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Evidence-Based Diabetes Management September 2018

Through "Information Shift" and Support, North Carolina Program Brings Dramatic A1C, Therapy Reductions

Mary Caffrey
A profile of a program that calls for residents in a rural area to become full partners in managing their type 2 diabetes, and in the process bring changes to their community.
Fighting diabetes in the hills outside Marion, North Carolina, is not easy. Though not technically part of the CDC’s designated “diabetes belt,”1 it’s just 90 minutes from where the area begins along Tennessee’s eastern border, and data show that 14.2% of the county’s residents have the disease.2

Rates like that will not fall by telling people to exercise and watch what they eat. In a place where it’s said that “gravy is its own food group,” people living with type 2 diabetes (T2D) must be retaught how to eat.

But it can be done, as Kimberly Freeman, RN, CDE, CIC, CTTS, and Michael Hanlon have shown. She is a nurse and certified diabetes educator in the Diabetes Program at Mission Hospital McDowell, part of Mission Health; he is the diabetes intervention director for the YMCA of Western North Carolina. Together they have built a partnership and a program with proven results: reductions of glycated hemoglobin (A1C) of 2%, reductions in blood pressure and resting heart rate, and a 50% increase in balance, a key indicator for preventing falls.

Called Taking Control of Type 2, or TCT2, the program has been so successful, it’s now a covered benefit for health system employees and is offered through Mission Health’s accountable care organization. Although Freeman and Hanlon do not guarantee that participants will reduce their need for medication, many have: “We’ve consistently seen a 56% decrease or elimination of medications for type 2, hypertension, hyperlipidemia—and there’s cost savings here,” Hanlon said. “There’s a level of passion around this program,” Freeman said.

Evidence of their success was published in July in The Diabetes Educator,3 the research-focused journal of the American Association of Diabetes Educators. In an interview with Evidence-Based Diabetes Management™, Freeman and Hanlon described their journey in building their program and their desire to teach other health professionals what they have learned.

Hanlon initially came to the YMCA in the rural area north of Asheville, North Carolina, to launch the Diabetes Prevention Program (DPP) there. This evidencebased, 12-month program has been studied for more than 15 years nationwide. It has been shown to keep more than half of those with prediabetes from progressing to type T2D over 3 years; among seniors, DPP’s success rate is even higher.4 After a community health assessment revealed a high level of T2D and a 73% level of obesity among the patients in the McDowell County area, it became clear that something had to be done.

Through a collaboration between the YMCA and Mission Health, Hanlon and Freeman developed a 28-session curriculum, using materials recognized by the American Diabetes Association, that offers people with T2D both clinical information and practical advice on how to shop, cook, and eat in ways that fit into their lives. The lessons are offered in a group setting of 12 to 15 participants, who must agree to follow the program for a year.

A yearlong commitment. The schedule resembles the original DPP, but after the initial phase of weekly sessions ends, the program switches to sessions every 2 weeks instead of once a month. “I never liked that,” Hanlon said, explaining that he felt that people who are trying to make lifestyle changes need more regular support, and evidence is accumulating to support this view. “It just doesn’t happen that quickly,” he said.

What it takes is an “information shift,” Freeman said, which calls for people with T2D to become partners with their clinicians in managing the disease. The first stage takes a more heavily clinical approach, as participants hear from certified diabetes educators, including registered dietitians, and other members of the diabetes health care team. “The first 16 weeks is the most intense and the most supported in terms of clinical expertise,” she said. 

The clinical background is critical for the next phase, which focuses on the more practical aspects of lifestyle management, such as managing carbohydrate intake and limiting hypoglycemia. “We’re setting them up to ask really good questions,” Hanlon said.

Learning what people of all ages can do. The partnership has broken down barriers—Mission Hospital McDowell and the YMCA have overcome transportation hurdles to enroll people who live up to 30 minutes away. They’ve encouraged primary care providers from all over the county to send patients to the program (a referral is required). Word of the success has spread: A competing health system sends patients, as well.

Freeman and Hanlon say they’ve shattered the beliefs some providers had about patients over 65 years of age. “[Some felt seniors] were set in their ways and weren’t going to have significant results,” Freeman said. “We didn’t listen. We admitted everyone—people in their late 70s, early 80s.”

“They were rocking!” Hanlon said.

What about spouses or caregivers? Yes, Hanlon said, spouses, partners, and best friends were welcome. “We immediately offered to include family members for the duration of the program,” Freeman said. A diagnosis of T2D affects a patient’s whole family, so it makes sense to engage all family members in the support process, from food tracking to shopping to setting goals.

And sometimes, the support person came back as a participant. 

Community-wide shifts. As the program grew, more graduates became advocates for healthy changes in their family, at their churches, and in their communities. Freeman and Hanlon described a shift in the community, as people asked for menu changes at local restaurants or for low-fat peanut butter at the supermarket. The Y logo now appears on healthy items added to local restaurant menus, which Hanlon calls “empowerment at its finest.”

“It was not something we were looking to do,” he said. “It was something we happened to witness.”

There are provisions for those who’ve completed the 12-month program to check in for additional support, and now the quest is to make the program itself as sustainable as the lifestyle it teaches. Initially funded through the Kate B. Reynolds Charitable Trust, the program receives some coverage from private payers and Medicare as Mission Health seeks reimbursement under Diabetes Self-Management Education and Support services. And the hospital has begun collecting monthly payments through the Chronic Care Management fee that CMS created in 2017 for health systems to manage care coordination of seniors who have more than 1 chronic condition, including diabetes.

Freeman and Hanlon are now working to bring the program to other YMCAs and federally qualified health centers, as well as health systems in other parts of North Carolina. 

What the program shows, Hanlon said, is the impact of supporting an individual in their own self-management over a sufficient period of time. The results can be significant, he said: “The 12-month program is really the beginning. It’s not the end.” 
References

1. CDC identifies diabetes belt. CDC website. cdc.gov/diabetes/pdfs/data/diabetesbelt.pdf. Accessed August 1, 2018.

2. County data. CDC website. cdc.gov/diabetes/data/county.html. Updated December 1, 2017. Accessed August 1, 2018.

3. Freeman K, Hanlon M, Denslow S, Hooper V. Patient engagement in type 2 diabetes: a collaborative community health initiative. Diabetes Educ. 2018;44(4):395-404. doi: 10.1177/0145721718784262.

4. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403. doi: 10.1056/NEJMoa012512.
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