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

Transcription

1 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 Published online June 5,

2 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: 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 Skovlund SE, et al. Diabetes Spectrum. 2005;18:

3 Pa4ents Do Not Feel Their Diabetes Is Under Control Type Type Overall USA Pa7ents With Great Extent of Control, % Base: all respondents. Rubin RR, et al. Diabetes Care. 2006;29: Psychological Problems (US) Psychological problems play only a small part in noncompliance GP Specialist MD Nurse Pa7ents Who Disagree, % Base: all respondents. Peyrot M, et al. Diabet Med. 2005;22:

4 Diabetes- Specific Worries 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 Type 1 Type 2 GP Specialist Nurse Pa7ents Who Agree, % Base: all respondents. Peyrot M, et al. Diabet Med. 2005;22: Nega4ve Reac4ons to Diagnosis Are Common Guilty Type 1 Type 2 Angry Depressed Anxious Pa7ents Who Agree, % Base: all respondents. Skovlund SE, et al. Diabetes Spectrum. 2005;18:

5 Access to Team Care Predicts Diabetes Outcomes (US) Access to Care Good diabetes control Good adherence High diabetes distress Overall US Pa7ents, % Rubin RR, et al. Diabetes Care. 2006;29: Nurses Address Cri4cal Psychosocial Needs Provide a feeling of security and hope Act as intermediary between doctor & pa7ent Brief doctors about possible complica7ons/ psychological problems Overall Data US Data Base: all nurses. Siminerio LM, et al. Diabetes Educ. 2007;33: Pa7ents Receiving Support, % 5

6 Providers Delay Prescribing Medica4on to Control Glucose I prefer to delay ini7a7on of oral therapy un7l absolutely essen7al I prefer to delay ini7a7on of insulin un7l absolutely essen7al Overall GP Specialist MD Nurse USA Pa7ents Who Agree, % Peyrot M, et al. Diabetes Care. 2005;28: 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 Peyrot M, et al. Diabetes Care. 2005;28:

7 Self- reported Comfort Level for Managing Diabetes by Professional Category Number of Par7cipants 90 Very 80 Comfortable 70 Somewhat Comfortable General Faculty Specialist Faculty PGY2 PGY3 Resident Resident PGY1 Resident Professional Category Nurse >10 yrs Nurse 6-10 yrs Nurse <5 yrs Somewhat Uncomfortable Very Uncomfortable Unanswered Derr RL, et al. Diabetes Spectrum. 2007;20: Pa4ent Perspec4ves Overwhelmingly nega7ve - Pa7ents not on insulin: 57% worried about star7ng 1 - Survey of 708 pa7ents with T2DM 2 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: Polonsky WH, et al. Diabetes Care. 2005;28:

8 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 Peyrot M, et al. Diabetes Care. 2005;28: Barriers to Ini4a4ng Insulin Therapy Among Privately Insured Pa4ents New Jersey, 2010 Educational Barriers Risks/benefits not well explained IniDated (n = 100) Did not inidate (n = 69) Inadequate health literacy Side effects of injection Hypoglycemia Doubt ability to adjust dose Negative social impact Negative job impact Too painful Patients With T2DM a With Moderate to Extreme Concerns (%) 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:

9 Insulin Ini4a4on Improves Quality of Life in T2DM 6 months aler insulin inidadon Before insulin inidadon QOL a Physical complaints Social worries Worries about future a Fear of hypoglycemia b Dietary restrictions Daily struggles a QOL Score (Higher Scores Indicate Better QOL) 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: 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:

10 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? Funnell MM, et al. Diabetes Educ. 2004;30: 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 Funnell MM, et al. Diabetes Educ. 2004;30:

11 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: 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 Duncan I, et al. Diabetes Educ. 2009;35:

12 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 Duncan I, et al. Diabetes Educ. 2009;35: 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 Duncan I, et al. Diabetes Educ. 2009;35:

13 Powers MA, et al. Diabetes Care Published online June 5, ADA Standards of Medical Care: Recommenda4ons 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. Diabetes Care. 2015;38(Suppl 1):S1-S93. 13

14 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 Powers MA, et al. Diabetes Care Published online June 5, DSME/S Algorithm of Care: Guiding Principles 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? Powers MA, et al. Diabetes Care Published online June 5,

15 DSME/S Algorithm of Care Reprinted with permission of American Diabetes Association, from Powers MA, et al. Diabetes Care. 2015;38: ; permission conveyed through Copyright Clearance Center. DSME/S Algorithm of Care (cont d) Reprinted with permission of American Diabetes Association, from Powers MA, et al. Diabetes Care. 2015;38: ; permission conveyed through Copyright Clearance Center. 15

16 DSME/S Algorithm of Care: Ac4on Steps Reprinted with permission of American Diabetes Association, from Powers MA, et al. Diabetes Care. 2015;38: ; permission conveyed through Copyright Clearance Center. Pa4ent- Centered Assessment 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? Arnold MS, et al. Diabetes Educ. 1995;21: Powers MA, et al. Diabetes Care Published online June 5,

17 Pt presents to PCP w/ type 2 diabetes PCP generates electronic referral form to the Diabetes Care Center for one or more of the following services if the padent is: Newly diagnosed Diabetes Self- Management EducaDon (DSME) Previously dxed, no h/o diabetes educa7on, lifestyle concerns In poor control: HbA1c 7.0 more than 1 yr Diabetes In AcDve Control (DIAC) Program In need of nutri7onal counseling/ meal planning Medical NutriDon Therapy (MNT) Pt receives consulta7on w/reg Die77an Endocrinology referral for the following: Type 1 diabetes Pt returns to PCP for regular care DCC staff may recommend referral to DSME or DIAC based on pa7ent response/need No Endometabolism consult for med management Pt s7ll in poor control amer 6 months? Yes DCC staff may recommend referral to DSME or DIAC based on pa7ent response/need Type 2 diabetes with mul7ple comorbidi7es, complica7ons, complex medical history DCC staff may recommend referral to DSME and/or MNT based on pa7ent response/need Devices: a) Con7nuous Glucose Monitoring System (CGMS)*; b) Insulin pumps 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 Powers MA, et al. Diabetes Care Published online June 5,

18 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 Powers MA, et al. Diabetes Care Published online June 5, 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 18

19 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/m 2. 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? 19