PA cAARds! An integrated intervention for diabetes and tobacco control professionals and paraprofessionals Marlin L. Williams, MBA Diabetes Symposium November,

Training Objectives Improve understanding of statewide and local resources for diabetes education and management and tobacco cessation services Improve understanding of integrated strategies and identify where organizations fit into the organizational integration continuum Encourage you to attend PA cAARds! Training Increase the use of the Ask Advise Refer brief intervention in diabetes and tobacco programs Increase the use of PA cAARds among community based health care organizations

PA cAARds! PA cAARds! is the first integrated initiative of its kind in Pennsylvania and a unique collaborative effort between the Pennsylvania Department of Health’s Diabetes and Tobacco Prevention and Control Programs PA cAARds! Is funded by the Pennsylvania Department of Health

Problem 133 million people, or almost half of all Americans live with a chronic condition. That number is projected to increase by more than one percent per year by 2030, resulting in an estimated chronically ill population of 171 million Tobacco Use is one of the single most modifiable risk factors of ALL chronic diseases Data from www.improvingchroniccare.org

Problem In 2007, it was estimated that 26.3 million individuals or 7.8% of the US population were diabetic. Of those, 5.7 million were undiagnosed. (CDC, 2008) A study published in the December issue of Diabetes Care suggests that the number of Americans with diabetes is expected to nearly double by 2034 (Diabetes Care, 2009) Smoking represents the leading cause of preventable death in the Unites States; Responsible for 1 in 5 deaths ( CDC, 2009 ) In Pennsylvania, there are more than 764,000 adults diagnosed with diabetes and approximately 17% of them smoke. (CDC 2005, BRFSS 2006)

Smoking & Diabetes A dangerous combination Smoking increases the harmful effects of diabetes by making diabetes more difficult to control (JRSPH, 1998) Smoking increases diabetes-related complications that include blindness, kidney disease, heart disease, and neuropathy (JRSPH, 1998)

Tobacco Use & Diabetes Tobacco use….. narrows blood vessels contributing to high blood pressure, heart disease and poor circulation in those with diabetes(CDC, 2004). increases insulin resistance and deteriorating diabetes control (Diabetes Care, 1999) increases the risk for Peripheral Arterial Disease, multiplying the likelihood of amputations by 5. (of people with diabetes who need amputations, 95% are smokers)(Diabetes Care, 2001) is suggested in studies to be an independent risk factor for type 2 diabetes (JAMA, 2007) doubles the risk of heart disease in people with diabetes (approximately 65% of people with diabetes die from heart disease and stroke (CDC, 2005)

For nonsmokers… Approximately 60% of non-smokers have biological evidence of TSP exposure The combination of diabetes and secondhand smoke. raises the risk of developing glucose intolerance decreases the ability of the pancreas to make insulin reduces the insulin sensitivity in people with type -2 diabetes

Smokeless tobacco products Spit, oral, chew, snuff and dip are not safe alternatives to smoking. People who dip or chew get comparable amounts of nicotine to regular cigarettes. Chew tobacco is high in sugar.

Economic Toll In 2004, cost for diabetes hospitalization in PA reached $673 million and accounted for more than 131,000 hospital days. (PADOH, 2007) Over the past five years, total costs in PA reached $2.6 billion and accounted for more than 649,000 hospital days. (PADOH, 2007) Direct health care and lost productivity costs due to smoking related illness are estimated for PA to be over $8.5 billion annually. (PADOH, 2008)

Due to the complex and overwhelming relationship between diabetes and tobacco use/exposure, addressing the harmful impact requires an integrated approach that emphasizes communication across disciplines.

Solution The goal of PA cAARds! is to proactively address the dual risks of unmanaged diabetes and tobacco use by maximizing utilization of regional and statewide resources. – educate health care and other CBOs providing diabetes and/or tobacco cessation in an integrated brief intervention and referral process – work with these organizations to sustain integrated tobacco, diabetes, and other chronic disease efforts.

PA cAARds! Integrated brief intervention and referral process where diabetes and tobacco professionals are trained to use the Ask, Advise, Refer intervention with their patients/clients The Ask, Advise, Refer model integrates the “5 A’s” (Ask, Advise, Assess, Assist, Arrange) Ask/Advise/Refer based on ADHA’s/SCLC’s adaptation of 5A’s

PA cAARds! Adapted from California’s Do you cAARd? Program Adapted to Pennsylvania Bidirectional between diabetes and tobacco

Development Process Literature review and environmental scan Recruited diabetes and tobacco control key stakeholders Facilitated a planning summit Solicited regional review and feedback Solicited DOH Feedback Pilot the initiative Implementation

Intervention Primary tool in addressing the dual risks of unmanaged diabetes and tobacco use/exposure Facilitate cross referral Do not need to be cross-disciplinary experts “Brief” Intervention Group & Individual Settings

Intervention Motivational Interviewing a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. The art of getting people to do what you want them to do because they want to do it. (Dwight Eisenhower)

Referral Goal: Facilitate cross referral to get patients/clients into appropriate services. Option of choosing between local or statewide services Provide referral tool (available on website and in your packets) Complete referral tracking form

Referral Local Resources Referral Lists and Regional Prescription – Community diabetes management/education programs – Community tobacco cessation programs Statewide Resources ( Take Charge Card ordered thru the website) – PA Free Quitline Community based health care organizations use Fax referral form along with the Take Charge Card) – American Diabetes Association

Quitline (Diabetes Providers) (1-800-Quit Now) Free evidence-based, individualized phone cessation counseling Multiple counseling sessions to callers committed to quit – Work with clients to set a quit date – Offer information about medications – Recommend tactics for dealing with urges – Provide suggestions for reducing triggers to smoke – Provide referrals to local cessation providers

National Diabetes Help Line (1-800-Diabetes) (1-888-Diabetes regional office) Center for Information & Community Support Provides information on managing diabetes and nutrition Local educations classes Support groups

Referral Tools Take Charge Card (statewide diabetes management/education and tobacco cessation) – Fax Referral provided in tandem with the Take Charge Card (Diabetes professionals/paraprofessionals) Regional Prescription Pad (local referrals)

Fax Referral PA DOH tobacco prevention and control program is partnering with PA cAARds! to pilot the fax referral process with community based health care providers Fax referral will serve as a tool to facilitate referral to the PA Quitline which is the statewide resource for PA cAARds!

Fax Referral Links the services of the Quitline directly to your patients with your help. Tobacco users no longer have to take the first step in calling the quitline. Quit coach pro-actively contacts your patients to provide an intervention after receiving a fax referral from you.

Technical Assistance Provide technical assistance related to integration readiness and implementation outreach and strategies to build organizational capacity – Providing training to utilize an evidence-based curriculum alone does not guarantee that a program will be successfully adopted within an organization – HPC will also provide ongoing comprehensive technical assistance (TA) for organizations participating in the training workshops to implement and sustain PA cAARds

Technical Assistance Programmatic T/A – help address and resolve any issues or questions regarding curriculum, tools, state and/or local resources and referrals (website) Intensive T/A – Increase organizational capacity to sustain integrated diabetes, tobacco and other chronic disease efforts (Leadership buy-in, Policy Development, Systems Change)

Integration Continuum Communication Fully Linked or INTEGRATED CooperationCoordinationPartnershipCollaboration Not Linked Not Linked -We don’t work together at all and have separate program goals. Communication –We share information only when it is advantageous Cooperation –We share information and work together when any opportunity arises Coordination - We work side-by-side (independently) to achieve common program goals Collaboration – We work side-by-side and actively pursue opportunities to work together Partnership – We work together with specified responsibilities to achieve common program goals Fully Linked or Integrated – We mutually plan, share staff and/or funding resources and evaluate activities to accomplish our common goals. Integration Model adapted from NACDD Tobacco Program Integration Report 2004

Website PA cAARds web portal is a trainee-specific tool that allows you to: – Download curriculum, tools and materials – Receive technical assistance – Communicate with the project staff and other trainees (message board and blog) – Report referrals and success stories – Access national and local resources (i.e. articles, toolkits, data reports etc.)

Continuing Education Credits UPMC Dietician, Social Work, Nursing, General Health Care Professional 5.5 credit hours Credit Designation Course Evaluation

North East Training December 1, am – 4pm Monroe County Public Safety Center 100 Gypsum Road, Suite 2 Stroudsburg, Pa To register please visit

THANK YOU on behalf of…….. Pennsylvania Department of Health Diabetes Prevention & Control Tobacco Prevention & Control Health Promotion Council

Acknowledgements BE A BRIDGE Partnership California Diabetes Program California Smoker’s Helpline Regional Advisory Council Members and Other Key Stakeholders

Marlin Williams