Anna Marshall, BSN, MSN candidateDecember 10, 2012

Implementing Best Practice in Diabetes Care: An Intervention to Improve Practice in the Community Health Care Setting

• Background

• Problem Statement

• Theoretical Framework

• Critical Appraisal of the Evidence

• Purpose

• Project Implementation

• Project Outputs

• Discussion

• Implications for Advanced Practice Nursing

Overview of Presentation

• Chronic disease – Annually, 7 out of 10 deaths among Americans from chronic

disease – Long-term management is challenging and requires an

organized, integrated approach

• Diabetes– Common, costly & preventable – 346 million people worldwide with diabetes (WHO, 2012) – On the rise worldwide, projected to increase 165% between

2000-2050– Fastest increases occurring in older and minority

subpopulations(Venkat Narayan, Boyle, Thompson, Sorenson, & Williamson, 2003)

Background of the Problem

• Community Health Centers (CHCs)– Deliver care to some of the most vulnerable

populations– Improve access to screening & preventative

services

• Role of AmeriCorps staff – As community health workers (CHW) to improve

functional capacity of CHCs

Background of the Project

• Heartland Community Health Center– Kansas Safety Net Clinic– Primary care services– Specialty services

• Case management• Diabetes Care & Prevention Program (DCPP)• Wellness program (smoking cessation

exercise, nutrition)

8.3% (103) of total patients served in 2011 were diabetic

Background of the Project

Currently, HCHC does not have a current guideline in place to guide the organized management and clinical care of diabetic patients , and has no formal process for educating AmeriCorps members about diabetes.

Problem Statement

• Social Learning Theory– Identifies psychological principles that govern

human behavior within the framework of social learning (Bandura, 1969)

– Attempts to explain how people think and what factors determine their behavior

Theoretical Framework

Albert Bandura

Social Learning Theory

http://recap.etr.org/recapp/index.cfm?fuseaction=pages.TheoriesDetail&PageID=380

• Theory of Self-efficacy– The belief in one's capabilities to organize and

execute the courses of action required to manage prospective situations (Bandura, 1995)

– Strategies for enhancing self-efficacy in chronic disease management:• Skill mastery• Role modeling• Persuasion• Re-interpretation of symptoms• Problem-solving• Decision making• Action planning

Theoretical Framework

• Databases searched:– MEDLINE, CINAHL, Cochrane, PubMed, National

Guideline Clearinghouse• Search terms:

– Chronic disease, chronic illness, self-management, self-care, diabetes mellitus type 2, indigent care & community health center

• Intervention-type question used for search:– In adult diabetic patients at CHCs (P), how does

implementation of an organized, comprehensive program promoting long-term disease management and risk reduction strategies (I), compared to usual practice (C), affect elements of chronic disease management (O)?

Critical Appraisal of the Evidence

• The literature consistently supported:– The notion that getting patients actively involved in

management of their chronic illness is essential to improving care (Adams et al. 2009; Allen et al., 2011; Fan & Sidani, 2009)

– Combined education about diabetes disease management and behavioral strategies to improve outcomes, and as integral component of diabetes care (McGowan, 2011)

– Programs in support of this to be incorporated into routine diabetes care as an adjunct to the clinical services delivered by health professionals (Fan & Sidani, 2009; McGowan, 2011).

Critical Appraisal of the Evidence

To integrate current best evidence and recommended practice guideline into the development of an organized system of care at HCHC, and to improve the delivery of care by both physician and non-physician team members.

Purpose

• AmeriCorps Education• Presentation to AmeriCorps staff• Clinical Worksheet for organizing

diabetic patient data

• Physician Training• Updated clinical guideline with

supplemental materials• Template design with links to patient

educational materials

Project Implementation

Overview of Diabetes Mellitus:

What it is? http://www.youtube.com/watch?v=MHlWM8_iqfA

What causes it? http://www.youtube.com/watch?v=PoTcXzXlW1g&feature=relmfu

How it affects the body http://www.youtube.com/watch?v=xgygHpgqcYA&feature=relmfu

AmeriCorps Education

How to live successfully with it http://www.youtube.com/watch?v=eEhmO_HOVFw&feature=relmfu

Healthful eating http://www.youtube.com/watch?v=XsBHg1SeeoM&feature=relmfu

Exercise

http://www.youtube.com/watch?v=NuCwjyjHmYw&feature=relmfu

Medicationhttp://

www.youtube.com/watch?v=d73H9nEJHM&feature=relmfu

AmeriCorps Education

Physician Training

Diabetes Care Templates:

• Diabetes 3 month follow-up

• Diabetes mellitus, type 2• Diabetes & Renal

manifestations• Diabetes & Ophthalmic

manifestations• Diabetes & Neurological

manifestations• Diabetes & Circulatory

complications

SubjectiveC/C - diabetes mellitus, type 2

3 month f/uHPI - Diabetes mellitus

Last follow-up was______ agoLab testing has included_____Last HbA1c was _______%

Response to therapy:--> at or below goal--> above goal

Sugars have been running: _____ first thing in the morning_____ pre-prandial_____ post-prandial_____ random

Complications _____________

Template Example

Immunizations: Current Medications:Medical HistoryAllergies:Surgical History:Family History:Social History:ROS:Objective:Vitals:Past Results:

Last lipid profile_________Last clinical foot exam________Last dilated eye exam_________

Physical Exam:

Template Example

• Control your BP through Lifestyle

• Diabetes & Diet

• Diabetes & Infections

• Diabetic Ketoacidosis

• Diet & Health

• Exercise

• Health Risks of Obesity

• High Fiber Diet

• Counting Carbohydrates (if you do not use insulin)

Diabetes-related Patient Education

Diabetes-related Patient Education

• Hyperosmotic Nonketotic Coma

• Low Blood Sugar in People with Diabetes

• Nerve Damage caused by Diabetes

• Prevention of Type 2 Diabetes

• The ABCs of Diabetes

• Type 1 Diabetes

• Type 2 Diabetes

• Using Insulin

• Should I switch to an insulin pump?

• Retrospective audit of charts for:– Consistent use of diabetes care templates in EMR

– Documentation of asking patients about blood glucose

self-monitoring

– Documentation of lipid profile within the past year

– Documentation of most recent clinical foot exam

– Documentation of dilated eye exam within past year

Data Collection and Analysis

• Sample of all adult diabetic patients seen by physicians at HCHC for one month after physician training session

• Data collected on abstraction tool and each patient record coded to match the abstraction tool

• Descriptive analyses completed in aggregate

Data Collection and Analysis

Instruments

Used template?

Yes - 22 of 33 No - 11 of 33

Asked pt. about blood glucose self-monitoring

Lipid profile w/in past 12 mo.

Footexam w/in 12 mo.

Dilated eye exam w/in 12 mo.

1 Yes 21 of 22 charts (95.5%)

19 of 22 charts

6 of 22 charts

6 of 22 charts

2 no 7 of 11 charts (63.6%)

11 of 11 charts

1 of 11 charts

1 of 11 charts

3 Totals 28 of 33 charts (84.8%)

30 of 33 (90.9%)

7 of 33 (21.2%)

7 of 33 (21.2%)

Notes on Foot ExamMonofilament ExamIndicate if the patient can feel the monofilament with (+), or if patient can NOT feel the monofilament with (-) in the 6 circles on the foot diagram:

Indicate if pulses are present with (+), or absent with (-):

Right Left

Dorsalis pedis

Posterior tibial

Condition of Skin: Intact / Cracked / Ulcerated Other ______________________________________________________________

Sensation - Intact / Not intact / Other ______________________________________________________________

Circulation – Pedal Pulses

Total number of (+) sensory sites

______/12

• 1. Impact on AmeriCorps members

• 2. Impact on Practice

Project Outcomes

• Impact on AmeriCorps members

– Increased level of diabetes-related knowledge & enhanced ability to create links between patients and appropriate community resources and services

– Positive impact on ability to teach & perform foot care reported

– Standardized training for incoming AmeriCorps members

Project Outcome 1

• Impact on Practice

– Increased use of standardized diabetic patient education materials by physicians

– Inconsistent use of templates by the physicians

– Detected resistance to certain EBP standards in routine diabetes care

Project Outcome 2

• Support for expanded roles for non-physician team members in diabetes management (patient advocates & coaches)

• Armed with knowledge, AmeriCorps CHWs create meaningful links between patients and appropriate community resources and services

Discussion

• Physicians more likely to discuss foot care and eye care when problems present, than as preventative service

• Perceptions about disadvantaged, uninsured patients receiving screening and preventative services

• Challenges: – Short time-frame– Physician non-adherence– Staff turnover– Issues related to template design

Discussion

• Change agent for the way health systems manage patients with chronic illness– Use of strategies that emphasize prevention

and early interventions to delay complications– Programs that focus on getting patients more

involved• Preparation of a manuscript for publication

Implications for Advanced Practice Nursing

• Integration of alternative ways to providing personalized education and behavioral support– For long-term support of self-management

efforts– To ease the burden of complex treatment

regimens

• Role of the APRN as a team member– Support for team-based care– Leader of effective, efficient coordination and

delivery of health care services

Implications for Advanced Practice Nursing

Questions