LCDR C. Fredette, BSN, CCHP, RN CDR R. Hunter Buskey, DHSc, CCHP, PA-C

OBJECTIVES: Review unique characteristics of inmates with diabetes Highlight clinical practice guidelines for correctional diabetic management Discuss practical methods to increase active inmate participation in diabetes management that incorporate personal behavior change Review glucose meter distribution program for inmates

DIABETES PREVELENCE: 438 million worldwide by million United States = 8% of US Population 7 th leading cause of death 2007 International Diabetes Federation (IDF); Centers for Disease Control and Prevention (CDC); Bureau of Justice Statistics (BJS)

DIABETES RISK FACTORS: Non-Modifiable African American, Native American, Hispanic Family history Chronic illnesses Modifiable Food choices Physical activity Weight

FEDERAL INMATE PROFILE White57.2 African-American39.2 Other 3.2 Hispanic32.2 Non-Hispanic67.8 Bureau of Justice Statistics, 2009

CHALLENGES FOR INMATES WITH DIABETES Lifestyle Health literacy and education Culture Health numeracy Non-formulary drugs Motivation Health beliefs

SURGEON GENERAL’S National Prevention Strategy Injury and violence free living Tobacco free living Preventing drug abuse and excessive alcohol use Healthy Eating Active Living Mental and emotional well being Reproductive and sexual health

COST FOR DIABETES CARE US diabetes related costs 2007: 174 billion; 116 billion for direct medical care Inmate average health care costs $7.15/day Range from $2.74-$11.96 US Department of Health and Human Services, 2011 The Council for State Governments, 2004; 1998 survey

IDFAACEADAADA InmateNCCHCFBOP Evidenced based, cost effective levels of care Aggressive, comprehensive Team based care Well and sick care for diverse populations Early assessment, staff training and coordination of resources Emphasize self- management, Quality improvem ent Primary care provider team, strive for target goals Chronic disease management models for diabetes Screening, diagnostic, therapeutic Categories for increased risk Testing Target goals Assessment of glycemic control All Guidelines Guidelines

Glycemic control HBA 1 C< 7.0% Preprandial plasma glucose mg/dl Peak postprandial plasma glucose<180 mg/dl Blood pressure< 130/80 mmHg Lipids LDL<100 mg/dl Triglycerides< 150 mg/dl HDL> 40/mg/dl ADA Treatment Goals WeightBMI Targets

FACILITY TIMELINE 2004 – Medical record review revealed clinical improvement opportunities for diabetic inmates (physical assessment, medication, patient education) 2005 – FCC Butner designation “Diabetes Center of Excellence” (DICE) 2006 – Committee launched diabetes awareness programs for staff and inmates, now annual 2007 – inmate education classes, re-established target clinical outcomes 2008 – initiation of inmate self monitoring blood glucose program

INMATE CHARACTERISTICS: ~20% known or at risk are in diabetes chronic care clinics Disproportionate number of federal inmates are overweight; many take anti-psychotics which can cause obesity Predominately Hispanic, African American

INMATE BARRIERS TO ACHIEVING TARGET GOALS Inmate contributions to food choices – commissary, menu Lockdowns Insulin timing Lack of community support Comorbidities

Quality Improvement The continual assessment of health care delivery to improve outcomes and reduce medical errors Areas to improve include: Appropriate utilization of medical services based on evidence, reduce service variability, address disparities, improve communication, increase patient-centered care, incorporate technology Agency for Healthcare Research and Quality (AHRQ), 2012

Performance Improvement Priorities Monitoring Parameters for Control and Complications Performance Improvement Priorities Monitoring Parameters for Control and Complications Every Visit 3-6 months Annual Blood Pressure Foot Exam Weight, Waist Circumference HBA1c Every 3 months (for poor control ): Initiate/change medication Every 6 months for stable control Dilated Eye Examination Lipid Levels* Microalbumin * Every 2 years if levels fall in lower risk categories American Diabetes Association. Clinical Practice Recommendations. Diabetes Care.

FACILITY DIABETES STATISTICS Majority Type 2 25% at or below target goals* ~500 insulin users Insulin use inevitably rises * estimated by random hemoglobin A1c review

FACILITY INSULIN EXPENDITURES Increase in insulin expenditures from 2010 to 2011 No significant change in Metformin or SFU costs Significant decrease in TZD costs 46K 42K Sulfonyurea = SFU; Thiazolidines = TZD

PHARMACY COSTS FOR DIABETES MEDICATIONS* Insulin is associated with the greatest staff resource** Insulin is associated with increased risk for medical errors, medical emergencies and morbidity *2010/2011 data; does not include lancets, needles, syringes, alcohol swabs, gauze, band aids **insulin prep time, pill line time, triage and emergency interventions

Federal Bureau of Prison Inmate Self monitoring program Agency glucose meter distribution program initiated in 2008 for inmate insulin users Considerations: Staff apprehension Oversight Education Cost Accountability Continuity during transfers Hundreds of glucose meters issued since program inception Noticeably Less Medical Emergencies D 50

PROGRAM REVIEW OUTCOMES Hemoglobin A1c (HBA1c) Values by groups Minimum Maximum Mean Std. Deviation Group one n=10 Target Glycemic Control Pre baseline Ø Post baseline Group two n=29 Mild-Moderate Glycemic Control Pre baseline Post baseline Group three n=22 Poor Glycemic Control Pre baseline Post baseline N=61 HBA1c expressed as %

CLINICIAN BARRIERS Definition of good glycemic control (treatment complacency) Accountability for glycemic monitoring and interventions Complexity: BS, BP, lipids, weight, personal behaviors for the incarcerated Specialist and expert availability

GOALS FOR PATIENT CENTERED CARE Education Nutritional support Physical activity Medications Self-monitoring blood glucose (SMBG) √ √ √ √ √

NEXT STEPS-TIME TO WORK TOGETHER Health Services Unit Management CustodyMarshalls Food ServiceCommissary Recreation INMATE

MOVING FORWARD Group medical visits Group session for education; train the trainer Staff and inmate lead physical activity sessions Quality of life groups for psychosocial support Foot clinic – Best Practice Self-Management clinic (food, activity, medication and insulin) Certified Diabetic Educator resources; Bureau of Prisons has issued an announcement for regional diabetic nurse consultants Inmate self referrals (dental, eye, foot care) Community partnerships – health fair, education for credit

What we learned is we cannot manage diabetes without a strategic self-management plan

Thank You… FCC Butner, Diabetes Center of Excellence Committee (DICE) Quality Management Department

QUESTIONS?