An Innovative Analysis of a Citywide Approach to Diabetes Self-Management Education in Camden, NJ

Francine Grabowski MS, RD, CDE; Steven Kaufman MD; Nadia Ali MPA; Andrew Katz

ABSTRACT RESULTS

FACILITATING/HINDERING FACTORS

TARGET POPULATION

INTRODUCTION

Goals: The primary goal of the Camden Citywide Diabetes Collaborative (CCDC) DSME program is to improve clinical outcomes and develop innovative strategies to reinforce DSME within Camden City primary care practices.

Method: Patients are referred to our DSME class through our network of community primary care providers and other community services. The four part weekly DSME class is held in two geographically different location each month. One class is English speaking and the other is Spanish speaking. Individual assessments are done at the start of each class followed by two hours of group learning. Communication is constant between the CDE and the patients primary care physician.

Target Population: Our target population for diabetes self-management education is Camden residents who receive their health care at one of our 12 participating primary care practice sites. Out of these 12 practices, 4 actively refer their patients with a diagnosis of diabetes.

Outcome Measures: Outcome measures include clinical (HbA1c) and attendance data (# classes attended, location of DSME class, instructor) collected in the Camden Citywide Diabetes Collborative Patient Tracking Database over a six month period.

Evaluation Results: Baseline and follow-up clinical data are reported for a sample of 21 patients who have attended at least 1 or more classes during a six-month period (November 2011-April 2012), with a decrease of mean HbA1c values from 9.9 to 8.3.

A patient is considered a DSME graduate if they have attended at least 4 classes. Of this sample, 15 graduated the program, and of the 15, 66% of patients had a decrease in their A1c levels. An analysis of attendance across English and Spanish DSME classes over a six-month period indicated similar rates between two groups. Across both groups there were lower attendance rates in the early months and highest attendance and completion (attendance of 4 classes) during November and December indicating seasonal variation.

The CCDC uses a multifaceted approach to improve diabetes care at the patient, provider and commu-nity level. The Collaborative aims to increase the capacity of community-based, primary care practices to provide comprehensive, proactive care to their patients with diabets and increase diabetes self-management education referrals and attendance. This is a report on the process and current outcomes of our diabetes self-management education efforts.

Facilitating Factors:• Personalization of interventions• Attention to cultural competency and patient engagement• Respectful consistent presence in providers offices• Use of community health workers as patient liaisons• City-wide tracking database• Project/Clinical management dyad to optimize clinical outcomes

Hindering Factors:• Limited Spanish speaking diabetes educators• Patients have competing health, financial or family issues• Patients are in pre-contemplation and contemplation stage of change• Undocumented patients with lack of resources for medication• Implementation of multi-level interventions• Limited support from providers and/or front office staff• Frequent change in patient phone number and address

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percent of population with at least 1 visit Diabetics by ZIP

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15.6%

17.0%

An average of 23.5% of each practices’ patients has dia-betes. The general population of Camden City, New Jersey is 48% African American and 47% Hispanic resi-dents. 36.1% of families live below the federal poverty level, 62% of residents over the age of 25 have a high school equivalency degree, and 40% of households report that they use a language other than English at home.

Camden City has distinct neighborhood communitities. The north and east communities primarily speak Spanish (Mexican, Puerto Rican and Dominican) and the southern communities are English speaking.

DSME A endance by Language 2011-2012 Year English Spanish Total 2011 91 71 162 2012 69 53 122 Total 160 124 284

DSME Referral breakdown 2011-2012 Number of Referring Physicians 35 Number Referred by source:

Physicians Other Total:

191 93

284

Gradua on Percentage: (# pts a ended 4 classes/# pts a ended 1st class)

November December January February March April

English 75 40 27 23 67 20 Spanish 0 100 50 0 67 82

CONCLUSIONPatients and providers need years of support to change culture. Baseline and follow up data from the primary care provider is necessary to optimize DSME and is a powerful resource to determine efficacy and of the intervention. New approaches are needed to engage patients and practices. Multi-disciplinary collaboration to tackle the challenges surrounding community based DSME.

An analysis of attendance across English and Spanish DSME classes over a six-month period indicated similar rates of referral between the two groups. Across both groups there were lower attendance rates in the early months of the yearand highest completion (attendance of 4 classes) during Novem-ber and December indicating a potential seasonal variation.

• Number of Patients who attended all four class types: 128• Total Classes attended: 1304• Average days between first and last re corded DSME attendance: 65 days• People attend same class multiple times.• People engage in classes for around 2 months.

• 21 patients who have attended at least 1 or more classes during a six-month period (November 2011-April 2012): decrease of mean HbA1c from 9.9 to 8.3• Graduates of Program: 15 patients• Percentage of graduates who showed decrease in HbA1c: 66%

STEPS TO DSME

Implementing DSME in the Community

Starting a community based DSME is a multi-faceted project that invovles engagement of all levels of provider office staff, community partners and patients. Here are the 9 steps to implementation:

1. Development of culturally and literacy competent patient education materials and curriculum, hiring of Spanish speaking CDE, establishing an educational culture of high patient expectations, and ac- quire relevant materials(local food sample labels, restaurant examples, etc).2. Establish patient friendly DSME location sites.3. Assess practice needs and current DM clinical practice. Access provider’s patient health record data for information regarding visits and diabetes quality metrics. Identify their unique strengths, goals, experiences, values, culture, and belief systems while re specting their timelines for change.4. Determine the need for and assign roles of program coordinator, practice liaison, pa tient advocate, scheduler, and community health worker.5. Meet with representatives of sites to discuss DSME referral, insulin training needs, pre ferred mode of communication, and decide on approach based on readiness of practice.6. Establish supportive, unified DSME referral process with referring primary providers to optimize referrals.7. Offer educational and decision support opportunities to clinical and office staff to en hance skills of diabetes management and empower staff members in practice transfor mation.8. Develop, implement, and track improvement measures.9. Periodically evaluate and review the process of DSME referrals and practice transformation/outcomes with clinical staff.

• Class 4: Exercise and Milk, Fruit and Vegetables

• Class 2: Medicine Reconciliation, How to Use and Code a Meter, Keeping Blood Glucose Logs, and Starches

• Class 3: Eating and Testing Blood Glucose, Review, and Fat and Protein

• Class 1: Complications of Diabetes, HbA1c and Sugary Drinks