lcdr c. fredette, bsn, cchp, rn cdr r. hunter buskey, dhsc, cchp, pa-c

LCDR C. Fredette, BSN, CCHP, RNCDR R. Hunter Buskey, DHSc, CCHP, PA-C

OBJECTIVES:Review unique characteristics of inmates with diabetes

Highlight clinical practice guidelines for correctional diabetic management

Discuss practical methods to increase active inmate participation in diabetes management that incorporate personal behavior change

Review glucose meter distribution program for inmates

DIABETES PREVELENCE:

438 million worldwide by 2030

25 million United States = 8% of US Population

7th leading cause of death 2007

International Diabetes Federation (IDF); Centers for Disease Control and Prevention (CDC); Bureau of Justice Statistics (BJS)

DIABETES RISK FACTORS:

Non-ModifiableAfrican American, Native American, HispanicFamily historyChronic illnesses

ModifiableFood choicesPhysical activityWeight

FEDERAL INMATE PROFILE

White 57.2

African-American 39.2

Other 3.2

Hispanic 32.2

Non-Hispanic 67.8

Bureau of Justice Statistics , 2009

CHALLENGES FOR INMATES WITH DIABETES

LifestyleHealth literacy and educationCultureHealth numeracyNon-formulary drugsMotivationHealth beliefs

SURGEON GENERAL’S National Prevention Strategy

Injury and violence free living

Tobacco free living

Preventing drug abuse and excessive alcohol use

Healthy Eating

Active Living

Mental and emotional well being

Reproductive and sexual health

COST FOR DIABETES CARE

US diabetes related costs 2007: 174 billion; 116 billion for direct medical care

Inmate average health care costs $7.15/day

Range from $2.74-$11.96

US Department of Health and Human Services, 2011

The Council for State Governments, 2004; 1998 survey

IDF AACE ADA ADA Inmate NCCHC FBOP

Evidenced based, cost effective levels of care

Aggressive, comprehensive Team based care

Well and sick care for diverse populations

Early assessment, staff training and coordination of resources

Emphasize self-management, Quality improvement

Primary care provider team, strive for target goals

6.5 6.5 7.0 7.0 7.0 7.0

Chronic disease management models for diabetesScreening, diagnostic, therapeutic Categories for increased riskTestingTarget goalsAssessment of glycemic control

All Guidelines

Guidelines

Glycemic control

HBA1C < 7.0%

Preprandial plasma glucose 90-130 mg/dl

Peak postprandial plasma glucose <180 mg/dl

Blood pressure < 130/80 mmHg

Lipids

LDL <100 mg/dl

Triglycerides < 150 mg/dl

HDL > 40/mg/dl

ADA Treatment Goals

Weight BMI Targets

FACILITY TIMELINE2004 – Medical record review revealed clinical

improvement opportunities for diabetic inmates (physical assessment, medication, patient education)

2005 – FCC Butner designation “Diabetes Center of Excellence” (DICE)

2006 – Committee launched diabetes awareness programs for staff and inmates, now annual

2007 – inmate education classes, re-established target clinical outcomes

2008 – initiation of inmate self monitoring blood glucose program

INMATE CHARACTERISTICS:

~20% known or at risk are in diabetes chronic care clinics

Disproportionate number of federal inmates are overweight; many take anti-psychotics which can cause obesity

Predominately Hispanic, African American

INMATE BARRIERS TO ACHIEVING TARGET GOALS

Inmate contributions to food choices – commissary, menuLockdownsInsulin timingLack of community supportComorbidities

Quality Improvement

The continual assessment of health care delivery to improve outcomes and reduce medical errors

Areas to improve include:Appropriate utilization of medical services based on evidence, reduce service variability, address disparities, improve communication, increase patient-centered care, incorporate technology

Agency for Healthcare Research and Quality (AHRQ), 2012

Performance Improvement Priorities

Monitoring Parameters for Control and Complications

Performance Improvement Priorities

Monitoring Parameters for Control and Complications

Every Visit

3-6 months

Annual

Blood PressureFoot ExamWeight, Waist Circumference

HBA1cEvery 3 months (for poor control ):

Initiate/change medicationEvery 6 months for stable control

Dilated Eye ExaminationLipid Levels*Microalbumin

* Every 2 years if levels fall in lower risk categoriesAmerican Diabetes Association. Clinical Practice Recommendations. Diabetes Care.

FACILITY DIABETES STATISTICS

Majority Type 2 25% at or below target goals*~500 insulin usersInsulin use inevitably rises

* estimated by random hemoglobin A1c review

FACILITY INSULIN EXPENDITURES

Increase in insulin expenditures from 2010 to 2011No significant change in Metformin or SFU costsSignificant decrease in TZD costs

46K42K

106141866

Sulfonyurea = SFU; Thiazolidines = TZD

PHARMACY COSTS FOR DIABETES MEDICATIONS*

Insulin is associated with the greatest staff resource**

Insulin is associated with increased risk for medical errors, medical emergencies and morbidity

*2010/2011 data; does not include lancets, needles, syringes, alcohol swabs, gauze, band aids

**insulin prep time, pill line time, triage and emergency interventions

Federal Bureau of Prison Inmate Self monitoring program

Agency glucose meter distribution program initiated in 2008 for inmate insulin users

Considerations:Staff apprehensionOversightEducationCostAccountability Continuity during transfers

Hundreds of glucose meters issued since program inception

Noticeably Less Medical EmergenciesD 50

PROGRAM REVIEW OUTCOMESHemoglobin A1c (HBA1c) Values by groups

  Minimum Maximum Mean Std. Deviation

Group one n=10 Target Glycemic Control

Pre baseline 5.9 6.8 6.4 0.3 Ø Post baseline 5.9 6.9 7.0 1.0

Group two n=29 Mild-Moderate Glycemic Control

  Pre baseline 7.1 9.5 8.1 0.7

Post baseline 7.1 9.5 8.7 1.4

Group three n=22  Poor Glycemic Control

Pre baseline 9.6 14.8 10.7 1.2

Post baseline 9.6 12.2 10.0 1.1

N=61 HBA1c expressed as %

CLINICIAN BARRIERS

Definition of good glycemic control (treatment complacency)

Accountability for glycemic monitoring and interventions

Complexity: BS, BP, lipids, weight, personal behaviors for the incarcerated

Specialist and expert availability

GOALS FOR PATIENT CENTERED CARE

Education

Nutritional support

Physical activity

Medications

Self-monitoring blood glucose (SMBG)

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NEXT STEPS-TIME TO WORK TOGETHER

Health Services

Unit Management

CustodyMarshalls

Food ServiceCommissary

Recreation

INMATE 1500

1200

1800

2100

MOVING FORWARD Group medical visits

Group session for education; train the trainer

Staff and inmate lead physical activity sessions

Quality of life groups for psychosocial support

Foot clinic – Best Practice

Self-Management clinic (food, activity, medication and insulin)

Certified Diabetic Educator resources; Bureau of Prisons has issued an announcement for regional diabetic nurse consultants

Inmate self referrals (dental, eye, foot care)

Community partnerships – health fair, education for credit

What we learned is we cannot manage diabetes without a strategic self-management plan

Thank You…

FCC Butner, Diabetes Center of Excellence Committee (DICE)

Quality Management Department

QUESTIONS?