Making Diabetes Self-Management Education Patient-Centered: Results From a North Carolina Program
Paige Johnson Cartledge, RN, BSN
At present in the United States, 29 million individuals have diabetes1 and 86 million have prediabetes, and the CDC estimates that 9 of every 10 persons with prediabetes are unaware of the condition.2 The annual financial toll of the disease is $245 billion in healthcare and lost productivity costs, according to the American Diabetes Association (ADA).3
How can we change these statistics? Based on my experiences as a nurse and diabetes educator, we will not be effective in fighting the nation’s diabetes epidemic without more foot soldiers in the trenches alongside our patients. It’s during this day-to-day work that we, as diabetes educators, spend time with our patients—evaluating them and encouraging them. Once we understand the daily barriers to success, we can make adjustments for when life happens.
In October 2014, Northwest Medical Partners of Mount Airy, North Carolina, created a Diabetic Center of Excellence. (The practice has since joined Northern Family Medicine of Surry County.4) From inception, this center was designed to produce measurable and reportable patient outcomes and, when possible, to reduce the amount of medication patients needed while improving glycated hemoglobin (A1C) levels.5 The overall goal of this program is to equip each patient with the resources, tools, and empowerment to achieve a quality of life that comes with effective management of diabetes. In the short term, the primary aim of this program is to help patients achieve A1C levels at or below 7.0%, in line with recommended ADA targets.6
Background of Northwest Medical Partners
D. Nelson Gardner, MD, founded Northwest Medical Partners in 2000 (now part of Northern Family Medicine) to provide care consistent with the principles of the Cooper Institute in Texas. The Cooper Institute’s mission is built around preventive health and the value of exercise. With that front-and-center, the institute works with leading academic institutions on scientific research in these areas.7 Gardner built a 30,000-square-foot facility that included a primary care practice, a pharmacy, and a medically directed weight loss program. The facility also featured a fully equipped fitness center featuring an indoor/outdoor pool, a basketball court, and an exercise room. This early vision positioned Northwest Medical Partners for the shift that came in 2010, when the Affordable Care Act (ACA) promoted the transition from fee-for-service to value-based medicine.8 By the time the ACA became law, the weight loss and smoking cessation initiatives were already designed as outcomes-based programs.
Our experience with patients enrolled in the weight loss program revealed that a subset of this group would benefit from a different education program, one that focused on diabetes management. A pilot program was proposed for 30 patients with A1C levels of at least 8.0%; the average A1C for this initial group was greater than 9.0%. The new program would allow evaluation of a patient-centered approach, while offering the opportunity to test value-based principles that would affect the private practice as it transitioned to risk-based reimbursement.
The program design promotes highly individualized disease management. Our unpublished data show that this intense interaction produces results, which cannot be achieved without support. We enrolled our first 30 patients in October 2014 and have since expanded to 116 patients—this includes patients with baseline A1C levels below 8.0%. Here, we report data through June 2015 for 58 patients for whom we had a baseline A1C and who successfully complied with the program (see Compliance below). These patients saw an average A1C reduction of 2.4%. The majority of the patients enrolled in the program have type 2 diabetes (T2D). The greatest A1C reductions, both numerically and on a percentage basis, have occurred in patients who are between 31 and 60 years of age (Figure 1) and who have had diabetes for anywhere between 5 and 10 years.
Program Design A vital component of the program is an evidence-based, 4-step pattern management approach that allows our Diabetes Center of Excellence to optimize therapy and engage patients in order to improve program outcomes. This approach includes simple, easy-to-use healthcare provider implementation and patient engagement tools to integrate and teach these concepts in a practice setting. This was particularly appealing since our plan was to duplicate the program.
The 4 steps are:
Step 1. Identify the patient’s chief glycemic abnormality. The patient learns about 3 priorities: reducing hypoglycemic events, reducing fasting hyperglycemia, and reducing postprandial hyperglycemia. Step 2. Determine the frequency and timing of priority events for each patient. Step 3. Investigate potential causes for these events. Step 4. Develop an action plan to reduce events.
Participants in our program engaged with blood glucose meters in the Accu-Chek 360° Diabetes Management System, made by Roche.9 Patients used either the Accu-Chek 360° Aviva model (Aviva; 17.5%); the Aviva Expert model, which includes a bolus advisor for patients using multiple daily injections (61.3%); or the Accu-Chek Aviva Combo (Combo) insulin pump (19.2%).
As education is crucial to patient success, we designed classes that met both corporate needs and the individual needs of our patients. Classes have 10 to 12 attendees to ensure adequate attention to personal needs. A small group medical visit is led by a physician’s assistant, who serves as program director, and a class on medication is taught by a pharmacist. Other units are presented by the program coordinator, who is a registered nurse. A series of 6 sessions, given once a month, involves the following:
Class 1. Patients are introduced to diabetes terms and the “diabetes triangle” of care, which calls for improved glucose levels, limited glucose variability, and avoidance of hypoglycemia through diet, exercise, and medication adherence.10 Patients are asked to complete the Roche Accu-Chek 360° View Tool, which offers a snapshot of blood glucose patterns over 3 days.11 This tool empowers patients to take ownership of their diabetes diagnosis; it places them on common ground, helps them recognize behavior patterns, and aids them in understanding the effects of diabetes and the consequences of noncompliance with a treatment regimen.
Class 2. The program director conducts a small group medical visit using a shared appointment model that includes 1-on-1 medical consultations that focus on individual care plans, which are derived from the Accu-Chek 360° View Tool.
Classes 3 through 5. These classes focus on carbohydrate counting, reading food labels, and meal planning. Classes are highly interactive and give patients a sense of normalcy. Many have commented that these classes “make them feel they are not alone in this crazy world of diabetes.”
Class 6. A pharmacist introduces terms in pharmacology and questions patients on the pertinent points in the program. Patients are instructed on how to use a maintenance guideline tool to closely track A1C levels. An informal, verbal knowledge test is given at the conclusion.
Program Advancement. The program began in October 2014 without additional dedicated funds. In March 2015, bonus payments received through the CMS Physician Quality Reporting System/Meaningful Use program were directed to support the initiative.12 Because the practice is aligned with a local hospital through a nonprofit partnership, the program has applied for and received a $148,500 grant from the Kate B. Reynolds Charitable Trust.13 With this step, the program is transitioning to a full diabetes self-management and support program.
Compliance. Patients who are receiving insulin attend monthly evaluations; however, A1C is measured quarterly. Those receiving oral medications also are evaluated quarterly. For the initial group of patients, 6 classes were required. Only the shared appointment with the physician assistant required a co-payment; the rest of the classes were free. Today, the program has been revised to 5 classes, which the participants must take to be in compliance.
Support. In addition to scheduled evaluations, all participants have ongoing access to the program coordinator, who is available for individual phone consultations. The program coordinator has advised individual patients on diet, activity, and medication adjustments during glycemic events, which has prevented trips to the emergency department and/or hospitalizations.
Input From Patients Is Key
As an integral part of the program, we have created a Patient Advisory Committee to further the goals of population health management within our personalized program model. We strive to provide a holistic preventive approach to patient care, so patients can be successful and bring about behavioral changes that improve their quality of life. Recommendations from the Patient Advisory Committee resulted in combining 2 of the original 6 classes into a single session. The curriculum reflects years of input from patients, starting with those in the practice’s weight loss clinic. Ours is an “in the trenches” approach that identifies individual patient needs and daily struggles. The program has a “home grown” character that reflects the values, socioeconomic status, and cultural realities for the patients we serve. For example, we address practical topics such as how to avoid sugary sweets when babysitting grandchildren. Meetings with the Patient Advisory Committee also led to the publication of a cookbook for people with diabetes,14 as well as 2 instructional videos on how to shop at the grocery store and how to prepare a healthy meal.
To obtain baseline A1C, we used either the most recent A1C result from the patient’s health records or the initial result after starting the program. The first 58 patients were evaluated in June 2015 and showed an average A1C reduction of 2.4% (Figure 1).
Reductions were seen across all age groups (15 to 30 years, 31 to 45 years, 46 to 60 years, 61 to 75 years, and 75 years and older), and 13 of the 53 participants who started with an A1C above 7% were able to attain A1C goal. The largest reductions were seen among patients with the highest A1C levels: of the 20 patients who began with an A1C ≥11%, 4 achieved the ADA recommended goal of <7% and 8 achieved an A1C between 7% and 8%.
The study showed a difference in results from patients using the Accu-Chek Aviva Expert meter relative to those who used the standard Aviva meter. This was especially true among patients 31 to 45 years and 61 to 75 years (Figure 2).
Patients using the Aviva Expert meter have been able to optimize their insulin doses; this allows them to use less insulin overall, resulting in weight loss and decreased glucose variability. Patients are encouraged by A1C reductions and the more accurate carb ratios produced by the 360° View tool, which allows them to see a relationship between behavioral change and improved results. By eliminating the effect of constantly “chasing a sugar,” as well as expected weight gain from insulin, patients show greater ability to maintain a healthy diet and exercise regimen.
Limitations Data from the following patients were not included:
1. Those who did not meet program compliance requirements of taking all class sessions
2. Those whose baseline A1C was not measured
3. Those who had not completed the 6-session program at the time of data collection.
The Diabetic Center of Excellence in Mount Airy, North Carolina, now part of Northern Family Medicine, has demonstrated that measurable reductions in A1C are achievable for patients with diabetes. The program director’s grandmother was a participant, having been diagnosed with T2D at the age of 71. By fully embracing the program, she began to exercise, make smarter food choices, and lose weight. She continued to drive herself to the facility’s gym for walks on a padded track until age 92. When she died at age 94, her A1C was 5.8%. This is the experience the program seeks to offer all participants: the opportunity for a high quality of life well into old age and a chance to spend time with loved ones.