic

6. Problem Statement Currently, HCHC does not have a current guideline in place to guide the organized management and clinical care of diabetic patients , and has no formal process for educating AmeriCorps members about diabetes.

7. Theoretical Framework • Social Learning Theory • Identifies psychological principles that govern human behavior within the framework of social learning (Bandura, 1969) • Attempts to explain how people think and what factors determine their behavior Albert Bandura

8. Social Learning Theory http://recap.etr.org/recapp/index.cfm?fuseaction=pages.TheoriesDetail&PageID=380

9. Theoretical Framework • Theory of Self-efficacy • The belief in one's capabilities to organize and execute the courses of action required to manage prospective situations (Bandura, 1995) • Strategies for enhancing self-efficacy in chronic disease management: • Skill mastery • Role modeling • Persuasion • Re-interpretation of symptoms • Problem-solving • Decision making • Action planning

10. Critical Appraisal of the Evidence • Databases searched: • MEDLINE, CINAHL, Cochrane, PubMed, National Guideline Clearinghouse • Search terms: • Chronic disease, chronic illness, self-management, self-care, diabetes mellitus type 2, indigent care & community health center • Intervention-type question used for search: • In adult diabetic patients at CHCs (P), how does implementation of an organized, comprehensive program promoting long-term disease management and risk reduction strategies (I), compared to usual practice (C), affect elements of chronic disease management (O)?

11. Critical Appraisal of the Evidence • The literature consistently supported: • The notion that getting patients actively involved in management of their chronic illness is essential to improving care (Adams et al. 2009; Allen et al., 2011; Fan & Sidani, 2009) • Combined education about diabetes disease management and behavioral strategies to improve outcomes, and as integral component of diabetes care (McGowan, 2011) • Programs in support of this to be incorporated into routine diabetes care as an adjunct to the clinical services delivered by health professionals (Fan & Sidani, 2009; McGowan, 2011).

12. Purpose To integrate current best evidence and recommended practice guideline into the development of an organized system of care at HCHC, and to improve the delivery of care by both physician and non-physician team members.

13. Project Implementation • AmeriCorps Education • Presentation to AmeriCorps staff • Clinical Worksheet for organizing diabetic patient data • Physician Training • Updated clinical guideline with supplemental materials • Template design with links to patient educational materials

14. AmeriCorps Education Overview of Diabetes Mellitus: What it is? http://www.youtube.com/watch?v=MHlWM8_iqfA What causes it?http://www.youtube.com/watch?v=PoTcXzXlW1g&feature=relmfu How it affects the body http://www.youtube.com/watch?v=xgygHpgqcYA&feature=relmfu

15. AmeriCorps Education How to live successfully with it http://www.youtube.com/watch?v=eEhmO_HOVFw&feature=relmfu Healthful eatinghttp://www.youtube.com/watch?v=XsBHg1SeeoM&feature=relmfu Exercisehttp://www.youtube.com/watch?v=NuCwjyjHmYw&feature=relmfu Medication http://www.youtube.com/watch?v=d73H9nEJHM&feature=relmfu

16. Physician Training Diabetes Care Templates: • Diabetes 3 month follow-up • Diabetes mellitus, type 2 • Diabetes & Renal manifestations • Diabetes & Ophthalmic manifestations • Diabetes & Neurological manifestations • Diabetes & Circulatory complications

17. Template Example • Subjective • C/C - diabetes mellitus, type 2 • 3 month f/u • HPI - Diabetes mellitus • Last follow-up was______ ago • Lab testing has included_____ • Last HbA1c was _______% • Response to therapy: • --> at or below goal • --> above goal • Sugars have been running: • _____ first thing in the morning • _____ pre-prandial • _____ post-prandial • _____ random • Complications _____________

18. Template Example Immunizations: Current Medications: Medical History Allergies: Surgical History: Family History: Social History: ROS: Objective: Vitals: Past Results: Last lipid profile_________ Last clinical foot exam________ Last dilated eye exam_________ Physical Exam:

19. Diabetes-related Patient Education • Control your BP through Lifestyle • Diabetes & Diet • Diabetes & Infections • Diabetic Ketoacidosis • Diet & Health • Exercise • Health Risks of Obesity • High Fiber Diet • Counting Carbohydrates (if you do not use insulin)

20. Diabetes-related Patient Education • Hyperosmotic Nonketotic Coma • Low Blood Sugar in People with Diabetes • Nerve Damage caused by Diabetes • Prevention of Type 2 Diabetes • The ABCs of Diabetes • Type 1 Diabetes • Type 2 Diabetes • Using Insulin • Should I switch to an insulin pump?

21. Data Collection and Analysis • Retrospective audit of charts for: • Consistent use of diabetes care templates in EMR • Documentation of asking patients about blood glucose self-monitoring • Documentation of lipid profile within the past year • Documentation of most recent clinical foot exam • Documentation of dilated eye exam within past year

22. Data Collection and Analysis • Sample of all adult diabetic patients seen by physicians at HCHC for one month after physician training session • Data collected on abstraction tool and each patient record coded to match the abstraction tool • Descriptive analyses completed in aggregate

23. Instruments

24. Notes on Foot Exam Monofilament Exam Indicate if the patient can feel the monofilament with (+), or if patient can NOT feel the monofilament with (-) in the 6 circles on the foot diagram: Condition of Skin: Intact / Cracked / Ulcerated Other ______________________________________________________________ Sensation - Intact / Not intact / Other ______________________________________________________________ Circulation – Pedal Pulses Total number of (+) sensory sites ______/12

25. Project Outcomes • 1. Impact on AmeriCorps members • 2. Impact on Practice

26. Project Outcome 1 • Impact on AmeriCorps members • Increased level of diabetes-related knowledge & enhanced ability to create links between patients and appropriate community resources and services • Positive impact on ability to teach & perform foot care reported • Standardized training for incoming AmeriCorps members

27. Project Outcome 2 • Impact on Practice • Increased use of standardized diabetic patient education materials by physicians • Inconsistent use of templates by the physicians • Detected resistance to certain EBP standards in routine diabetes care

28. Discussion • Support for expanded roles for non-physician team members in diabetes management (patient advocates & coaches) • Armed with knowledge, AmeriCorps CHWs create meaningful links between patients and appropriate community resources and services

29. Discussion • Physicians more likely to discuss foot care and eye care when problems present, than as preventative service • Perceptions about disadvantaged, uninsured patients receiving screening and preventative services • Challenges: • Short time-frame • Physician non-adherence • Staff turnover • Issues related to template design

30. Implications for Advanced Practice Nursing • Change agent for the way health systems manage patients with chronic illness • Use of strategies that emphasize prevention and early interventions to delay complications • Programs that focus on getting patients more involved • Preparation of a manuscript for publication

31. Implications for Advanced Practice Nursing • Integration of alternative ways to providing personalized education and behavioral support • For long-term support of self-management efforts • To ease the burden of complex treatment regimens • Role of the APRN as a team member • Support for team-based care • Leader of effective, efficient coordination and delivery of health care services

32. Questions