LCDR C. Fredette, BSN, CCHP, RN CDR R. Hunter Buskey, DHSc, CCHP, PA-C

1. LCDR C. Fredette, BSN, CCHP, RN CDR R. Hunter Buskey, DHSc, CCHP, PA-C

2. OBJECTIVES: Review unique characteristics of inmates with diabetes Highlight clinical practice guidelines for correctional diabetic management Discuss practical methods to increase active inmate participation in diabetes management that incorporate personal behavior change Review glucose meter distribution program for inmates

3. DIABETES PREVELENCE: 438 million worldwide by 2030 25 million United States = 8% of US Population 7th leading cause of death 2007 International Diabetes Federation (IDF); Centers for Disease Control and Prevention (CDC); Bureau of Justice Statistics (BJS)

4. DIABETES RISK FACTORS: Non-Modifiable • African American, Native American, Hispanic • Family history • Chronic illnesses Modifiable • Food choices • Physical activity • Weight

5. FEDERAL INMATE PROFILE White 57.2 African-American 39.2 Other 3.2 Hispanic 32.2 Non-Hispanic 67.8 Bureau of Justice Statistics , 2009

6. CHALLENGES FOR INMATES WITH DIABETES • Lifestyle • Health literacy and education • Culture • Health numeracy • Non-formulary drugs • Motivation • Health beliefs

7. SURGEON GENERAL’S National Prevention Strategy Injury and violence free living Tobacco free living Preventing drug abuse and excessive alcohol use Healthy Eating Active Living Mental and emotional well being Reproductive and sexual health

8. COST FOR DIABETES CARE US diabetes related costs 2007: 174 billion; 116 billion for direct medical care Inmate average health care costs $7.15/day Range from $2.74-$11.96 US Department of Health and Human Services, 2011 The Council for State Governments, 2004; 1998 survey

9. Chronic disease management models for diabetes • Screening, diagnostic, therapeutic • Categories for increased risk • Testing • Target goals • Assessment of glycemic control All Guidelines Guidelines

10. ADA Treatment Goals Glycemic control HBA1C < 7.0% Preprandial plasma glucose 90-130 mg/dl Peak postprandial plasma glucose <180 mg/dl Blood pressure < 130/80 mmHg Lipids LDL <100 mg/dl Triglycerides < 150 mg/dl HDL > 40/mg/dl Weight BMI Targets

11. FACILITY TIMELINE • 2004 – Medical record review revealed clinical improvement opportunities for diabetic inmates (physical assessment, medication, patient education) • 2005 – FCC Butner designation “Diabetes Center of Excellence” (DICE) • 2006 – Committee launched diabetes awareness programs for staff and inmates, now annual • 2007 – inmate education classes, re-established target clinical outcomes • 2008 – initiation of inmate self monitoring blood glucose program

12. INMATE CHARACTERISTICS: • ~20% known or at risk are in diabetes chronic care clinics • Disproportionate number of federal inmates are overweight; many take anti-psychotics which can cause obesity • Predominately Hispanic, African American

13. INMATE BARRIERS TO ACHIEVING TARGET GOALS Inmate contributions to food choices – commissary, menu Lockdowns Insulin timing Lack of community support Comorbidities

14. Quality Improvement The continual assessment of health care delivery to improve outcomes and reduce medical errors Areas to improve include: Appropriate utilization of medical services based on evidence, reduce service variability, address disparities, improve communication, increase patient-centered care, incorporate technology Agency for Healthcare Research and Quality (AHRQ), 2012

15. Performance Improvement Priorities Monitoring Parameters for Control and Complications • Every Visit • 3-6 months • Annual Blood Pressure Foot Exam Weight, Waist Circumference HBA1c Every 3 months (for poor control ):Initiate/change medication Every 6 months for stable control Dilated Eye Examination Lipid Levels* Microalbumin * Every 2 years if levels fall in lower risk categories American Diabetes Association. Clinical Practice Recommendations. Diabetes Care.

16. FACILITY DIABETES STATISTICS • Majority Type 2 • 25% at or below target goals* • ~500 insulin users • Insulin use inevitably rises * estimated by random hemoglobin A1c review

17. FACILITY INSULIN EXPENDITURES 1866 10614 46K 42K Increase in insulin expenditures from 2010 to 2011 No significant change in Metformin or SFU costs Significant decrease in TZD costs Sulfonyurea = SFU; Thiazolidines = TZD

18. PHARMACY COSTS FOR DIABETES MEDICATIONS* • Insulin is associated with the greatest staff resource** • Insulin is associated with increased risk for medical errors, medical emergencies and morbidity *2010/2011 data; does not include lancets, needles, syringes, alcohol swabs, gauze, band aids **insulin prep time, pill line time, triage and emergency interventions

19. Federal Bureau of Prison Inmate Self monitoring program Agency glucose meter distribution program initiated in 2008 for inmate insulin users Considerations: Staff apprehension Oversight Education Cost Accountability Continuity during transfers Hundreds of glucose meters issued since program inception Noticeably Less Medical Emergencies D 50

20. PROGRAM REVIEW OUTCOMES Hemoglobin A1c (HBA1c) Values by groups   Minimum Maximum Mean Std. Deviation Group one n=10 Target Glycemic Control Pre baseline 5.9 6.8 6.4 0.3Ø Post baseline 5.9 6.9 7.0 1.0 Group two n=29 Mild-Moderate Glycemic Control Pre baseline 7.1 9.5 8.1 0.7 Post baseline 7.1 9.5 8.7 1.4 Group three n=22  Poor Glycemic Control Pre baseline 9.6 14.8 10.7 1.2 Post baseline 9.6 12.2 10.0 1.1 N=61 HBA1c expressed as %

21. CLINICIAN BARRIERS Definition of good glycemic control (treatment complacency) Accountability for glycemic monitoring and interventions Complexity: BS, BP, lipids, weight, personal behaviors for the incarcerated Specialist and expert availability

22. GOALS FOR PATIENT CENTERED CARE Education Nutritional support Physical activity Medications Self-monitoring blood glucose (SMBG) √ √ √ √ √

23. NEXT STEPS-TIME TO WORK TOGETHER Health Services 1200 Marshalls Custody INMATE 2100 1500 Commissary Food Service 1800 Unit Management Recreation

24. MOVING FORWARD Group medical visits Group session for education; train the trainer Staff and inmate lead physical activity sessions Quality of life groups for psychosocial support Foot clinic – Best Practice Self-Management clinic (food, activity, medication and insulin) Certified Diabetic Educator resources; Bureau of Prisons has issued an announcement for regional diabetic nurse consultants Inmate self referrals (dental, eye, foot care) Community partnerships – health fair, education for credit

25. What we learned is we cannot manage diabetes without a strategic self-management plan

26. Thank You… FCC Butner, Diabetes Center of Excellence Committee (DICE) Quality Management Department

27. QUESTIONS?