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