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PA cAARds!
An integrated intervention for diabetes and tobacco control professionals and paraprofessionals
Marlin L. Williams, MBADiabetes SymposiumNovember, 17 2010
Training Objectives• Improve understanding of statewide and local resources for
diabetes education and management and tobacco cessation services
• Improve understanding of integrated strategies and identify where organizations fit into the organizational integration continuum
• Encourage you to attend PA cAARds! Training• Increase the use of the Ask Advise Refer brief intervention in
diabetes and tobacco programs • Increase the use of PA cAARds among community based
health care organizations
PA cAARds!
• PA cAARds! is the first integrated initiative of its kind in Pennsylvania and a unique collaborative effort between the Pennsylvania Department of Health’s Diabetes and Tobacco Prevention and Control Programs
PA cAARds! Is funded by the Pennsylvania Department of Health
Problem
133 million people, or almost half of all Americans live with a chronic condition. That number is projected to increase by more than one percent per year by
2030, resulting in an estimated chronically ill population of 171 million
Tobacco Use is one of the single most modifiable risk factors of ALL chronic diseases
Data from www.improvingchroniccare.org. 2008
Problem• In 2007, it was estimated that 26.3 million individuals or 7.8%
of the US population were diabetic. Of those, 5.7 million were undiagnosed. (CDC, 2008)
• A study published in the December issue of Diabetes Care suggests that the number of Americans with diabetes is expected to nearly double by 2034 (Diabetes Care, 2009)
• Smoking represents the leading cause of preventable death in the Unites States; Responsible for 1 in 5 deaths (CDC, 2009)
• In Pennsylvania, there are more than 764,000 adults diagnosed with diabetes and approximately 17% of them smoke. (CDC 2005, BRFSS 2006)
Smoking & Diabetes
A dangerous combination
• Smoking increases the harmful effects of diabetes by making diabetes more difficult to control (JRSPH, 1998)
• Smoking increases diabetes-related complications that include blindness, kidney disease, heart disease, and neuropathy (JRSPH, 1998)
Tobacco Use & Diabetes Tobacco use…..• narrows blood vessels contributing to high blood pressure, heart disease
and poor circulation in those with diabetes(CDC, 2004).• increases insulin resistance and deteriorating diabetes control (Diabetes
Care, 1999)• increases the risk for Peripheral Arterial Disease, multiplying the
likelihood of amputations by 5. (of people with diabetes who need amputations, 95% are smokers)(Diabetes Care, 2001)
• is suggested in studies to be an independent risk factor for type 2 diabetes (JAMA, 2007)
• doubles the risk of heart disease in people with diabetes (approximately 65% of people with diabetes die from heart disease and stroke (CDC, 2005)
For nonsmokers…
• Approximately 60% of non-smokers have biological evidence of TSP exposure
• The combination of diabetes and secondhand smoke.• raises the risk of developing glucose intolerance• decreases the ability of the pancreas to make insulin• reduces the insulin sensitivity in people with type -2
diabetes
Smokeless tobacco products• Spit, oral, chew, snuff and dip are not safe
alternatives to smoking.
• People who dip or chew get comparable amounts of nicotine to regular cigarettes.
• Chew tobacco is high in sugar.
Economic Toll
• In 2004, cost for diabetes hospitalization in PA reached $673 million and accounted for more than 131,000 hospital days. (PADOH, 2007)
• Over the past five years, total costs in PA reached $2.6 billion and accounted for more than 649,000 hospital days. (PADOH, 2007)
• Direct health care and lost productivity costs due to smoking related illness are estimated for PA to be over $8.5 billion annually. (PADOH, 2008)
Due to the complex and overwhelming relationship between diabetes and tobacco use/exposure, addressing the harmful impact requires an integrated approach that emphasizes communication across disciplines.
Solution
• The goal of PA cAARds! is to proactively address the dual risks of unmanaged diabetes and tobacco use by maximizing utilization of regional and statewide resources.– educate health care and other CBOs providing diabetes
and/or tobacco cessation in an integrated brief intervention and referral process
– work with these organizations to sustain integrated tobacco, diabetes, and other chronic disease efforts.
PA cAARds!
• Integrated brief intervention and referral process where diabetes and tobacco professionals are trained to use the Ask, Advise, Refer intervention with their patients/clients
• The Ask, Advise, Refer model integrates the “5 A’s” (Ask, Advise, Assess, Assist, Arrange)
• Ask/Advise/Refer based on ADHA’s/SCLC’s adaptation of 5A’s
PA cAARds!
• Adapted from California’s Do you cAARd? Program
• Adapted to Pennsylvania
• Bidirectional between diabetes and tobacco
Development Process
Literature review and environmental scanRecruited diabetes and tobacco control key
stakeholdersFacilitated a planning summitSolicited regional review and feedback Solicited DOH FeedbackPilot the initiative
Implementation
Intervention
• Primary tool in addressing the dual risks of unmanaged diabetes and tobacco use/exposure
• Facilitate cross referral • Do not need to be cross-disciplinary experts• “Brief” Intervention• Group & Individual Settings
Intervention
Motivational Interviewing• a directive, client-centered counseling style for
eliciting behavior change by helping clients to explore and resolve ambivalence.
The art of getting people to do what you want them to do because they want to do it.
(Dwight Eisenhower)
Referral
Goal: Facilitate cross referral to get patients/clients into appropriate services.
• Option of choosing between local or statewide services
• Provide referral tool (available on website and in your packets)
• Complete referral tracking form
Referral
• Local Resources Referral Lists and Regional Prescription
– Community diabetes management/education programs– Community tobacco cessation programs
• Statewide Resources ( Take Charge Card ordered thru the website)
– PA Free Quitline• Community based health care organizations use Fax referral form
along with the Take Charge Card)
– American Diabetes Association
Quitline (Diabetes Providers) (1-800-Quit Now)• Free evidence-based, individualized phone cessation
counseling • Multiple counseling sessions to callers committed to
quit– Work with clients to set a quit date– Offer information about medications– Recommend tactics for dealing with urges– Provide suggestions for reducing triggers to smoke– Provide referrals to local cessation providers
National Diabetes Help Line (1-800-Diabetes)(1-888-Diabetes regional office)
• Center for Information & Community Support• Provides information on managing diabetes and nutrition• Local educations classes• Support groups
Referral Tools
• Take Charge Card (statewide diabetes management/education and tobacco cessation)– Fax Referral provided in tandem with the Take Charge
Card (Diabetes professionals/paraprofessionals)
• Regional Prescription Pad (local referrals)
Fax Referral
• PA DOH tobacco prevention and control program is partnering with PA cAARds! to pilot the fax referral process with community based health care providers
• Fax referral will serve as a tool to facilitate referral to the PA Quitline which is the statewide resource for PA cAARds!
Fax Referral
• Links the services of the Quitline directly to your patients with your help.
• Tobacco users no longer have to take the first step in calling the quitline.
• Quit coach pro-actively contacts your patients to provide an intervention after receiving a fax referral from you.
Technical Assistance
• Provide technical assistance related to integration readiness and implementation outreach and strategies to build organizational capacity
– Providing training to utilize an evidence-based curriculum alone does not guarantee that a program will be successfully adopted within an organization
– HPC will also provide ongoing comprehensive technical assistance (TA) for organizations participating in the training workshops to implement and sustain PA cAARds
Technical Assistance
Programmatic T/A– help address and resolve any issues or questions regarding
curriculum, tools , state and/or local resources and referrals (website)
Intensive T/A– Increase organizational capacity to sustain integrated
diabetes, tobacco and other chronic disease efforts (Leadership buy-in, Policy Development, Systems Change)
Integration Continuum
CommunicationFully Linked or INTEGRATED
CooperationCoordination PartnershipCollaboration
Not Linked
Not Linked -We don’t work together at all and have separate program goals.
Communication –We share information only when it is advantageous
Cooperation –We share information and work together when any opportunity arises
Coordination - We work side-by-side (independently) to achieve common program goals
Collaboration – We work side-by-side and actively pursue opportunities to work together
Partnership – We work together with specified responsibilities to achieve common program goals
Fully Linked or Integrated – We mutually plan, share staff and/or funding resources and evaluate activities to accomplish our common goals.
Integration Model adapted from NACDD Tobacco Program Integration Report 2004
Website
• PA cAARds web portal is a trainee-specific tool that allows you to:– Download curriculum, tools and materials– Receive technical assistance– Communicate with the project staff and other
trainees (message board and blog)– Report referrals and success stories– Access national and local resources (i.e. articles,
toolkits, data reports etc.)
Continuing Education Credits
• UPMC• Dietician, Social Work, Nursing, General Health Care
Professional• 5.5 credit hours• Credit Designation • Course Evaluation
North East Training
December 1, 2010 10am – 4pm
Monroe County Public Safety Center100 Gypsum Road, Suite 2Stroudsburg, Pa 18360
To register please visit www.pacaards.org
THANK YOU
on behalf of……..
Pennsylvania Department of HealthDiabetes Prevention & ControlTobacco Prevention & Control
Health Promotion Council
Acknowledgements
BE A BRIDGE PartnershipCalifornia Diabetes ProgramCalifornia Smoker’s Helpline
Regional Advisory Council Members and Other Key Stakeholders
