1. An Innovative Approach to Managing Diabetes in a Large Public Health System Donna J. Calvin, PhD, FNP-BC, CNN Post Doctoral Research Associate University of Illinois at Chicago College of Nursing Department of Health Systems Science October 29, 2012

2. Oak Forest Hospital Fantus Clinic Woodlawn Health CenterEnglewood Health Center

3. Background Disparity in the Prevalence of Diabetes in Chicago

4. Background Chicago Diabetes Death Rates per 100,000 CDPH, 2004

5. Background Chicago Plan for Public Health System Improvement, 2012-2016 Diabetes Hospitalizations by Chicago Zip Codes, 2007

6. Access Cultural incongruence Lack of knowledge - Provider - Patient Background

7. United States 13 million Mean A1C 7.6% 50% < 7 25% > 9.0 Chicago-County Clinics 40,000 Mean A1C 8.8% 18% < 7.0% 60% > 9.5% 2001 data

8. Purpose To determine the impact of a system-level quality assurance program aimed to improve diabetes outcomes among an urban minority population. Goal Reduce the average blood glucose level (A1C) among a low income, predominately African American and Hispanic population. Optimal HbA1c (A1C) <7.0 % A measure of chronic glucose control, and reflects the prevailing level of glycemia over the past three months.

9. Cost of managing diabetes: $174 billion total $116 billion medical expenditures $58 billion in reduced national productivity Significance

10. Benefits of Decreasing A1C by 1% Significance 14% Decrease in risk of all Diabetes complications 40% Decrease in risk of microvascular diseases

11. Decreasing A1C Prevents: Blindness Kidney Failure Amputation Significance

12. What Should We Do?

13. Our Evidence-Based Program Network Diabetes Program

14. Ophthalmologists Physician/NURSE Dieticians Social Worker & Psychologist Pharmacists Family/FriendsPodiatrists Patient. Providers Our Evidence-Based Program

15. Motivational interviewing Apply multidisciplinary approach ABC goals Signs, symptoms and treatment of hyper/ hypoglycemia self-management of hypo and hyperglycemia Glucometer (prepare for testing and action if meter breaks or not functioning) Provider-Level Strategies: Nurses receive three days of intensive education

16. Our Evidence-Based Program Motivational interviewing - self management The use of insulin in diabetes management - “Clinical inertia” Treat to target - Implementing the ABCs of Diabetes Foot exams Provider-Level Strategies: Physicians receive two days of intensive education

17. Our Evidence-Based Program Patient-Level Strategies Multicultural staff provide one-on-one encounters: Knowledge Test Basic discussion of diabetes Review of lab results Assessment of: dietary habits, lifestyle, psychosocial problems

18. Our Evidence-Based Program Patient-Level Strategies Adjustment of diabetes medication Referral to: PCP, ophthalmology, podiatry, social worker and/or psychologist as needed Appointment to attend diabetes class

19. Our Evidence-Based Program Overview of diabetes Basic self-management skills Glucose monitoring A personal consultation after the group class to discuss concerns and misperceptions HbA1c c arbo hydrate s stroke Retinopathy Heart disease Foot care ESRD Eating out Diabetes Class (Spanish & English)

20. Our Evidence-Based Program Nurses Physicians ABC goals implementations throughout system Annual Update “Sugar Beat,” a quarterly diabetes publications with updates in diabetes management System-Wide Activities

21. Results Mean A1C: 7.8% < 7% Mean A1C: 8.8% > 7% A1C 2001 System-Level Data 2008

22. Results System-Level Data A1C over 9.5% 2001 2008 < 9.5 > 9.5

23. NDP Data - More Complex Patients Crossectional Analysis 2001-2012 Results A1C N=4,589

24. Summary of QA Program Our Evidence-based Program is Effective: Meeting national goals American Diabetes Association (ADA) recognition Continuity of care

25. Future Directions Lifestyle Center Last chance clinic Diabetes Group visits Collect and analyze data to determine what aspect of our program has the greatest impact

26. Elements of the Program Treating difficult patients Enhancing provider’s skills Uniform management in the system (ABC)

27. Thank You! Model for other publicly financed primary health care systems

28. Thank You! Questions?