1356 kruger slide handout file ver2 - rose rock group kruger/1356... · published online june 5,...

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Improving Patient Care Through Diabetes Self-‐management Education

Davida F. Kruger, MSN, APN-BC, BC-ADM Certified Nurse Practitioner Henry Ford Health System

Division of Endocrinology, Diabetes, Bone Disease Detroit, MI

Diabetes Self-‐management Educa4on and Support (DSME/S)

•  Diabetes is a chronic disease that requires the person with diabetes to make a mul7tude of daily self-‐management decisions and perform complex care ac7vi7es

•  DSME/S provides the founda7on to help people with diabetes navigate these decisions and ac7vi7es

•  DSME/S has been shown to improve health outcomes

•  DSME/S is the process of facilita7ng the knowledge, skill, and ability necessary for diabetes self-‐care

Powers MA, et al. Diabetes Care. 2015. Published online June 5, 2015.

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Diabetes A>tudes, Wishes and Needs (DAWN) Study •  The largest global psychosocial diabetes study ever undertaken

•  Objec7ve: to assess percep7ons and aHtudes regarding diabetes care among people with diabetes and health care professionals (HCPs)

•  Focus on psychological health, since studies have shown that psychological health is associated with beOer diabetes outcomes

Skovlund SE, et al. Diabetes Spectrum. 2005;18:136-142.

DAWN Study (cont’d)

•  Cross-‐sec7onal study •  Survey of 5000 adults with type 1 and type 2 diabetes mellitus

•  Survey of 4000 HCPs - PCPs - Specialists - RNs

•  13 countries


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Rubin RR, et al. Diabetes Care. 2006;29:1249-1255.

Pa4ents Do Not Feel Their Diabetes Is Under Control

Base: all respondents.

49

46

24

36

0 20 40 60 80 100

Type 1

Type 2

OverallUSA

Pa7ents With “Great Extent” of Control, %

Psychological Problems (US)

Peyrot M, et al. Diabet Med. 2005;22:1379-1385. Base: all respondents.

73

82

80

0 50 100

GPSpecialist MDNurse

Pa7ents Who Disagree, %

“Psychological problems play only a small part in noncompliance”

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Peyrot M, et al. Diabet Med. 2005;22:1379-1385. Base: all respondents.

Diabetes-‐Specific Worries

47

55

53

49

51

52

43

49

41

43

39

39

47

49

35

0 20 40 60 80

Type 1Type 2GPSpecialistNurse

“I am very worried about risk of hypoglycemic events”

“I am constantly afraid of my disease geHng worse”

“I feel that my diabetes is preven7ng me from doing what I want”

Pa7ents Who Agree, %


Nega4ve Reac4ons to Diagnosis Are Common

Base: all respondents.

28

30

39

5060

45

48

12

0 20 40 60 80

Guilty

Angry

Depressed

Anxious

Type 1Type 2


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Access to Team Care Predicts Diabetes Outcomes (US)

Rubin RR, et al. Diabetes Care. 2006;29:1249-1255.

Access to Care

31

36

39

40

22

28

0 20 40 60 80

OverallUS

Good diabetes control

Good adherence

High diabetes distress

Pa7ents, %

Nurses Address Cri4cal Psychosocial Needs

Siminerio LM, et al. Diabetes Educ. 2007;33:152-162. Base: all nurses.

Provide a feeling of security and hope

Act as intermediary between doctor & pa7ent

Brief doctors about possible complica7ons/ psychological problems

Pa7ents Receiving Support, %

74

55

92

78

67

81

0 20 40 60 80 100

Overall Data US Data

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Providers Delay Prescribing Medica4on to Control Glucose

Peyrot M, et al. Diabetes Care. 2005;28:2673-2679.

“I prefer to delay ini7a7on of oral therapy un7l absolutely essen7al”

“I prefer to delay ini7a7on of insulin un7l absolutely essen7al”

32

46

10

36

23

43

0 20 40 60 80 100

USA

Overall

47

50

34

42

68

59

0 20 40 60 80 100

GPSpecialist MDNurse


Provider Barriers

•  DAWN study - United States in top 3 countries of greatest insulin delay - 50% of MDs and RNs believe insulin has a posi7ve effect on care - MDs underes7mated the number of pa7ents who blamed themselves for ini7a7on of insulin - 65% of providers reported that pa7ents’ concerns delay the ini7a7on of insulin


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Derr RL, et al. Diabetes Spectrum. 2007;20:177-185.

Self-‐reported Comfort Level for Managing Diabetes by Professional Category

0 10 20 30 40 50 60 70 80 90 Very

Comfortable

Somewhat Comfortable

Somewhat Uncomfortable

Very Uncomfortable

Unanswered Num

ber o

f Par7cipants

General Faculty

Specialist Faculty PGY3

Resident

PGY2 Resident PGY1

Resident

Nurse >10 yrs Nurse

6-‐10 yrs

Nurse <5 yrs

Professional Category

Pa4ent Perspec4ves

•  Overwhelmingly nega7ve - Pa7ents not on insulin: 57% worried about star7ng1 - Survey of 708 pa7ents with T2DM2

•  28% would be unwilling to administer insulin even if prescribed

•  <25% pa7ents “Very Willing” to begin insulin therapy

•  Resistance can lead to inadequate glycemic control

1. Peyrot M, et al. Diabetes Care. 2005;28:2673-2679. 2. Polonsky WH, et al. Diabetes Care. 2005;28:2543-2545.

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Psychological Barriers

•  Insulin represents failure in self care - 48% believed they were to blame for not following instruc7ons

•  Pain/fear of injec7ons •  Belief that insulin use is complicated

•  Loss of independence/change in lifestyle •  S7gma from needle use


Barriers to Ini4a4ng Insulin Therapy Among Privately Insured Pa4ents—New Jersey, 2010

Statistically significant factors influencing insulin use from a survey of 169 privately insured, insulin-naive patients with poorly controlled T2DM; P < .05, not adherent vs adherent for all factors shown. a Percentages of omitted responses not shown. Karter AJ, et al. Diabetes Care. 2010;33:733-735.

0 10 20 30 40 50 60

Too painful

Negative job impact

Negative social impact

Doubt ability to adjust dose

Hypoglycemia

Side effects of injection

Inadequate health literacy

Risks/benefits not well explained

Patients With T2DMa With Moderate to Extreme Concerns (%)

Educational Barriers IniDated (n = 100) Did not iniDate (n = 69)

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0 10 20 30 40 50 60 70 80 90 100

Daily struggles

Dietary restrictions

Fear of hypoglycemia

Worries about future

Social worries

Physical complaints

QOL

QOL Score (Higher Scores Indicate Better QOL)

a

a

a

b

6 months aLer insulin iniDaDon Before insulin iniDaDon

Insulin Ini4a4on Improves Quality of Life in T2DM

Results from 42 insulin-naive older (mean age 68.4 y) German adults with T2DM who initiated insulin with a structured diabetes education program. a P < .05; b P < .01. Braun A, et al. Patient Educ Couns. 2008;73:50-59.

Assessment Ques4ons

• What is your greatest concern about your diabetes?

• What is the hardest thing for you in taking care of your diabetes?

•  How sa7sfied are you with your current therapy for diabetes?

•  How sa7sfied are you with your current level of glucose control?

• What do you need to know to consider insulin therapy?

• What is your biggest fear about insulin?

Funnell MM, et al. Diabetes Educ. 2004;30:274-280.

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Assessment Ques4ons (cont’d)

• What problems do you think you will encounter?

• What do you see as the biggest nega7ve?

• What do you see as the most posi7ve for you?

• What supports do you have to overcome barriers?

•  Are you willing to start insulin? If not, what would cause you to start taking insulin?


Assessing and Addressing Common Concerns •  Fear of needles/painful injec7ons •  Fear of hypoglycemia

• Weight gain

•  Adverse impact on lifestyle

•  Loss of personal freedom and independence


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Assessing the Value of Diabetes Educa4on (DE) Hypotheses •  Pa7ents who par7cipate in DE are more likely to follow diabetes care standards than similar pa7ents who do not par7cipate in DE

•  Claims of pa7ents who par7cipate in DE are lower than those of similar pa7ents who do not par7cipate in DE

Duncan I, et al. Diabetes Educ. 2009;35:752-760.

Study Design/Study Popula4on

•  This study used administra7ve claims data to compare process measures and cost of those pa7ents who par7cipate in DE and those who do not

•  Study popula7on consisted of members of commercial and Medicare Advantage health plans


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Results: Overall Outcomes

•  Commercially insured members who use DE cost, on average, 5.7% less than members who do not par7cipate in DE

•  Medicare members who use DE cost 14% less than those who do not par7cipate in DE

•  Source of difference: Commercial members with DE have lower claims for acute care (inpa7ent) and higher claims for primary and preven7ve services and prescrip7on claims. Professional service claims are significantly lower in those without DE

•  Rate of claims for those without DE increases at a rate of 8% per year; those with DE only 3.3% per year


Assessing the Value of DE

•  DE is associated with increased use of primary and preven7ve services and lower use of acute inpa7ent hospital services

•  Those receiving DE are more likely to follow best prac7ces treatment recommenda7ons and have lower claims cost

•  Results indicate a rela7onship between DE and the likelihood to follow treatment recommenda7ons

•  DE is associated with higher compliance rates for nearly all HEDIS measurements, especially Medicare Popula7on


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•  People with diabetes should receive DSME/DSMS according to Na7onal Standards for Diabetes Self-‐Management Educa7on and Support at diagnosis and as needed thereamer B

•  Nutri7on therapy is recommended for all people with type 1 and type 2 diabetes as an effec7ve component of the overall treatment plan A

•  DSME/DSMS should address psychosocial issues, since emo7onal well-‐being is associated with posi7ve outcomes C

•  Because DSME/DSMS and medical nutri7on therapy can result in cost-‐savings and improved outcomes B, DSME/DSMS and medical nutri7on therapy should be adequately reimbursed by third-‐party payers E

ADA Standards of Medical Care: Recommenda4ons

ADA. Diabetes Care. 2015;38(Suppl 1):S1-S93.

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DSME/S •  Ini7al DSME/S typically provided by a HCP

•  Ongoing DSME/S may be provided by personnel within a prac7ce and a variety of community-‐based resources

•  DSME/S is designed to address the pa7ent’s health beliefs, cultural needs, current knowledge, physical limita7ons, emo7onal concerns, family support, financial status, medical history, health literacy, and numeracy


1.  Engagement. Provide DSME/S and care that reflects person’s life, preferences, priori7es, culture, experiences, and capacity

2.  Informa7on sharing. Determine what the pa7ent needs to make decisions about daily self-‐management

3.  Psychosocial and behavioral support. Address the psychosocial and behavioral aspects of diabetes

4.  Integra7on with other therapies. Engage integra7on and referrals with and for other therapies

5.  Coordina7on of care across specialty care, facility-‐based care, and community organiza7ons. Ensure collabora7ve care and coordina7on with treatment goals DSME/S best provided?

DSME/S Algorithm of Care: Guiding Principles


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DSME/S Algorithm of Care

Reprinted with permission of American Diabetes Association, from Powers MA, et al. Diabetes Care. 2015;38:1372-1382. © 2015; permission conveyed through Copyright Clearance Center.

DSME/S Algorithm of Care (cont’d)


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DSME/S Algorithm of Care: Ac4on Steps


Pa4ent-‐Centered Assessment

Arnold MS, et al. Diabetes Educ. 1995;21:308-312. Powers MA, et al. Diabetes Care. 2015. Published online June 5, 2015.

Sample ques7ons to guide a pa7ent-‐centered assessment 1.  How is diabetes affec7ng your daily life and that of your family?

2.  What ques7ons do you have?

3.  What is the hardest part right now about your diabetes, causing you the most concern or is most worrisome to you about your diabetes?

4.  How can we best help you?

5.  What is one thing you are doing or can do to manage your diabetes beOer?

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Pt presents to PCP w/ type 2 diabetes

Newly diagnosed

In poor control:

HbA1c ≥7.0 more than 1 yr

In need of nutri7onal counseling/ meal planning

Previously dxed, no

h/o diabetes educa7on, lifestyle concerns

PCP generates electronic referral form to the Diabetes Care Center for one or more of the following services if the paDent is:

Diabetes Self-‐Management EducaDon (DSME)

Endometabolism consult for med management

“Diabetes In AcDve Control” (DIAC) Program

Devices: a) Con7nuous

Glucose Monitoring System (CGMS)*; b) Insulin pumps

Medical NutriDon Therapy (MNT)

Pt s7ll in poor control amer

6 months?

Endocrinology referral for

the following:

Pt returns to PCP for regular care

Pt receives consulta7on w/Reg Die77an

Yes

No

Type 1 diabetes

Type 2 diabetes with

mul7ple comorbidi7es, complica7ons,

complex medical history

DCC staff may recommend referral to DSME or DIAC based

on pa7ent response/need DCC staff may recommend

referral to DSME or DIAC based on pa7ent response/need

DCC staff may recommend referral to DSME and/or MNT based

on pa7ent response/need

Summary

•  It is the posi7on of the American Diabetes Associa7on that all individuals with diabetes receive DSME/S at diagnosis and as needed thereamer

•  The goals of DE are to improve the pa7ent experience of care and educa7on; improve the health of individuals and popula7ons; and reduce diabetes-‐associated per capita health care costs


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Summary (cont’d) •  Clear communica7on among the heath care team, which includes a provider, educator, and a person with diabetes, is cri7cal to ensure goals are clear, progress toward goals is being made, and that appropriate interven7ons (educa7onal, psychosocial, medical, and/or behavioral) are being used

•  A pa7ent-‐centered approach at diagnosis provides the founda7on for current and future needs

•  Ongoing educa7on helps the pa7ent overcome barriers and cope with ongoing demands, and facilitate changes during the course of treatment and life transi7ons


A Case Study: Susie

Davida F. Kruger, MSN, APN-BC, BC-ADM Certified Nurse Practitioner Henry Ford Health System

Division of Endocrinology, Diabetes, Bone Disease Detroit, MI

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Susie

•  37-‐year-‐old Hispanic woman, married with 2 children. Works 3 days per week. Husband is a schoolteacher. Works summers as well for the income

•  Commercial insurance, but has an annual deduc7ble of $2000 and co-‐pay of $40 for outpa7ent visits

•  Daughter has asthma. Husband and son are healthy •  Family history includes mother and aunt with type 2 diabetes. Father with hypertension

•  Diagnosed with type 2 diabetes 4 years ago. Found at rou7ne GYN visit. A1c was 7.9%. Placed on metormin 1000 mg twice daily. Follow-‐up 3 months later: A1c was 7.3%. No diabetes educa7on. No MNT. Not checking her blood glucose

•  BP is typically 138/92 mm Hg, LDL 110 mg/dL. BMI 28 kg/m2. Nonsmoker

•  A1c today: 8.9%

MNT, medical nutri7on therapy.

Susie (cont’d)

• Medica7ons • Metormin 1000 mg twice daily. Takes most days, may miss second dose

•  Lisinopril 10 mg daily • Mul7vitamin

What should her treatment goals be?

1356 kruger slide handout file ver2 - rose rock group kruger/1356... · published online june 5,...

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