Meeting the Challenge of Meeting the Challenge of Patient-Centered Care: Patient-Centered Care:

Diabetes EducationDiabetes Education

Roberta Eis, RN, MBA Roberta Eis, RN, MBA

Sr. Program Manager, Diabetes Initiatives, HFHSSr. Program Manager, Diabetes Initiatives, HFHS

Pamela Milan, RD, CDE, MBAPamela Milan, RD, CDE, MBA

Operations Manager, Diabetes Care Centers, HFHSOperations Manager, Diabetes Care Centers, HFHS

What is Diabetes What is Diabetes Self-Management Education?Self-Management Education?

Diabetes Self-Management Education (DSME) is Diabetes Self-Management Education (DSME) is a crucial element of care for all people with a crucial element of care for all people with diabetesdiabetes

DSME is necessary in order to improve patient DSME is necessary in order to improve patient outcomesoutcomes

National Standards are designed to assist National Standards are designed to assist diabetes educators in providing evidence-based diabetes educators in providing evidence-based informationinformation

Henry Ford Health System has five “Diabetes Henry Ford Health System has five “Diabetes Care Centers” offering DSME, using traditional Care Centers” offering DSME, using traditional educational approaches until 2008.educational approaches until 2008.

Why Change?Why Change?

New national standards for Diabetes Self Management New national standards for Diabetes Self Management Education (DSME) were released in June 2007, new Education (DSME) were released in June 2007, new version expected in 2012. version expected in 2012.

The new standards challengedThe new standards challenged American Diabetes American Diabetes Association (ADA) Recognized Programs to Association (ADA) Recognized Programs to develop a develop a curriculum delivered in a creative, patient-centered curriculum delivered in a creative, patient-centered approachapproach, encouraging patients set the agenda for their , encouraging patients set the agenda for their education.education.

AimAim

To shift from primarily didactic presentation model to a To shift from primarily didactic presentation model to a facilitator stylefacilitator style..

To To standardized DSME class formatstandardized DSME class format for all sites while allowing for all sites while allowing instructors to individualize the presentation to the groups as instructors to individualize the presentation to the groups as needed.needed.

To To maintain the programs’ high customer satisfactionmaintain the programs’ high customer satisfaction rating rating while aligning to the new process.while aligning to the new process.

To develop curriculum exemplifying the To develop curriculum exemplifying the use of action-oriented, use of action-oriented, behavioral goals & objectivesbehavioral goals & objectives delivered in a creative, delivered in a creative, interactive and patient-centered method of education.interactive and patient-centered method of education.

To To maintain best practicesmaintain best practices from the established past from the established past curriculum: depression screening and education tool kits.curriculum: depression screening and education tool kits.

The Patient-Centered Education ModelThe Patient-Centered Education ModelConversation MapConversation Map® educational tool® educational tool created by Healthy created by Healthy Interactions, Inc. in conjunction with the ADA and supported Interactions, Inc. in conjunction with the ADA and supported by Merck & Co., Inc. was adopted.by Merck & Co., Inc. was adopted.

Map is a large tabletop display tool with colorful visual Map is a large tabletop display tool with colorful visual images & metaphors, with printed cards is used to images & metaphors, with printed cards is used to initiate initiate various discussion topics.various discussion topics.

The diabetes educatorThe diabetes educator engages engages a group of a group of patientspatients seated seated around the map in around the map in interactive discussions and exercisesinteractive discussions and exercises..

The map is navigated sequentially with The map is navigated sequentially with content specific to content specific to the DSME educational curriculumthe DSME educational curriculum for each session. for each session.

Patients are central part of the learning processPatients are central part of the learning process, and , and through the group model they discover and share many through the group model they discover and share many challenges in managing the disease. challenges in managing the disease.

Diabetes Conversation Map Diabetes Conversation Map ®®

Conversation MapConversation Map®® Session Session

Teaching the TeachersTeaching the Teachers

The change process evolved over time and required a The change process evolved over time and required a tiered learning approach for the diabetes educatorstiered learning approach for the diabetes educators. .

All diabetes educators attended a half-day workshop All diabetes educators attended a half-day workshop provided by Healthy Interactions representatives on the provided by Healthy Interactions representatives on the introduction and use of the Diabetes Conversation Mapintroduction and use of the Diabetes Conversation Map®® in February 2008.in February 2008.

In the first groups attending this workshop, two In the first groups attending this workshop, two educators embraced the new model and agreed to be educators embraced the new model and agreed to be early adoptersearly adopters. They . They piloted the curriculumpiloted the curriculum at their site. at their site.

A meeting was held with the entire DSME staff to gain A meeting was held with the entire DSME staff to gain team acceptance of the new teaching method.team acceptance of the new teaching method.

Educators Still Not ReadyEducators Still Not Ready

2

5

6

0

1

2

3

4

5

6

Not Ready 2 3 Very Ready

How ready are you to start using the Conversation Map tools as a stand-alone approach to patient education?

Not Ready

2

3

Very Ready

Long Road to New SkillsLong Road to New Skills

The staff were encourage to attend the Taylor pilot site The staff were encourage to attend the Taylor pilot site to observe classes which provided opportunity for to observe classes which provided opportunity for on-site on-site mentorship supportmentorship support..

In order to assist the staff with transitioning to facilitation In order to assist the staff with transitioning to facilitation of groups, of groups, a workshop on advance facilitation skillsa workshop on advance facilitation skills was was conducted by a master trainer from Healthy Interactions, conducted by a master trainer from Healthy Interactions, Inc. Inc.

The staff still struggled with adaptation to the facilitation The staff still struggled with adaptation to the facilitation model, so multiple training sessions were provided on model, so multiple training sessions were provided on motivational interviewingmotivational interviewing..

Standardization and Best Practices Standardization and Best Practices

The standardized curriculum The standardized curriculum blended the best practicesblended the best practices of of the the traditional DSMEtraditional DSME class content like education tool kits, class content like education tool kits, practice with labels & food models and other hands on practice with labels & food models and other hands on activities activities with the new education stylewith the new education style..

Training in health literacyTraining in health literacy was completed. This knowledge was completed. This knowledge was used as the basis for revising standardized patient was used as the basis for revising standardized patient education materials. education materials.

Depression screening was a core component of DSME Depression screening was a core component of DSME program that we wanted to maintain. After numerous program that we wanted to maintain. After numerous iterations, we have now iterations, we have now successfully incorporated successfully incorporated depression screeningdepression screening in the initial assessment. in the initial assessment.

Maintain High Customer Maintain High Customer Satisfaction ScoresSatisfaction Scores

4.84.8

4.7

4.8

4.7

4.84.8

4.8

4

4.2

4.4

4.6

4.8

5

5.2

5.4In

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ctor

s kn

owle

dgea

ble

Com

fort

able

to

ask

ques

tions

The

pro

gram

wor

thw

hile

Wou

ldR

ecom

men

d

PRE

POSTLikert Scale:

1 to 5

Satisfaction Survey Results Pre and Post Diabetes Conversation Map® Implementation

Improved Patient Engagement in Improved Patient Engagement in ClassesClasses

Average Class Completion Rates for the Diabetes Care Center Sites Pre and Post Diabetes Conversation Map

Implementation

74%

62%

53%

65%

83% 82% 80% 82%

71%

80%

68%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Taylor SterlingHeights

Fairlane Columbus NewCenter

Program

Pre

Post

Sites were less than 1 year in operation – mixed model to start not totally didactic.

15% Increase in Class Completion15% Increase in Class Completion

9%7%

12%

20%18%

15%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Taylor SterlingHeights

Fairlane Columbus New Center Program

% Change in Completion Rates after Diabetes Conversation Map Program Implementation

Three years after change

Patient Centered CarePatient Centered Care

Patients teach each other: Patients teach each other: – We can hold up a divided plate to discuss We can hold up a divided plate to discuss

portion sizes, but when a patient shares his portion sizes, but when a patient shares his personal weight loss story by using the small personal weight loss story by using the small plate his wife started a month ago, the impact plate his wife started a month ago, the impact is much greater. is much greater.

Patients support/bond with each other:Patients support/bond with each other:– At one site the group set up an email based At one site the group set up an email based

support group.support group.

Participant Behavioral Outcomes Participant Behavioral Outcomes 20102010

N = 553N = 553

# who # who Selected Selected

GoalGoal# Reporting # Reporting

SuccessSuccess% Met % Met GoalGoal BenchmarkBenchmark

Healthy Eating 248 181 73% 60%

Being Active 210 126 60% 60%

Monitoring 27 23 85% 60%

Taking Medications 9 8 89% 60%

Problem Solving 5 5 100% 60%

Healthy Coping 8 5 63% 60%

Reducing Risk 32 23 72% 60%

Unknown 14 10 71% 60%

Behavior goal categories based on AADE7 Self-Care Behaviors™

Self Reported Behavior Change Self Reported Behavior Change 20102010

N = 313 Less Often No Change More Often # of responses % of more often

Testing your blood sugar level 21 137 146 304 48%

Handling your stress or coping 10 163 131 304 43%

Taking your medications as directed 5 173 108 286 38%

Caring for your feet 5 130 167 302 55%

Eating smaller portions 18 70 214 302 71%Your amount of

activity/exercise 18 131 152 301 50%

Your amount of smoking 18 109 6 133 5%

   Yes No # of responses % of yes

Keeping doctor appt every 4 to 6 months 293 8 301 97%

Impact of Diabetes EducationImpact of Diabetes Education

Patient FeedbackPatient Feedback

““Learning from other patients with diabetes like myself Learning from other patients with diabetes like myself and being able to discuss my concerns was very and being able to discuss my concerns was very helpful.”helpful.”

““The other participants made the classes fun and The other participants made the classes fun and interesting. It’s good to know we are not alone.”interesting. It’s good to know we are not alone.”

““These classes told and helped me learn about things These classes told and helped me learn about things that my doctor could not have done for me. Thank you!!”that my doctor could not have done for me. Thank you!!”

Lessons LearnedLessons Learned

Accept that change is evolutionary and takes time, Accept that change is evolutionary and takes time, especially when staff are entrenched in the current process. especially when staff are entrenched in the current process. Communication and engagement skills, positive Communication and engagement skills, positive reinforcement and patience are crucial.reinforcement and patience are crucial.

Realization that staff who have developed a lifelong Realization that staff who have developed a lifelong teaching style need to be thoroughly trained in a new style teaching style need to be thoroughly trained in a new style of education.of education.   ““Early adoptingEarly adopting”” colleagues colleagues made the made the best best trainers for the process.trainers for the process.

Teamwork is essentialTeamwork is essential in providing quality patient care. in providing quality patient care. Collaboration between nurses, dietitians, behavioral nurse Collaboration between nurses, dietitians, behavioral nurse practitioners and management was essential to the practitioners and management was essential to the development of appropriate evidence-based diabetes development of appropriate evidence-based diabetes education curriculum.education curriculum.

Lessons LearnedLessons Learned

The patientThe patient’’s agenda for learning needs to be considered s agenda for learning needs to be considered in the development of an education program. The in the development of an education program. The Conversation MapConversation Map®® environment of learning, allows environment of learning, allows patients to learn from each other and results in more patients to learn from each other and results in more enthusiasm with the informationenthusiasm with the information delivered. delivered.  

Attempting a new approach that fostered engagement Attempting a new approach that fostered engagement trumped the inclination to remain static, i.e., trumped the inclination to remain static, i.e., ““WeWe’’ve ve always done it this wayalways done it this way””. .

A consistent, standardized approach results in more A consistent, standardized approach results in more reliable, replicable outcomesreliable, replicable outcomes and increased and increased transportability transportability of the programof the program..

Continuous Improvements Continuous Improvements Since ImplementationSince Implementation

Establish a Establish a Peer Review processPeer Review process to maintain to maintain consistency throughout the Diabetes Care Centers.consistency throughout the Diabetes Care Centers.

Share Share class completion ratesclass completion rates to investigate trends for to investigate trends for process improvement with DSME Staff each month.process improvement with DSME Staff each month.

The program has The program has changedchanged patient feedback surveys & patient feedback surveys & program follow up to program follow up to reflect the patient-centered, healthy reflect the patient-centered, healthy behavior questions.behavior questions.

Continue to collect data to look for additional ways to Continue to collect data to look for additional ways to improve diabetes outcomesimprove diabetes outcomes..

Continue tracking race, sex, gender data to look for Continue tracking race, sex, gender data to look for trends in healthcare disparitiestrends in healthcare disparities and possible program and possible program improvement.improvement.

QuestionsQuestions