PEMISCOT MEMORIAL HEALTH SYSTEM BSMOD PROGRAM Final Project Status Report January December 2009

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1 PEMISCOT MEMORIAL HEALTH SYSTEM BSMOD PROGRAM Final Project Status Report January December To what extent were the project s original goal(s) and objective(s) achieved? If goal(s) and/or objective(s) changed, how and why? Discuss the results in terms of the variables tracked and described the instruments used to collect data Please provide quantifiable numbers in discussing the results. (See pages 4-10). The following represents the results of the quantifiable goals and objectives that our BSMOD program was to have achieved during the 3-year period. 2. What challenges did your organization face in connection with this project? How did you address these challenges? During the 3-year funding period, there were multiple unanticipated challenges that presented themselves, as follows: Non-Show Referrals: Individuals referred to the program often did not attend their introductory meeting with the BSMOD staff. As possible, we contacted them beforehand as a reminder and they would still not participate. This is a common occurrence with populations that are impoverished, with low health literacy capacity, and without easily available transportation. The hospital owns and operates a transportation service, which was offered to residents of Pemiscot County. This, in and of itself, was not a remedy for this issue. Fatalistic View of Medical Conditions: Bootheel residents, to a significant extent, appear to accept the inevitability of disease. Diabetes runs is families and many individuals admitted to the program had resigned themselves to a life of adverse consequences related to having diabetes. In other words, for treatment to be successful they would need to feel empowered to positively affect their condition. We regard this as a long term cultural issue. Follow-up Specialty Care: Many of the BSMOD patients enrolled in the program needed to see specialty physicians for follow-up care, i.e. endocrinologist. Such services were often difficult to access because of two reasons: (1) many of the specialists are not available in the immediate area which necessitated them traveling to Memphis, Jonesboro, or Cape Girardeau which is not often possible due to a variety of issues and (2) many specialists do not see Medicaid patients or those classified as charity care. High Correlation with Depression: It was noted that there appears to be a high correlation between diabetes and depression. Those BSMOD patients who were depressed lacked motivation and felt powerless to address the severity of their diabetic condition. 1

2 Trust. We worked with a significant number of Hispanic individuals during the course of the program. Speaking generally, they exhibited was a high level of distrust when interacting with the medical establishment. Provider Support: For some unknown reason, there were some of the physicians and midlevel practitioners in the local medical establishment that were never supportive of the program. 3. Discuss any new insights gained in the course of completing the project. If you were developing your project today, what would you do differently? Multi-disciplinary Treatment Approach: More importance would be placed on a multidisciplinary team approach to the evaluation and treatment objectives for specific BSMOD patients. Strategies would need to be put into place to ensure physician involvement. Support Staff: The program support staff would ideally be someone with a medical background, i.e., an LPN. The Data Entry Clerk that currently occupies this position is superior with data gathering and analysis, but is not versed in medical terminology or procedures. There is a definite learning curve with certain medical aspects of this program. Focus on Prevention: The BSMOD program was structured to treat diabetics; however, with an impoverished population such as we have in the Bootheel some of the programs challenges are precipitated by deeply rooted cultural issues. So, emphasis needs to be placed on pre-diabetic prevention efforts. Provider Feedback: In retrospect, we would develop a means to frequently feed back to each referral source their respective numbers of referrals and the status of their referred patients. 4. What has changed within your target population, organization and community as a result of this project? Do you anticipate continued follow-up beyond Missouri Foundation for Health's granting period? We believe we have positively impacted the health of the residents of our service area. The residents of Pemiscot, New Madrid, and Dunklin are now more aware of the importance of seeking diabetic care and, more importantly, we believe we have empowered our patients to successfully modify their medical condition. 5. What tools were used to monitor the effectiveness of the project? Was there input from the participants on the effectiveness of the project? If so, please describe. A satisfaction survey tool was developed specific to the BSMOD Pemiscot program. Approximately 200 were distributed. The results were reviewed and if there were opportunities for improvement this was considered and acted upon. 2

3 6. Given the results of your project, are there any recommendations for other organization(s) undertaking this kind of project? The number one lesson learned which has application to future grantees is to carefully consider the service-related volumes that are projected. We initially said we would see 1,500 individuals. In retrospect, this was an impossibility given the challenges the program faced. 7. Is there a continuing need for the activities developed under this project? If so, how will the project be sustained with the end of Foundation funding? Yes, the need continues. We are undecided at this point as to how we will proceed. We are considering integrating the BSMOD program efforts into one or more of our Provider Based Rural Health Clinics as part of the service mix offered to our patients. 3

4 PROGRAM EVALUATION Project Objectives, Activities, and Measures Status as of December 31, 2009 Objective 1: Within six months of grant award, increase the number of programs from zero to one that address the clinical care needs, preventive behaviors, and self-management aspects of diabetes in three rural counties. This program was successfully implemented as outlined within the grant application. Three separate planning meetings were held with representatives from the applicant organization, Pemiscot Memorial Health Systems, and Piggott Community Hospital participating. Activities: Implement a shared management arrangement between one rural hospital and nine rural primary care clinics. Hire DNE, RD, and data entry clerk by January 1, Select and implement evidence-based guidelines and establish registry system by January 15, This has been successfully accomplished. The primary care sites include: 1) Portageville Primary Care - Portageville 2) Pemiscot Primary Care - Hayti 3) Women s Primary Care - Hayti 4) Doctor s Clinic - Caruthersville 5) Convenient Care Clinic Hayti 6) Bootheel Primary Care, Hornersville 7) Bootheel Primary Care, Hayti 8) Bootheel Primary Care, Caruthersville 9) Campbell Medical Clinic - Campbell The following represent the staff initially hired on the following dates: 1) Janie Ricketts-Huckaba, DNE (December, 2006) 2) Jennifer Stratman, RD (December, 2006) 3) Tyrena Hall, Data Entry Clerk,(January, 2007) 4) Elaine Nixon, DNE (December, 2006) 5) Carol Stow, DNE (December, 2006) 6) Selma Kinser, RD (June 14, 2007) 7) Marilyn Jimerson, DNE (June, 2008) 8) Johnna McCreary, Data Entry Clerk (September, 2008) 9) Mahmud Arshad was hired on as a replacement for Johnna McCreary who received an internal promotion at Pemiscot Memorial Health Systems. This evidence-based guideline implementation has been accomplished. The Health Disparities Collaborative model promoted by the Health 4

5 Resources Services Administration was the model selected. The initial intent of this grant application was to purchase a canned registry system. Several were evaluated, but none were able to accommodate all of the indicators that this new program tracks. As an interim measure all information is being maintained via an Excel spreadsheet program. Provide provider and care team instruction on use of self-management tools and best practices. Develop physician-written protocols and train medical assistants/nurses by February 28, Develop individual and group clinical visit structure by February 28, This has been accomplished. This was completed in January, This has been accomplished with individual and group visits being held on an on-going basis. Report on the completion of a comprehensive education program to verify integration of the selfmanagement component at a rural hospital and six primary care clinics. Provide copies of training materials. Report on the status of staff hired. At final report, submit payroll registers. Submit copies of updated organizational charts and/or Memorandums of Understanding to show shared management agreement. Report on number of programs in three rural counties meeting stated objective. The educational program has been developed which is an integral component of the selfmanagement approach to diabetes. The following personnel have staffed the BSMOD program: Diabetic Nurse Educator, Registered Dietitian, and Data Entry Clerk. As expected, some of the original staff has been replaced over the course of the last 36 months. There are no updated organizational charts or Memorandums of Understanding. The grant is being implemented as described in the original grant application. The diabetic program was offered to patients at 9 primary care sites in Pemiscot, New Madrid, and Dunklin counties in the Missouri Bootheel. Objective 2: Within three years of grant award, enroll 630 patients in the diabetes self-management program, enrolling all patients into the diabetes registry: 168 patients in Year One, 210 in Year Two, and 252 in Year Three. For the 3-year period there have been 346 patients referred to the program with 307 deemed eligible to participate (89%) in the BSMOD program. This is 49% of the total needed for the funding period. 5

6 Activities: Beginning March 15, 2007, recruit and enroll patients. We began recruiting and enrolling patients on March 15. Track and report the unduplicated number of patients enrolled monthly in the program and registry. This has been accomplished. Objective 3: Conduct baseline physical measures for all patients enrolled in the program at the time. This is included as part of the patients initial assessment, as possible. Activities: Perform hemoglobin A1c tests in patients. Perform fasting lipid profile, serum creatinine analysis, and urinalysis. Perform comprehensive foot exam at enrollment. This is included as part of the program protocols. This is included as part of the program protocols. This is included as part of the program protocols. Track and report mean baseline clinical measures monthly as stated in Activities section. This is included as part of the on-going data gathering process. Objective 4: During the third year of the grant, an additional 252 patients would be entered into the registry patients (70%) will participate in comprehensive diabetes self-management education patients (90%) will develop selfmanagement goals (80%) of the patients will meet their goals. For this reporting period there have been 78 new individuals enrolled in the BSMOD program. For this reporting period of this evaluation period, 67 of those enrolled have participated in comprehensive diabetes self-management education., During this evaluation period, there were 67 enrolled patients who developed selfmanagement goals. During this evaluation period, there were 16 patients who met their self-management goals. 6

7 Activities Develop curriculum and patient educational materials and begin educational program by February 15, Recruit patients, assess specific education needs, identify self-management goals, provide patientoriented education, and evaluate the achievement of goals on an ongoing basis. Plan an initial team visit with each patient. Refer to community resources or for specialist care as indicated. Work collaboratively with patients to refine shared self-care goals and action plans on an ongoing basis. Develop plan for ongoing contact between the patient and the appropriate team members. Provide ongoing individual education. Schedule weekly community-based education beginning March 20, Plan comprehensive annual visit to provide clinical interventions and reassess for complications. Modify plans accordingly. The first educational program began on March 15 th. Completed as planned. This is completed for each referred patient. Rather than include the entire team in the screening process, it is customary for the DNE to conduct a preliminary assessment to determine (1) clinical appropriateness for the program and (2) capacity to participate in the program. This is completed on a continual basis with each program participant. This is included as part of each patients individual treatment plan. This began on March 17. With this being a start-up program there has been no need yet for annual comprehensive visits; however, this will be completed when required. Track and report the number of patients entered into the diabetes registry. Track and report the percentage of patients entered into the registry that participated in diabetes selfmanagement education. Track and report the number and percent of patients that developed self-management goals. Report on number and percent of patients that met their goals. Submit samples of curriculum and patient education materials. Each patient evaluated for admission to the program is entered into the patient registry. This is being done on an on-going basis. This is being done on an on-going basis. These were previously submitted to the MFFH. 7

8 Objective 5: During each year of the grant award, 630 (100%) of all enrolled patients will participate in risk reduction activities. During the grant period 247 of the enrollees participated in risk reduction behaviors. Activities: Establish a program that addresses both clinical care needs and preventive behaviors. Identify patients at risk for diabetes complications. Assess factors relating to diabetes complications. Conduct group discussions about risk factor reduction and self-management issues. Determine the patients who have had diabetes complications or other co-morbidities in a previous two-year period. Assess for cognitive, psychological, and social barriers that limit participation in diabetes selfmanagement. Educate on being active, eating healthy, taking medications appropriately, monitoring blood glucose, problem solving, reducing risks of diabetes complications, and psychosocial adaptations for living with diabetes. Link to appropriate community resources to support self-management behaviors. Both clinical care needs and preventive behaviors are integrated into the treatment regimen. This is completed as part of the patient s initial assessment. Patients are administered a comprehensive initial evaluation. If there are related complications those enrolled in the program are referred to other providers as appropriate. Most commonly, patients are referred to their primary care physician who oversees the treatment plan. Group meetings are offered as part of the program, as appropriate. This is included as part of the initial evaluation. This is included as part of the patient s initial evaluation. We are finding that many of those patients referred for evaluation prohibit or impede their ability to participate in this program. This is included as part of our standard treatment protocols. Patients are referred to community resources as needed. Track and report the number of patients that participate in risk reduction activities as described This is being tracked on an on-going basis. 8

9 in Activities section and duration of activities. Objective 6: At the end of the three-year grant period, of the 630 patients enrolled in the program: (90%) will have had two HbA1c s, at least three months apart (70%) will have had blood pressure reading less than 130/80 at last reading (90%) will have had a comprehensive foot exam annually (90%) of the 630 patients will have had an influenza vaccination. This program period there were 307 individuals enrolled in the BSMOD program. The results indicated that 85 individuals met this criterion. There were 90 program participants that achieved this objective. Sixty eight (68) enrollees had a foot exam as indicated. There have been 82 individuals who received influenza vaccinations the 3-year evaluation period. Activities: Assess HbA1c values; evidence of microalbuminuria; smoking habits; alcohol use; or family history of diabetes complications. Offer group discussions about risk factor reduction and self-management issues; Determine the patients who have had diabetes complications or other co-morbidities in a previous 2-year period to identify who will require more extensive resources and frequent follow-up. Identify patients at break points that include new onset of diabetes, HbA1c consistently above eight percent, new onset of significant complications, frequency of uncontrolled hypoglycemia, or initiation of insulin therapy. Assess for cognitive, psychological, and social barriers that limit participation in diabetes selfmanagement. Educate on being active, eating healthy, taking medications appropriately, monitoring blood glucose, problem solving, reducing risks of diabetes complications, and psychosocial adaptations for living with diabetes. These interventions are included as part of the on-going program. This is part of the evaluation process. This is part of the standard evaluation process. This is part of the program that we ve developed. 9

10 Link to appropriate community resources to support self-management behaviors. There were multiple community resources that facilitated the BSMOD grant in one way or another, as follows: MU Extension Center; Butler County Health Department; New Madrid County Health Department; New Madrid County Schools; Hayti Schools; Caruthersville schools; Cooter schools; First Baptist Church in Hayti had a cooking class; Caruthersville Community Center (Dalton Center) had a walk-to-walk program with pedometers; United Migrants Patient Services (Hispanic population) which required the use of a translator; Tri-County Diabetes and Hypertension Task Force; Heart and Soul gym; Kids Beat in Lilbourn; Nutrition Center in Kennett; Hayti Nursing Home; and the Women s Club in Hayti. Track and report the number and percent of patients who have had two HbA1c's, at least 3 months apart. This indicator is being tracked with the data gathered on a continual basis. Many of the individuals have seen dramatic reduction in their HbA1c's. This was reported earlier in this evaluation. Report the aggregate A1c scores Track and report the number of patients with a blood pressure reading less than 130/80 at last reading. Track and report the number and percent of patients that received a comprehensive foot exam in the past year. Track and report the number and percent of patients that had an influenza vaccination in the last 12 months