Implementation and Evaluation of a Primary Care Diabetes

Implementation and Evaluation of a Primary Care Diabetes Education Program 1, 2 Elizabeth C. Cobb MSN, FNP-C, RN; 2 Pamela Biernacki, DNP, FNP-C, RN; 3 Dr. Mary Lynn Davis Ajami, PHD, MBA, MS, FNP-C, RN; 4 Christopher Heck, MD 1 Carilion Clinic, Roanoke, VA; 2 Virginia Commonwealth University School of Nursing, Richmond, VA; 3 Indiana University School of Nursing, Bloomington campus, Bloomington, IN; 4 Valley Family & Elder Care, Harrisonburg, VA Abstract Methods Discussion Purpose: Development of a Nurse Practitioner (NP) led educational program in the primary care setting to improve physiologic biomarkers and patient self-efficacy managing type II diabetes mellitus (T 2 DM). § A pre-and post-design project using Health Belief Model and Self. Efficacy theory provided theoretical framework principles for health belief and self-care management in patients with T 2 DM. § Benefits of DSME have been documented in a variety of settings with no superiority of results based on the type of provider performing the education. Participants: Adults ages 18 -64 in two rural Augusta County, VA family practices with a Hb. A 1 c > 8% and body mass index (BMI) > 30 kg/m 2 monitored over a three-month period. § Eighty-two adults diagnosed with T 2 DM with a Hb. A 1 c > 8% and a BMI > 30 kg/m 2 were eligible through EHR chart reviews, with final enrollment of 23 adults attending at least one initial appointment, Three participants were lost to follow-up and did not reschedule. § A strong patient-provider relationship has been correlated to increased patient trust and better disease self-management. Method: A quality improvement (QI) design incorporating educational guidelines outlined by the American Association of Diabetes Educators (AADE). Self efficacy was measured using the Diabetes Self. Management Questionnaire (DSMQ). Use of the electronic health record (EHR) patient portal for between visit participant follow up was encouraged, to reinforce education. Results: Pre- and post-Hb. A 1 c, BMI and self-efficacy scoring with the DSMQ were not statistically significant. Recruitment and participant engagement was limited due to participants’ lack of familiarity with the NP within the practice. Follow-up during the three-month period was low due to decreased participant engagement with the electronic patient portal. Discussion: Future examination of the patient-provider relationship and electronic interventions enhancing participation and adherence for diabetes education within the ambulatory care setting is warranted. § The initial office visit included § Hb. A 1 c testing § Weight and height measurement for BMI calculation § Guided discussion of topics by the NP related to the seven domains of diabetes care established by the AADE § Administration of DSMQ AADE Seven Self Care Behaviors § Three-month follow up § Hb. A 1 c retest § Weight for repeat BMI § DSMQ post-test Healthy Eating Learning about carbohydrates, portions, meal planning, hypo- and hyperglycemia Being Active Learning benefits of physical activity, both cardio and resistance training Healthy Coping Learning the emotional impact of diabetes and healthy coping mechanisms Monitoring Learning how to measure glucose levels at home and target levels for Hb. A 1 c Problem Solving How to manage high and low blood glucose readings and set goals for glucose control Reducing Risks Learning the complications of diabetes and importance of preventative screening exams Results Taking Medication Learning about prescribed medication regimen and following prescribed instructions of use § T 2 DM is a chronic health condition with over 1. 7 million new cases diagnosed yearly in the US. The pre- and post-Hb. A 1 c, BMI and DSMQ results were compared for the evaluation the DSME intervention. Statistical analysis by Wilcoxon matched pairs test was utilized due to the N < 30. Significance level set at p <. 05. § In the Commonwealth of Virginia (VA), the incidence of T 2 DM in adults over 18 years of age rose from 4. 2% in 1995 to 8. 3% in 2010, and is the seventh leading cause of death. § Of the 20 participants, all received pre- and post-Hb. A 1 c and BMI measurements; Nine completed pre-and post DSMQ questionnaires. § Approximately 154 million adults classified as obese having a BMI greater than 30 kg/m 2. § Data did not reflect a statistically significant change based on pvalue of <. 05 from pre- and post-Hb. A 1 c results. § In VA, 29% of persons age 20 and older are obese, including 27% of Augusta County, VA residents. § Participants measured a mean Hb. A 1 c of 9. 99% at baseline, with reduction to 9. 19%. § DSME following standardized educational guidelines is recommended to improve patient outcomes and decrease complications. § BMI readings showed no decrease, while having a mean increase from 36. 44 kg/m 2 of the initial BMI, to 37. 09 kg/m 2 at the threemonth follow-up. § Diabetes is perceived by the Augusta County to be a major problem due to lack of access to health education. The NP providing educational and medical management of diabetes in the office setting is a competent solution to this need. § Pre- and post-DSMQ survey results revealed self-efficacy scores were unchanged over the three-month period. Introduction Project Aim § To develop a structured diabetes educational intervention in primary care targeting adults age 18 -64 years, with poorly controlled type II diabetes (defined as Hb. A 1 c > 8. 0%) and comorbid obesity (defined as BMI > 30 kg/m 2). § The desired outcome § decrease Hb. A 1 c and BMI. § increase patient perceived self-efficacy to improve diabetes management, measured within a six-month time frame. Initial DSMQ Mean Three month Score DSMQ Mean Change (M) Standard Deviation (SD) P value (p) § Patient-provider relationship impacted the areas of participant recruitment and participation in EHR interactions for this intervention. § Tailored patient communication methods are linked to patients’ willingness to access the patient portal. § The NP was not a regular employee in the clinic, therefore did not have a standing provider relationship with the patients, making it more challenging to recruit and engage buy-in to elicit visit participation and patient portal contact. § Development of patient care teams led by the NP. § NPs diagnose, adjust treatment regimens, prescribe medications, and lead educational interventions. Collaborative care team led by the NP help address needs of complex chronic disease patients. Patient – NP provider relationships are enhanced when the NP is the primary provider. Implications for Practice § Standardized guidelines to enhance patient learning and selfefficacy are available to clinicians for use in a variety of practice settings, however, the results demonstrate evidence based tools alone may not impact patient outcomes. § Consistent patient-provider relationship, tailored communication methods, and a cohesive patient care team are key factors impacting diabetes care and outcomes. § Increasing the leadership role of the NP within the patient care team for chronic disease management should be more widely implemented with today’s health care climate focusing on quality, cost-effective care. References American Association of Diabetes Educators. (2010). AADE 7 self-care behaviors. Retrieved from https: //www. diabeteseducator. org/patient-resources/aade 7 -self-care-behaviors Beckerle, C. M. , & Lavin, M. A. (2013). Association of self-efficacy and self-care with glycemic control in diabetes. Diabetes Spectrum, 26(3), 172 -178. Retrieved from http: //proxy. library. vcu. edu/login? url=http: //search. ebscohost. com/login. aspx? direct=true&Auth. Type=ip, url, cookie, uid&db=ccm&AN=104214184&site=ehostlive&scope=site Glucose Management 5. 55 7. 44 1. 88 2. 52 . 07 Dietary Control 5. 22 5. 66 0. 22 1. 30 1. 00 Physical Activity 3 3. 11 0. 11 1. 76 . 99 Health Care Usage 3. 88 4. 55 0. 88 2. 20 . 21 Centers for Disease Control and Prevention. (2014). National diabetes statistics report: estimates of diabetes and its burden in the united states. Atlanta, GA: U. S. Department of Health and Human Services. Overall Self-Care 1. 55 . 68 Go, A. S. , Mozaffarian, D. , Roger, V. , Benjamin, E. J. , Berry, J. D. , Blaha, M. J. , . . . Lackland, D. T. (2014). Executive summary: Heart disease and stroke statistics--2014 update: A report from the american heart association. Circulation, 129(3), 399 -410 12 p. doi: 10. 1161/01. cir. 0000442015. 53336. 12 1. 11 0. 22 Hemoglobin A 1 c and BMI pre- and post. Mean 40 Hurley, A. C. (1990). The health belief model: Evaluation of a diabetes scale. Diabetes Educator, 16(1), 44 -48. Retrieved from http: //proxy. library. vcu. edu/login? url=http: //search. ebscohost. com/login. aspx? direct=true&Auth. Type=ip, url, cookie, uid&db=ccm&AN=107411707&site=ehostlive&scope=site Peyrot, M. , Peeples, M. , Tomky, D. , Charron-Prochownik, D. , & Weaver, T. (2007). Development of the american association of diabetes educators' diabetes selfmanagement assessment report tool. Diabetes Educator, 33(5), 818 -826. Retrieved from http: //proxy. library. vcu. edu/login? url=http: //search. ebscohost. com/login. aspx? direct=true&Auth. Type=ip, url, cookie, uid&db=ccm&AN=105919746&site=ehostlive&scope=site 20 10 Pre Post Campbell, H. M. , Khan, N. , Cone, C. , & Raisch, D. W. (2011). Relationship between diet, exercise habits, and health status among patients with diabetes. Research In Social & Administrative Pharmacy, 7, 151 -161. doi: 10. 1016/j. sapharm. 2010. 03. 002 Lyles, C. R. , Sarkar, U. , Ralston, J. D. , Adler, N. , Schillinger, D. , Moffet, H. H. , . . . Karter, A. J. (2013). Patient-provider communication and trust in relation to use of an online patient portal among diabetes patients: The diabetes and aging study. Journal of the American Medical Informatics Association, 20(6), 1128 -1131. 10. 1136/amiajnl-2012 -001567 30 0 0. 83 Caldwell, H. D. , Minkoff, N. B. , & Murthy, K. (2017). Patient web portals and patient-provider relationships: A summary perspective. International Journal of Technology Assessment in Health Care, 33(1), 63 -68. 1017/S 0266462317000137 Hb. A 1 c (%) p value 9. 99 9. 19 0. 1 BMI p value (kg/m 2) 36. 64 0. 45 37. 09 Skovlund, S. E. , & Peyrot, M. (2005). Lifestyle and behavior. the diabetes attitudes, wishes, and needs (DAWN) program: A new approach to improving outcomes of diabetes care. Diabetes Spectrum, 18(3), 136 -142. Retrieved from http: //proxy. library. vcu. edu/login? url=http: //search. ebscohost. com/login. aspx? direct=true&Auth. Type=ip, url, cookie, uid&db=ccm&AN=106536142&site=ehostlive&scope=site Wooley, D. S. , & Kinner, T. J. (2016). Comparing perceived self-management practices of adult type 2 diabetic patients after completion of a structured ADA certified diabetes self-management education program with unstructured individualized nurse practitioner led diabetes self-management education. Applied Nursing Research, 32, 171 -176. 1016/j. apnr. 2016. 07. 012