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MARTHA PELAEZ, PH.D.HEALTHY AGING REGIONAL
COLLABORATIVE OF SOUTH FLORIDA
Diabetes and Multiple Chronic Conditions in a Geriatric
Population
Agenda
Complexities of managing multiple chronic conditions in a geriatric population
The three legged stool for managing diabetes in older adults
The Stanford Patient Education Center model for Diabetes Self Management
“I want you to quit smoking and lose 35 pounds. Then I want you to come back and tell me how the hell you did it.”
Caption adaptedfrom Bizarro, UniversalPress, 1997.
PREVALENCERISK FACTORS
HEALTH CARE COST
Complexities of managing multiple chronic conditions in a geriatric population
PREVALENCE
Number of Chronic Conditions per Medicare Beneficiary
Number of Conditions
Percent of Beneficiaries
Percent of Expenditures
0 18 1
1 19 4
2 21 11
3 18 18
4 12 21
5 7 18
6 3 13
7+ 2 14
63% 95%
http://partnershipforsolutions.org/
Percent of Adults Reporting Diabetes Mellitus by Age and Sex, 2004-2005
0 2 4 6 8 10 12 14 16 18 20
18-24
25-44
45-64
50-64
65-74
75-84
85 and over
Male Female
Percent (%)
Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007
Diagnosed and Undiagnosed Diabetes Among Persons Age 65 and Over (age-adjusted) by Sex, 2001-2004
0
5
10
15
20
25
30
Total diabetes Diagnosed Undiagnosed
Male Female
Perc
en
t (%
)
Data source: Trends in Health and Aging web-site, National Health and Nutrition Examination Survey, accessed July 2007
Percent of Persons Age 65 and Over (age-adjusted) Reporting Diabetes Mellitus by Sex and Race/Ethnicity, 2004-2005
0
5
10
15
20
25
30
Hispanic White non-Hispanic Black non-Hispanic
Male Female
Perc
en
t (%
)
Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007
Distribution of Age at Diagnosis of Diabetes Among Adult Incident Cases Aged 18–79 Years, United States, 2008
In 2008 68% of the adult
incident cases (i.e, cases diagnosed within past year) of diabetes were diagnosed between the age of 40 and 64 years.
About 15% were diagnosed before the age of 40 and about 17% were diagnosed at age 65 or older.
Percentage of Civilian, Non-institutionalized Population with Diagnosed Diabetes, by Age, United States, 1980–
2009
From 1980 through 2009, the percentage of diagnosed diabetes increased in all age groups. In general, throughout the time period, people aged 65–74 years had the highest percentage, followed by people aged 75 or older, people aged 45–64 years, and people younger than 45 years of age.
In 2009, the percentage of diagnosed diabetes among people aged 65–74 (19.9%) was over 11 times that of people younger than 45 years of age (1.7%).
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
People with Chronic Conditions Suffer
Tired of lacking in energy
In physical pain
Stressed
Depressed or unhappy
Angry
34%
32%
22%
14%
7%
45%
39%
42%
36%
42%
Always/frequently Occasionally
79%
71%
64%
50%
49%
Americans Speak Out about Life with Chronic Conditions; National Survey of Americans Aged 44+January 2009, http://www.ncoa.org/improving-health/chronic-disease/healthier-lives.html
Where’s the Help?38% Feel
Abandoned45% Feel Unheard 45% Not Connected
“I’m tired of feeling on my own when it comes to taking care of my health problems.”
“I’m tired of describing same conditions or problems every time I go to a hospital or doctor’s office.”
“I’m not told about other people who can help with health problems (classes, dieticians, health educators).” www.ncoa.org/improving-health/chronic-disease/healthier-lives
RISK FACTORS
Percent of Persons Age 65 and Over (age-adjusted) Participating in Leisure-Time Physical Activity by Sex, 1998-2005
0
5
10
15
20
25
30
1998-1999 2000-2001 2002-2003 2004-2005
Male
Female
Perc
en
t (%
)
Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007
Measured Obesity by Age, Selected Years
0
10
20
30
40
50
60
70
80
25-44 45-64 50-64 65-74 75 and over
1988-1994 2001-2004
Perc
en
t (%
)
Data source: Trends in Health and Aging web-site, National Health and Nutrition Examination Survey, accessed July 2007
HEALTH CARE COSTS
Health Care Expenditure for Medicare Beneficiaries Age 65 and Over (age-adjusted) With and Without Diabetes by Type of
Service, 2003
0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000
Other
Outpatient hospital
Prescription medicine
Long-term care facility
Physician/Supplier
Inpatient hospital
Total
No Diabetes
Diabetes
2003 Dollars
Data source: Trends in Health and Aging web-site, Medicare Current Beneficiary Survey, accessed July 2007
Average Health Care Expenditure of Medicare Beneficiaries Age 65 and Over (age-adjusted) with Any Chronic Condition and Diabetes,
1992-2003
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Diabetes
Any chronic condition
200
3 d
oll
ars
Data source: Trends in Health and Aging web-site, Medicare Current Beneficiary Survey, accessed July 2007
CHRONIC CARE MODELTREATMENT, EDUCATION, SELF-MANAGEMENT SKILLS BUILDING
The three legged stool for managing diabetes in older adults
Informed,ActivatedPatient
ProductiveInteractions
Prepared,Proactive
Practice Team
Delivery
SystemDesign
Decision
Support
ClinicalInformati
onSystems
Self-Managemen
t Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
Improved Outcomes
Chronic Care Model for Diabetes Patient
Diagnosis and Treatment
Diabetes
Education
Self management Skills
and Support
Improved Outcomes
The Case of Maria
Nancy is a 66 year old women, recently diagnosed with type 2 Diabetes and Hypertension. She suffers from chronic pain due to Osteoarthritis and has Depressive symptoms.
Nancy lives with a younger sister who works full time; she is a loner and tends to isolate herself from social and physical activity.
Mary’s contact with health care providers….
The Physician prescribes four medications: Metformin; Benicar HCT; Glipizide and Lipitor.
The diabetes educator teaches her about the disease and the need to monitor her glucose in order to prevent complications. Classes are very informative and she gets motivated to do everything she can to avoid loosing her sight or get very sick. The healthy eating classes are great and she even buys walking shoes to start a walking program.
What happens?
Nancy becomes frustrated with the meds side effects.
Changing eating habits is difficult and besides, no meal is complete without dessert.
Her walking routine never gets going due to her arthritis and knee pain.
Nancy has a low degree of self-efficacy so she is convinced that she just has to learn to live with diabetes -- there is not much she can really do to change this.
What else could you offer Nancy?
Can a program designed to increase self-efficacy help improve Nancy’s diabetes?
The Stanford Diabetes Self Management, in a randomized control trial program participants were able to show a decrease in HbA1c.
•PROGRAM PHILOSOPHY
•PROGRAM APPROACH TO BUILDING SELF EFFICACY AND EMPOWER FOR SELF CARE MANAGEMENT
•PROGRAM OUTCOMES
The Stanford Patient Education Center
Diabetes Self Management
28
Stanford Chronic Disease Self Management Program: Background
Self-Management: A Key to Effectiveness & Efficiency in Care of Chronic DiseaseThe present health care system is neither effective or efficient in addressing chronic care because it was designed for acute disease. For effective treatment of chronic disease, the patient must engage continuously in different health care practices (Holman & Lorig, 2004)
The Chronic Disease Self-Management Program (CDSMP) is based on self-efficacy theory (Bandura,1977) which states: Self-management skills are learned and behavior is self-directed. Person-centered definition of the problem and person-selected
targets for improvement. Motivation and confidence in managing one’s conditions dictate
success. The social environment (work, family, health care provider)
support or impede progress.
CDSMP is a patient self-management education course, designed for adults 18+ with any chronic condition(s), that has three underlying assumptions: patients with different chronic diseases have
similar self-management problems and disease-related tasks;
patients can learn to take responsibility for the day-to-day management of their disease(s); and
confident, knowledgeable patients practicing self-management will experience improved health status and will utilize fewer health care resources (Lorig, el.al. 1999).
Diabetes Self-Management Program (DSMP)
Based on the Chronic Disease Self-Management Program developed at Stanford.
Content is based on focus groups with diabetes educators and people with diabetes and meets the content standards of both the ADA and the AADE.
The DSMP was originally written in Spanish for a research project funded by the National Institute of Nursing Research.
DSMP Assumptions
People with diabetes have similar concerns and problems
People with diabetes must deal not only with their disease(s), but also with the impact these have on their lives and emotions.
Lay people with diabetes, when given a detailed Leader’s Manual, can teach the Program as effectively, than health professionals
The process or way the Program is taught is as important, if not more important, than the subject matter that is taught.
DSMP Research Outcomes
The study results demonstrated that participants, as compared with people who did not take the workshop, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits. At one year, the improvements were maintained.
Self efficacy is improved in the following ways…
Goal setting, making an action plan, feedback and sharing on a weekly basis
Modeling Reinterpreting symptomsPersuasion
This is not a workshop to learn facts. It is a workshop designed to teach skills that will make people better self-managers.
Workshop Overview
Overview of self-management and diabetes
Making an action planMonitoringNutrition/healthy eatingFeedback/problem-solvingPreventing low blood
sugarPreventing complicationsFitness/exerciseStress managementRelaxation techniques
Difficult emotionsMonitoring blood sugarDepressionPositive thinkingCommunicationMedicationsWorking with health
care professionals and system
Sick daysSkin and foot careFuture plans
35
Stanford Diabetes Disease Self Management Program meets the standards for accreditation by the American Association of
Diabetes Educators (AADE) and American Diabetes Association (ADA)
The program is delivered during an eight week intervention including:
Individual assessment conducted by the program’s primary qualified instructor (PQI), a registered nurse. Based on the results of the individual assessment an education plan is developed. A key component of the individual assessment is the establishment of individualized goals and self-management support strategies.
Group intervention. Series of 6 sessions, 1 session per week, 2-1/2 hours per session held in community settings and led by two peer leaders or health promoters. Ideally, at least one facilitator has a diabetes. Peer modeling is a core component of the Stanford model. The peer leaders are supervised by the PQI while they use a highly scripted manual with an established curriculum.
Follow-up assessment by the PQI to review the effectiveness in achieving the goals of the individualized educational plan. This review provides the PQI the opportunity to augment and modify the participant’s disease self-management plan, if necessary.
Take Home Message
Gaps in quality care lead to thousands of avoidable deaths each year.
Best practices could avoid the accelerated increase in health care cost.
Patients recognize the need to change behaviors but may not be feel that they are able to do anything about it.
Increasing self-efficacy will decrease morbidity/frailty in older years.
Diabetes Educators and Community Based Self-Management Programs are two key ingredients in supporting improved outcomes for persons with diabetes.
