The Grantees of the Better Self-Management of Diabetes Program

Transcription

1 The Grantees of the Better Self-Management of Diabetes Program

2 Funding for this project was provided in whole by the Missouri Foundation for Health. The Missouri Foundation for Health is a philanthropic organization whose vision is to improve the health of the people in the communities it serves. Copyright 2009 Washington University in St. Louis

3 BETTER SELF-MANAGEMENT OF DIABETES A Program of the Missouri Foundation for Health Preface The Missouri Foundation for Health designed the Better Self-Management of Diabetes (BSMOD) Priority Area Grant to support the implementation and expansion of the nationally recognized Chronic Care Model developed for the management of chronic illness at the primary care level. The program focuses on the self-management component of the model and its application to improving diabetes care. The mission of the BSMOD program is to demonstrate that collaborative, multi-component, self - management diabetes programs can be delivered in a variety of health care and community settings, including those with high-risk, low-income, uninsured, underinsured, or underserved populations. The Missouri Foundation for Health provided two rounds of funding beginning in December Eight sites were funded in December 2006; eight more were funded in October Each of the 16 sites was awarded a 3-year grant. The BSMOD grantees were funded to develop and implement comprehensive diabetes selfmanagement programs and integrate these into their organization s services. Specifically, grantees were asked to address Education and Skills Training for Patients Training for Providers and Care Teams Collaboration with Community Partners Follow-Up Care and Communication Program Sustainability This booklet describes each of the sixteen BSMOD grantees and the communities they serve. For each grantee, key intervention strategies and key accomplishments to date are included.

4 TABLE OF CONTENTS Round One Grantees Barton County Memorial Hospital.. 1 CoxHealth Diabetes Center 3 Jordan Valley Community Health Center. 4 Mississippi County Health Department. 6 Missouri Highlands Health Care 8 Morgan County Health Center.. 10 Pemiscot Memorial Health System. 12 University of Missouri-Columbia, School of Medicine 14 Round Two Grantees Grace Hill Neighborhood Health Centers, Inc Hannibal Regional Hospital 18 Myrtle Hilliard Davis Comprehensive Health Centers, Inc. 20 Northeast Missouri Rural Health Network.. 21 Pike County Health Department, Home Care & Hospice.. 23 St. John s Mercy Hospital. 25 St. John s Regional Medical Center. 27 Washington University Diabetes Center at Barnes-Jewish Hospital 29

5 BARTON COUNTY MEMORIAL HOSPITAL BCMH Better Self-Management of Diabetes Barton County Memorial Hospital (BCMH) serves as the sole hospital with an ADA-recognized diabetes education program in the rural Southwest Missouri counties of Barton, Cedar, and Dade. Many of these counties residents have difficulty attaining medical care due to poverty and lack of transportation. This area is also experiencing an increase in its Hispanic population, which creates a need for translational services. The Better Self-Management of Diabetes program at BCMH focuses on providing patients with diabetes an opportunity to gain the knowledge, confidence, skills, and tools to live well with their chronic disease. By training BCMH healthcare providers at key points of care including emergency room, inpatient, rural clinics, and cardiac rehabilitation, the program aims to increase availability of patient diabetes self-management support. The program has facilitated selfmanagement training by identifying patients with Key Intervention Strategies: Out-patient Diabetes Self-Management Education Program In-patient Diabetes Self-Management Education Program Group visits in hospital clinics Diabetes Support Group diabetes and giving them a culturally relevant packet containing informational sheets such as a diabetes self-management goal sheet, Basic Meal Planning Guidelines for People with Diabetes, Getting the Very Best Care for Your Diabetes, All About Blood Glucose for people with Type 2 Diabetes, Goals for Control, and an information sheet outlining the BCMH Diabetes Education program. To accommodate the rural patients of the surrounding area who might find it difficult to attend the various appointments necessary for their diabetes care, BCMH arranged for quarterly group visits held in hospital clinics. The group visits, which serve 8 to 10 patients at a time, provide patients with the opportunity to learn basic diabetes self care; receive individual counseling for nutrition and goal setting; review their weight, blood glucose, and medication-intake; and meet with a provider for a wellness exam. By attending a group visit, patients can receive a variety of services and diabetes selfmanagement training in one day and at a reduced cost. Follow-up is done with patients who attend the group visits as well as every patient seen in the Diabetes Education Department. Referring physicians are sent a follow-up form every six months to 1

6 allow the department to monitor patient improvement in health indicators such as weight, blood pressure, and latest lab results. The Diabetes Education Department at BCMH also offers several other services to members of the community. They have partnered with the University of Missouri Extension Service to offer the Stay Strong, Stay Healthy exercise class, the Eat Well, Be Well with Diabetes cooking classes, and the Living a Healthy Life With a Chronic Condition program. They have also collaborated with area schools in offering nutrition education and diabetes education for students. The Diabetes Education Department coordinates an annual Community Health Fair every fall and a Diabetes Health Fair every spring. These health fairs are widely supported by the business in the community and are a wonderful picture of collaboration helping people choose health over illness. The Diabetes Education Department is frequently asked to provide presentations to community and civic organizations. In Key Accomplishments: Improved record keeping Measurable outcomes Physicians more receptive to education program Better communication with physicians offices A BCMH diabetes self-management education class in progress addition, the Department hosts monthly diabetes support groups and a reimbursable Diabetes Self- Management Follow-up class. One of their newest services is a foot clinic in which patients are seen every six to eight weeks and diabetes education and foot care are included if applicable. The extensive services that the BCMH Diabetes Education Department provides exemplify their commitment to wellness in their community and serve to promote their hospital as a site for trainings. BARTON COUNTY MEMORIAL HOSPITAL 29 N.W. 1st Lane Lamar, MO Phone:

7 COXHEALTH DIABETES CENTER Diabetes CARE Project The CoxHealth Diabetes Center is a recognized leader in diabetes care in Southwest Missouri. The Diabetes Center has achieved American Diabetes Association recognition every three years since 1990 to assure the program meets the National Standards for Diabetes Self-Management Education Programs. Ten percent of the patients seen at the Diabetes Center are uninsured or underinsured. These patients tend to be at the highest risk of diabetes complications due to their socioeconomic status or their cultural beliefs regarding diabetes and its management. The Better Self-Management of Diabetes program at the CoxHealth Diabetes Center seeks to ensure that all patients confidence in their ability to selfmanage improves and that they have the necessary tools and skills to do so. Because cost is a major barrier to receiving care for the uninsured and underinsured, the Diabetes Center provides these patients with the opportunity to participate in the program at no charge. In this way, the program eliminates a barrier to care so patients are free to access programs and services that support their health and wellness. As a way to create awareness of their healthcare opportunity, the Diabetes Center regularly runs ads in several local publications to engage different populations such as the Native American, Latin American, and African American communities. To effectively respond to the needs of different audiences and provide culturally competent care, the staff at the Diabetes Center practices Key Accomplishments: Decrease in ABC (A1C, Blood Pressure, & LDL cholesterol) levels for Case Management participants Routine documentation of goals High level of goal attainment among participants Key Intervention Strategies: Motivational Interviewing Goal setting Group visits in hospital clinics Continuity of care / education / support case management and utilizes Motivational Interviewing. Motivational Interviewing involves reflective listening, open-ended inquiries, and empathy to ensure patientcenteredness and improve communication among patients and providers. The patient-centered care offered by the Cox- Health Diabetes Center allows patients to plan all interventions and activities in collaboration with their primary care provider. These interventions include diabetes selfmanagement training, nutrition and meal planning counseling, development of physical activity plans, behavioral health counseling, smoking cessation assistance if necessary, and referrals to specialists and community partners. The Center even provided free taxi vouchers to those in need of transportation to and from their appointments. Patients are encouraged to set goals for themselves and to keep a copy of this goal in a visible place. To assist patients in achieving their goals, a copy of their goal sheet is kept in their file at the Diabetes Center and given to their primary care physician so it can be discussed at appointments. Through these approaches, the Diabetes Center provides education and individualized support for self-management and behavior change, which also helps fulfill the Center s mission. COXHEALTH DIABETES CENTER 1423 N. Jefferson Springfield, MO Phone: Website: {search: DIABETES} 3

8 JORDAN VALLEY COMMUNITY HEALTH CENTER Advocates for a Healthy Community, Inc. The Jordan Valley Community Health Center is a federally qualified health center that serves patients in Southwest Missouri, including Springfield and Marshfield. According to the 2000 census data, 51% of this target population has incomes at or below 200% of the federal poverty level. This population is also undergoing a high level of unemployment. As a result, a large portion of the target population cannot afford the diabetes selfmanagement and education services available in the area. Through the development of a program based on the American Diabetes Association s 2006 Key Intervention Strategies: One-on-one education in exam rooms per provider referrals, addressing selfmanagement services, weight loss, and smoking cessation Monthly diabetes class Smoking cessation classes in the clinic Community diabetes education classes, and one-on-one education with gestational diabetes patients Educational DVD promoting selfmanagement services Standards in Medical Care-Diabetes and the Chronic Care Model, the Better Self-Management of Diabetes program at the Jordan Valley Community Health Center aims to improve the health outcomes of diabetic patients. This program utilizes evidencebased care and fully integrated self-management support, which includes lifestyle education, goal setting, and improved access to community resources. The addition of a diabetes educator and a dietitian to the Jordan Valley staff allows the program to provide specialized care to patients with diabetes. The program promotes diabetes selfmanagement by providing one-on-one and group self-management education. This education primarily focuses on understanding diabetes, nutrition, physical activity, weight loss, and smoking cessation. Educators work with patients to establish goals, and a staff member follows up with each patient to check progress towards the goal and help the patient overcome barriers. Providers are also involved in the goal setting process by documenting patients goals at each encounter. 4

9 Patients can also obtain selfmanagement information from the Diabetes Management Center s website. The online center has tips for selfmanagement, a list of services the center provides, diabetes related publications, diabetes self-management videos, and an option to ask the staff questions. The videos cover a variety of topics including basic diabetes information, exercise, foot care, medications, complications, basic diet principles, food labels, and portion control. The Jordan Valley Community Health Center also distributes a quarterly newsletter about diabetes to all of their patients with diabetes. In One-on-one diabetes self-management education sessions are a key intervention strategy at Jordan Valley Community Health Center addition, the Health Center provides patients with the opportunity to receive screenings and care from an optometrist and dental hygienist once a month at a reduced rate and at a familiar location. Key Accomplishments: 547% increase in patient education encounters from year one to year two Conducted nursing in-services to increase recognition of patient education needs Developed Education to Go DVD highlighting self-management services As a result of the variety of services offered by the Jordan Valley Community Health Center, residents of the Springfield area are able to take an active role in learning about and improving their health. JORDAN VALLEY COMMUNITY HEALTH CENTER 630 W. Kearney Springfield, MO Phone: Website: diabetes/index.html 5

10 MISSISSIPPI COUNTY HEALTH DEPARTMENT Diabetes Management Center The Mississippi County Health Department s Diabetes Center serves a population in which the prevalence of diabetes, lack of health coverage, and number of residents with fair to poor health status is higher than Missouri s overall average. As such, the Better Self-Management of Diabetes program at Key Intervention Strategies: Assure all patients have a primary care provider and receive routine follow-up care per Diabetes Standards of Care Provide A1c and lipid panel work for those patients with little or no insurance Work with local physicians and nurse practitioners to increase awareness of services offered at the Diabetes Center and to review the Standards of Care Provide educational opportunities for local professionals to enhance diabetes knowledge and improve diabetes care Provide DSME classes, peer support groups, and outreach services Provide glucometers and strips to patients meeting guidelines the Diabetes Center focuses on patients who typically do not engage in diabetes self-management behaviors or seek routine health care or preventive services due to affordability, accessibility, or efficiency of those services. To better serve this population, the Diabetes Center met the requirements of the American Diabetes Association to be a Recognized Education Program, which allows the program to bill Medicare for diabetes education. The Diabetes Center arranges for diabetes patients to receive case management and patient education at their point of service by providing registered dietitians who work with local physicians and nurse practitioners to implement the American Diabetes Association s Standards of Care. Unlike other diabetes education programs offered in the area, the Better Self-Management of Diabetes program at the Diabetes Center is offered at no charge to patients. By coordinating free educational services with medical appointments, the Diabetes Center is able to reduce the number of appointments and transportation needed for patients who might otherwise be unable to attend due to time 6

11 and financial limitations. Another benefit of delivering the education in conjunction with the primary care office visit is that it enhances patientprovider communication by allowing the care provider to get involved in the patients selfmanagement training. The education provided by the Diabetes Center is offered in a way that encourages patients to take a more active role in their care. Patients are counseled on problem solving and setting reasonable goals so they can carry out self-management Key Accomplishments: Improved referrals from local physicians and nurse practitioners Increased awareness and utilization of the Diabetes Standards of Care among local providers behaviors. To facilitate patients achievement of self-selected behavior change goals and improvement in self-efficacy, the Diabetes Center practices intense follow-up including phone calls, one-on-one visits, and peer support groups. In addition to providing education at point of service, the Diabetes Center also conducts outreach programs on a monthly basis throughout the community at places such as senior nutrition centers, local banks, retail stores, schools, and churches. The outreach programs are used to increase awareness of diabetes, screen at-risk individuals, and refer patients to the program. By making health care education and screening accessible to community members, the Diabetes Center is accomplishing its goal of facilitating diabetes prevention and control within Mississippi County. Increased awareness of diabetes in Mississippi County Increased availability of services for those with diabetes and pre-diabetes Achieved recognition by the ADA as a certified provider of Diabetes Self- Management Education Increased follow-up rates and tracking of enrolled patients through use of the DiaMed data system MISSISSIPPI COUNTY HEALTH DEPARTMENT 1200 East Marshall Charleston, MO Phone:

12 MISSOURI HIGHLANDS HEALTH CARE Diabetes Self-Management in Rural Communities Missouri Highlands Health Care serves the rural population of Butler, Carter, Iron, Reynolds, Ripley, and Shannon counties in the Ozark Highlands. This area suffers from extreme poverty, with 48% of its residents having incomes below 200% of the federal poverty level. As a result, Missouri Highlands Health Care caters to the uninsured, underinsured, and medically underserved and provides health services to anyone seeking care, regardless of insurance coverage or ability to pay. Although the organization offers these services, many residents tend to delay seeking medical care and are more likely to use hospital emergency departments for primary care. Others are unable to seek care at Missouri Highlands Health Care due to a lack of transportation. The Better Self-Management of Diabetes (BSMOD) program at Missouri Highlands Health Care aims to assist patients in developing the Key Intervention Strategies: Individualized diabetes education with a nutritionist in the clinic site Community group education classes Participation in Quality Improvement Initiatives in chronic disease management confidence, capacity, and motivation to perform the appropriate self-management behaviors and the problem solving and coping skills to overcome barriers to self-management behaviors that enhance their physical and psychological wellbeing. By providing self-management education and support, the program hopes to improve health outcomes, including the six core national measures for diabetes and the BSMOD core measures. Missouri Highlands Health Care has facilitated self-management services by collaborating with 10 primary care clinics in six rural counties. These clinics refer patients for self-management counseling and education services. Missouri Highlands provides the clinics with electronic versions of diabetes education materials so they can print out the educational tools for patients during clinic visits. The program also arranges for a nutritionist to conduct education and counseling visits at each clinic site on a monthly basis. In addition to referring 8

13 patients for self-management services, the clinics involved with Missouri Highlands Health Care s diabetes program also document patients selfmanagement goals as a way of tracking their progress and encouraging them to achieve their goals. Missouri Highlands Health Care collaborates with other partners in the community to promote participation in self-management education. As a result of these community partnerships, area clinics and nutrition centers encourage their patients to participate in classes or individual education sessions. Participants report positive results such as learning more about diabetes, seeing improvements in blood glucose levels, and having the skills to plan a meal. Together with area organizations, Key Accomplishments: Improvement in patient clinical measures Improved continuity of care for patients because 100% of Missouri Highlands Health Care providers make referrals to the nutritionist Missouri Highlands Health Care is improving diabetes self-management for the residents of the Ozark Highlands. MISSOURI HIGHLANDS HEALTH CARE Strengthened community partnerships as a result of a collaborative approach to group education classes P.O. Box 157 Ellington, MO Phone: Website: 9

14 MORGAN COUNTY HEALTH CENTER 6.5 Steps Toward Better Sugar Control in Central Missouri The Morgan County Health Center was the lead agency for the Jack Gunn Community Clinic, a volunteer-based primary care clinic for residents of Camden, Morgan, Miller, and Moniteau Counties. Since May of 2006, the Jack Gunn Community Clinic has relocated to a separate building to better serve the growing numbers of uninsured patients. Morgan County Health Center and Jack Gunn Community Clinic continue to have a strong relationship and are continually referring services to one another. In cooperation with the Jack Gunn Community Clinic, the Morgan County Health Center caters to the people who face the greatest barriers to care, most commonly Key Intervention Strategies: One-on-one diabetes nutrition counseling with a Registered Dietitian Free one-year membership to area gyms Monthly support group meetings led by Registered Dietitian Water aerobics classes offered at indoor and outdoor pools Blood glucose monitors and testing supplies provided Cholesterol and Hemoglobin A1c testing provided the low-income and uninsured residents. The Morgan County area is home to more than 250 Mennonite families and a growing Ukrainian population. The culture and customs of these populations as well as their tendency to be uninsured can cause significant barriers to receiving necessary healthcare. The Better Self-Management of Diabetes program at the Morgan County Health Center utilizes the American Association of Clinical Endocrinologists educational campaign, 6.5 Steps Toward Better Blood Sugar Control, to provide patients with information and guidance for managing their diabetes. The program aims to empower patients to make better health choices and bring their diabetes under control through the use of the cornerstones of effective diabetes management eating healthy, being physically active, monitoring blood sugar, seeing a healthcare professional, and taking medication when appropriate. The Morgan County Health Center encourages dedication to the program by having the patients and their provider sign patient-provider contracts promising to follow a system of intensive diabetes self- management. The contract confirms the 10

15 patient s commitment to a system of healthy eating, exercise, medication, and self monitoring and the physician s promise to provide leadership for a diabetes team that includes the physician, a registered dietitian, and a registered nurse. As part of the program, patients can receive one-on-one nutrition counseling from a registered dietitian as well as diabetes education from a registered nurse. A monthly newsletter is sent to clients to keep them informed about the Health Center and provide additional information on diabetes. The program also offers a support group in which participants can discuss their problems and achievements in managing their diabetes. Meetings are advertised in the local newspaper and continue to have a large turnout. Morgan County Health Center s Better Self- Management of Diabetes program also offers services outside of the clinic. The program conducts health fairs throughout Morgan and Moniteau counties. Screening clinics are offered at numerous faith-based organizations to make the services more accessible to residents. The program arranged for swimming classes Key Accomplishments: Patient satisfaction with services and improved goal attainment Successful morning Aquacise water aerobics classes High level of support and referral from area doctors Library collaboration that resulted in creation of a section dedicated to diabetes education Successful first Lunch and Learn cooking demonstration Seven diabetes screenings in Morgan and Moniteau counties that also included education Developed a plan to open a satellite clinic in Laurie, MO to be held several times a week at no cost to their participants. Classes are offered at an outdoor pool during the summer and transportation is made available for clients to attend an indoor water aerobics class. The Health Center has also partnered with the local optician and local fitness centers to obtain services at reduced costs for their diabetic clients. By involving community organizations in their approach for Better Self-Management of Diabetes, the Morgan County Health Center is able to assist their clients efforts to carry out the components of effective diabetes management in their daily lives. MORGAN COUNTY HEALTH CENTER 104 W. Lafayette Versailles, MO Phone:

16 PEMISCOT MEMORIAL HEALTH SYSTEM Better Self-Management of Diabetes Program The Pemiscot Memorial Health System serves patients in Dunklin, New Madrid, and Pemiscot Counties, where the diabetes epidemic is growing at an alarming rate. The population that Pemiscot Memorial Health System treats is culturally diverse, low-income, and high risk. Despite this need for treatment and prevention practices, the area is medically underserved and a health professional shortage area. The Better Self-Management of Diabetes program at Pemiscot Memorial Health System coordinates senior leaders and health care providers at an acute care hospital and six rural primary care clinics to utilize the Chronic Care Model as a way of establishing an organizational approach to care for people with diabetes. Care teams comprised of a Key Intervention Strategies: Individual diabetes education in the clinic Group education in the schools and in community settings, including churches Mini health fair in collaboration with the clinic staff in Homersville, MO physician and/or nurse practitioner, diabetes nurse educator, and registered dietitian work collaboratively with patients to elicit their readiness to make behavior changes and agree on patientoriented goals and action plans. By facilitating interactions between an informed, activated patient and a prepared, proactive practice team, Pemiscot Memorial Health System aims to enhance clinical status, reduce diabetes complications, and improve health outcomes. The program strives to accommodate the various needs of their diverse population. An instructional team, including the diabetes nurse educator and registered dietitian develop individualized, patient-oriented educational plans for each patient. The educational materials created by the program are patient friendly and account for different cultural and learning styles. Educators work with the patient to develop and maintain healthy selfmanagement behaviors that improve health status. 12

17 The Pemiscot Memorial Health System plans clinical visits in both group and individual settings. These visits include an assessment, review of the care plan and self-management goals, problem solving, and development of a follow-up plan. Patients visit the health care team quarterly to ensure that behavior changes are sustained over time. In addition to seeing patients in a clinical communication processes with a network of medical specialists in order to assure that primary care providers have access to expert support in areas such as cardiology, optometry, podiatry, and dental. In doing so, Pemiscot Memorial Health System fosters productive interactions between care teams and patients in an effort to help patients become effective self managers and make healthier lifestyle choices in their everyday lives. setting, the program also facilitates access to community-based resources such as cooking classes, exercise programs, weight management programs, child care, senior meal programs, transportation, and prescription medication assistance programs. Pemiscot Memorial Health System has partnerships with local mental health providers to address patients psychological needs. The program has also arranged for streamlined Key Accomplishments: Collaboration with the United Migrant Opportunity Service to reach the Hispanic population PEMISCOT MEMORIAL HEALTH SYSTEM Collaboration with University of Missouri Extension to offer cooking classes, Conversation Map group sessions, and Pemiscot County Walk the Walk, a 10 week walking program P.O. Box 489 Hayti, MO Phone:

18 UNIVERSITY OF MISSOURI-COLUMBIA, SCHOOL OF MEDICINE Better Self-Management of Diabetes Program Improving access to diabetes self-care information and resources for people in two rural Missouri counties Callaway and Howard is the focus of the University of Missouri (MU) Better Self-Management of Diabetes (BSMOD) project. The project seeks to address selfmanagement needs by helping participating primary care practices develop an enhanced care model to support self-management among patients with diabetes, and by working with Community Advisory Boards to develop community-based activities and resources. Approximately 4200 people in Callaway and approximately 1000 in Howard County have diabetes. Most are adults age 45 and older; almost one-third did not complete high school and 70% did not attend college. Only 27% were employed and half had annual incomes under $25,000, with a disproportionate Key Intervention Strategies: Education and information sessions for patients based on established curricula Tracking and follow-up of patient data in participating clinics Quality of care improvement efforts in participating communities Health fairs and health screenings Classes, support groups, cooking demonstrations, exercise demonstrations number of those in poverty being non-white minorities. Forty-four percent reported that they never or rarely exercised and 28% rarely followed a meal plan. The BSMOD project includes MU University Physicians family medicine clinics in the towns of Fulton and Fayette as well as three private practices Fulton Family Health Associates, hospital-based Fulton Medical Clinic, and Family Health Inc. in Fayette. In each, the MU BSMOD project has (1) implemented a computer-based system, compatible with the clinic s medical records system, for tracking key clinical data of patients with diabetes, and (2) placed or identified a designated nurse (or in some cases a care team) to track key health indicators such as HbA1c, provide patient education, communicate with physicians about patient needs, and connect patients with community resources. Community Advisory Boards (CABs) that were formed in each county have representation from county health departments, community service agencies, primary care clinics, churches, local businesses and community volunteers. CABs meet monthly with the MU team for strategic planning and to carry out various services and activities aimed at connecting diabetic patients with resources for information, motivation and assistance. A MU outreach coordinator who works specifically with ethnic and socioeconomic minorities in the two counties and minority representation on both CABs ensure that the needs of underserved minority populations are considered in overall 14

19 strategic planning and that activities specifically aimed at reaching this population are included. Education and informational sessions are provided for patients who would otherwise have to travel to Columbia (approximately 30 miles) for diabetes education, and who may or may not have insurance coverage to pay for such services. In appropriate instances, transportation is provided to enable individuals to attend. These sessions are based on established materials and curricula such as Milner- Fenwick s Library of Patient Handouts for Diabetes Education, Healthyi Conversation Maps, and University of Missouri Extension s Eat Well, Be Well. Individual consultation and meal planning with registered dietitians is another key component of the project. BSMOD funding has helped underwrite Key Accomplishments: Support and buy-in from community businesses, organizations, and volunteers Providing nutritional education and meal-planning consultation not previously available in the target counties Active diabetes support group formed with coordination between nurse care coordinators and community volunteers, meeting monthly in Howard County churches Enthusiastic community response to WOW contest the cost of placing a registered dietitian in each county to provide one-on-one consultation and meal planning at no charge. MU Extension has provided dietitians to help lead educational and informational activities in each county. C&R Markets, a grocery store chain serving both Fayette and Fulton, is sponsoring a Working on Wellness (WOW) contest that launched in early 2009 and will continue throughout the year. Open to the community at large, the contest seeks to encourage good nutritional habits and physical activity by awarding points to participating teams for setting goals/action plans, tracking physical activity and intake of fruits and vegetables, and participating in WOW-sponsored activities such as exercise demonstrations and grocery store tours led by a dietitian. C&R is providing a $250 prize for the top team in each county, plus an additional $250 for the winning team overall. This community-initiated activity not only reaches out to those with diabetes, but also to a broader audience with the aim of helping to prevent diabetes and other chronic diseases. Currently under development is a MU BSMOD website ( featuring health tips, project information, information from the CABs, and links to other online resources. UNIVERSITY OF MISSOURI- COLUMBIA, SCHOOL OF MEDICINE Curtis W. and Ann H. Long Department of Family and Community Medicine M239 Medical Science Building, DC Columbia, MO Phone:

20 GRACE HILL NEIGHBORHOOD HEALTH CENTERS, INC. GHNHC Better Self-Management of Diabetes Grace Hill Neighborhood Health Centers, Inc. (GHNHC) provides health care through six community health centers in the City of St. Louis. GHNHC s diverse population has a number of economic barriers that contribute to poor diet, poor medication management, and limited physical activity, which lead to additional stress and poor diabetes selfmanagement. Patients are often unable to seek services for diabetes care and self-management due to a lack of transportation or an inability to afford the cost associated with these programs. The Better Self-Management of Diabetes program at GHNHC integrates the health center s Self-Management Goal Support Program with a Chronic Disease Holistic Self-Care Model as a way of expanding the scope and capacity, allowing the Key Intervention Strategies: 8 Visit Diabetes Module Diabetes Clusters Wellness Center Chronic Disease Self-Management Program Diabetes Conversation Mapping Grace Hill Chronic Disease Department health center to reach additional patients. The program established a Wellness Center at Grace Hill s Soulard-Benton Health Center, which offers multiple services in one location. The Wellness Center is available to all patients diagnosed with diabetes and operates within normal health center hours. Patients involved in GHNHC s diabetes program are taught holistic self-care practices by Health Care Coaches who are educated in conventional medical care. The coaches also empower the patients to take part in their own health care. Bilingual health coaches provide training to ensure that culturally appropriate care is provided. One of the main self-management practices taught is healthy eating. The Health Care Coaches aim is to improve the quality of the patient s diet by raising their awareness of what they eat, how they eat and how they feel, as well as combining this awareness with a better understanding of what their bodies need to achieve good health. To complement selfmanagement training, GHNHC also teaches 16

21 exercise and movement classes that provide physical benefits and stimulate relaxation. Group participation is used to facilitate self awareness and to provide patients with an opportunity to learn from each other and to give and receive acceptance, support, and inspiration from their peers. In addition to providing services at the Wellness Center, GHNHC also accommodates patients through the Diabetes Care Hotline. The hotline is a dedicated number for patients to call for Health Coaching regarding their diabetes or lifestyle modifications. Patients are also offered a Key Accomplishments: Expanded GHNHC to offer podiatry services Implementation and execution of a Diabetes Care Hotline Double the number of Diabetes Clusters offered each month Successful expansion of the Diabetes Lifestyle program classes to additional location Implementation of the Wellness Center within the Soulard-Benton Site All Health Care Coaches completed both the Chronic Disease Self- Management Program and Diabetes Conversation Mapping training Healthy eating is one of the main self-management practices taught by the Grace Hill Health Care Coaches. quarterly patient newsletter that includes a schedule of upcoming activities, promotes the diabetes hotline and shares success stories. As a way of helping patients overcome economic factors that limit their access to care, Grace Hill has established collaborations with community partners. These collaborations increase patients ability to obtain medications and medical supplies and facilitate access to community resources that increase patient opportunities for healthy eating and exercise. Through these outreach services and those provided at the Wellness Center, Grace Hill supports their patients with diabetes to make and sustain lifestyle changes and improve health. GRACE HILL NEIGHBORHOOD HEALTH CENTERS, INC Hadley Street St. Louis, MO Phone: Website: 17

22 HANNIBAL REGIONAL HOSPITAL Diabetes & Wound Ostomy Center The Hannibal Regional Hospital Diabetes & Wound Ostomy Center serves the rural communities of Marion, Ralls, Monroe, Shelbina, Lewis, and Pike counties in northeast Missouri. Many of the residents in these counties do not have primary physicians and therefore tend to put off seeing a physician for health concerns, often resorting to seeking care in the emergency department. Residents may find it difficult to obtain medical care due to a lack of reliable or consistent transportation or an inability to afford the travel to distant points of service. The Diabetes Center s Better Self- Management of Diabetes program focuses on Key Intervention Strategies: An integrated database management system Goal setting sheets for patients Follow-up for 3 years regarding A1c, blood pressure, weight, lipid panel, eye and foot exams Promotion and collaboration with the local physicians empowering patients by providing them with an opportunity to gain knowledge of risk factors and treatment options and the necessary skills to appropriately manage their own care. By providing education that assists patients with developing problem-solving and coping skills that affect behavior change, the Diabetes Center aims to ultimately decrease emergency room visits, extended-stay hospitalizations, and deaths due to diabetes complications. The Diabetes Center offers active group education sessions, which consist of no more than five patients and family support members. These groups meet for four sessions over a six-month period. To accommodate patients who may have difficulties finding or affording transportation, the Diabetes Center created a partnership with a local cab company to provide transportation at little or no cost to the patient or the organization. The care providers at the Diabetes Center, a registered dietitian and a registered nurse, are trained to 18

23 assess individual strengths and assist the patient in setting independent, attainable goals. Patients progress toward their goals is monitored at each of their group sessions. In addition to goal setting, the education provided at group sessions also teaches skills that build capacity among patients to take control of their diabetes through exercise, healthy eating, proper monitoring of blood pressure and glucose levels, and knowledge of diabetes complications and ways to prevent them. The program also offers other services to members of the community. A free monthly support group provides participants with an opportunity to discuss ways to manage and cope Marie Neimeyer, Dietitian and Certified Diabetes Educator, teaches a patient strategies for healthy eating. with diabetes. Each meeting is facilitated by a certified diabetes educator and features guest speakers who cover various topics including heart health, exercise, diabetes medicines, preparation Key Accomplishments: More efficient scheduling of patients Implementation of group classes and consistent return rate Development of new forms for reporting to physicians that replaced dictation Compilation of a binder of selfmanagement information for group class Development of an E-newsletter for physicians for traveling with diabetes, and yoga instruction. The Diabetes Center also offers a Diabetes Fair that includes foot checks, blood sugar and blood pressure screenings, and educational information. Through these activities, the Diabetes Center is able to encourage patients to take an active role in their own care. HANNIBAL REGIONAL HOSPITAL DIABETES & WOUND OSTOMY CENTER 6000 Hospital Drive Hannibal, MO Phone:

24 MYRTLE HILLIARD DAVIS COMPREHENSIVE HEALTH CENTERS, INC. MHDCHC Better Self-Management of Diabetes Myrtle Hilliard Davis Comprehensive Health Centers, Inc. (MHDCHC) provides individualized healthcare to the medically underserved population of St. Louis City, especially the uninsured and underinsured. Many of the patients seen at MHDCHC have difficulty engaging in self-management due to financial constraints, reading deficits, lack of support, consuming life events and/ or emotional issues. The Better Self-Management of Diabetes program at MHDCHC allows patients to work with a health care team to establish individualized treatment plans with self-management goals for exercise, medication management, healthy eating, weight management, glucose monitoring, and stress management. By involving the patient in decision making, the program hopes to empower patients to take an active role in preventing or reducing long-term complications of diabetes. MHDCHC utilizes a multidisciplinary Provider Coordinated Diabetes Care Team that involves the patient, a family member or significant other, a primary care provider, nursing support, health educators, nutritionist, medical social worker, podiatrist, ophthalmologist, dentist, and pharmacist. Members of the care team have been trained to assist patients who have educational, literacy, or cultural issues that make navigating the healthcare system difficult. Health educators address patient health literacy through a wide variety of information and materials designed to meet their needs. To evaluate and improve patients knowledge and understanding of diabetes and its complications the MHDCHC Better Self-Management of Diabetes program developed diabetes quizzes. By facilitating an understanding of the stages of diabetes, educators are able to demonstrate to patients the importance of following treatment plans and creating healthy lifestyles. To further enforce the importance of lifestyle changes, the organization developed an ABC card that patients use to record their A1c, blood pressure, and cholesterol levels. These cards increase patient awareness of test results and help them see how changes in diet, exercise, and medication usage affect laboratory results. Since exercise and healthy eating are key diabetes self-management strategies, MHDCHC provides patients access to exercise instruction and healthy food options. The program offers a one-hour onsite exercise session with a personal trainer three times per week. Exercise equipment including hand weights, stationary bikes, and exercise chairs for the elderly and physically challenged are available during these sessions. MHDCHC has also partnered with a local YMCA to offer free or reduced rate memberships to the Fit for Life program. The YMCA staff tracks patients progress and reports the data to the MHDCHC care team. To facilitate healthy eating, MHDCHC collaborates with HOPEBUILD, a nutritional program that provides an onsite fresh produce vendor. Gift certificates for fresh fruits and vegetables are given to patients to assist them in meeting their nutritional self-management goals. By providing access to these and other health improvement assets, MHDCHC supplies patients with the means to improve their health and quality of life. MYRTLE HILLIARD DAVIS COMPREHENSIVE HEALTH CENTERS, INC Dr. Martin Luther King Drive St. Louis, MO Phone:

25 NORTHEAST MISSOURI RURAL HEALTH NETWORK CareLink Regional Services for Better Self- Management of Diabetes Program Key Intervention Strategies: Implementation of the ADA seven-question risk assessment tool as part of the routine visit questionnaire Assessment appointments during which plans of care and initial goals are established The CareLink Regional Services for Better Self- Management of Diabetes Program is a collaborative project between multiple member agencies of the Northeast Missouri Rural Health Network to develop a coordinated system of care for uninsured, underinsured, and underserved type 2 diabetes patients in an eleven-county area. The program facilitates a means for early intervention, provides training for development of self-management skills and care coordination services, and links patients with other resources as needed. Within this region, all the counties have median household incomes far below the state average and 17% of the population reports income below the federal poverty level. It is estimated that 18.4% of this region is uninsured and while others may have health insurance coverage, they may not have benefits for diabetes education and support. Through educational sessions and dedicated followup, the CareLink Regional Services for Better Self- Management of Diabetes Program provides patients with the tools and support necessary to Patient encounter forms and care coordination documentation shared among providers and care team to track progress and assess needs Option of self-management group training or one-on-one education Use of handouts designed for patients with low literacy skills Routine follow-up contacts by patient navigators and care coordinator Implementation of provider diabetes flow sheet redesigned to encourage utilization of the ADA Clinical Practice Standards Transportation and prescription medication assistance services Assessment and self-management training conducted via telehealth when needed Community self-management classes successfully manage their diabetes, improve their health, and their quality of life. 21

26 The Northeast Missouri Rural Health Network (NMRHN) was created to achieve regional health improvements through collaboration, coordination, and sharing of services and resources Key Accomplishments: Partner clinics and health departments trained Continuous offerings of self-management classes throughout service region among its member agencies, which include health departments, hospitals, federally qualified health centers, an independent physicians association, ambulance districts, mental health providers, and nursing homes. For more information on the Network, its member agencies and other patient-based programs, please visit their website at Responded to unmet need to reach uninsured, at-risk women with gestational diabetes Implemented a patient navigator program Number of patients with A1c level less than 7 has increased Improved clinical procedures outcome measures Improved patient achievement in setting self-management goals Improvements made in following food plans Increased total number of minutes spent in physical activity NORTHEAST MISSOURI RURAL HEALTH NETWORK Program services extended to reach high risk patients with pre-diabetic conditions Provided care coordination for all patients completing self-management training 117 West Potter Avenue Kirksville, MO Improved referral and monitoring process Phone: Toll Free: Website: 22

27 PIKE COUNTY HEALTH DEPARTMENT, HOME CARE AND HOSPICE A1CMD: Anyone Can Manage Diabetes Pike County Health Department, Home Care & Hospice serves the low-income, uninsured, underinsured, and general population of Pike County. Records show that 44.5% of Pike County Hospital admissions are Medicare beneficiaries and 17.9% of adults in the area have no health coverage. In addition, 15.5% of the population is at or below federal poverty level and nearly 7% of the population is below 50% of the poverty level. Due to these financial constraints, many of the residents with diabetes are unable to access care and selfmanagement education. Key Intervention Strategies: Nutrition consultations Fitness consultations Diabetes medical visits Diabetes self-management education Support groups Social Services consultation Testing supplies provided Cooking classes The Better Self-Management of Diabetes program at Pike County uses a multidisciplinary team approach that includes a nurse practitioner, registered dietitian, fitness trainer, care manager, and diabetes educator working with the patient to achieve optimal outcomes. Because Pike County believes that participation of a primary physician is an essential component of disease management, the program strives to incorporate input from physicians in all areas of program design and implementation. By utilizing a data registry system, nurse practitioners and physicians are able to access useful data including adherence to the Standards of Care established by the American Diabetes Association, test results, diagnoses, health status, and selfmanagement goals, thereby facilitating effective monitoring of patient progress. 23

28 To expand the reach of the program, the collaborative team travels to three locations across the county on a rotating schedule. This allows patients who might otherwise not be able to obtain self-management support services due to lack of transportation or other access barriers to visit the clinic. Local churches and community centers provide space for the team to use as a community clinic. These community clinics accommodate uninsured and underinsured patients by allowing them to see the nurse practitioner or physician at no cost. While visiting the clinic, patients consult with the patient care team to review their monitoring logs, set selfmanagement and education goals, receive appropriate lab tests, and schedule appointments. The patient care team also provides selfmanagement education and screenings in the community, and a number of patients opt to participate only in educational services. One of the goals of the educational program is to improve patient health status by empowering the patient to make critical behavior changes that will prevent complications. The educational sessions provide Key Accomplishments: Services provided for people needing education and supplies/assistance in managing their diabetes have significantly increased Developed a Diabetes Coalition to encourage knowledge and prevention of diabetes in the community patients with easy access to professionals and ongoing supports to help them better manage their disease. Patients are encouraged to learn as much as they can and to establish their own goals for managing their diabetes. With support from the Pike County Diabetes Program, patients are taking a more active role in controlling their disease and improving their health. Assisted patients in getting medications via patient assistance programs Developed a mobile program, reaching more uninsured people Greatly increased referrals through active marketing PIKE COUNTY HEALTH DEPARTMENT, HOME CARE & HOSPICE 5 East Church Street Bowling Green, MO Phone: Website: 24

29 ST. JOHN S MERCY HOSPITAL Take Control The Diabetes and Wellness Center and McAuley Clinic at St. John s Mercy Hospital focus on treating poor and underserved residents of Franklin County. For many patients, transportation in this rural area presents a tremendous barrier to attending clinic visits and education classes. Financial barriers often result in patients having to choose between healthcare and food for their families. As a result of their inconsistent participation in their disease management, many of the patients seen at these clinics had previously been labeled as non-compliant by practitioners. However, St. John s Mercy recognizes that patients will improve self-management if they are given the right support. The Better Self-Management of Diabetes program allowed St. John s Mercy to implement a Key Intervention Strategies: Motivational Interviewing Individual and group classes with dietitian and nurse Patient database Lab work assistance Eye exam assistance Social worker assistance self-management component to the hospital s existing Take Control diabetes program. This program offers a team approach involving the primary care physicians in the community and the registered nurses, registered dietitians, and social workers in the Diabetes and Wellness Center at St. John s Mercy Hospital. Participants in the program can receive eye exams, medications and supplies, and lab work at reduced prices. Although these services resulted in improved health outcomes for participants, the program experienced a 25% drop-out rate. By adding a self-management component, the program aims to more effectively collaborate with patients in an effort to encourage their ongoing participation. One of the ways the program has implemented self-management is through the use of a goal-setting tool. Patients write down goals in their own words and are expected to bring this tool to each meeting. Coaches use this tool to facilitate 25

30 a review of accomplishments, barriers, and plans for future goals. To assist patients who are poor, the program connects them to the existing Take Control program. During the first three months patients are in the self-management program, they receive free or low-cost assessment, education, coaching, medications, supplies, lab tests, and support from a social worker who helps them apply for available assistance programs. A dietitian and registered nurse help patients get the care outlined in best practice guidelines. The registered nurse works closely with the patient s primary care physician making suggestions to prescribe a medication and care plan that are affordable and effective. Motivational Interviewing has broaden the staff s ability to assist their patients to better self-manage Key Accomplishments: Developed a new form, Stress Identifiers, that is used by the social worker to identify patients who need additional support Implemented the HeartMath Program Developed a diabetes information packet to send to community members on request Initiated a diabetes support group Developed a new patient goal form for use with all patients their chronic disease. Incorporating the techniques of Motivational Interviewing into the program has enabled the patient to take charge of their disease management. This has improved the quality of life and sense of well being for many patients. The program also established a monthly diabetes support group. The support group is a way of providing encouragement and fostering patient empowerment for healthy self-management of diabetes. The groups discuss a variety of topics including heart health, physical activity, shopping and cooking, label reading, and quality of life. Staff members have found that an interactive group session makes the learning process more effective. The hospital also offers a free diabetes education series for community members with diabetes and their families. Through these services, the diabetes program contributes to St. John s Mercy s mission to implement and advocate for innovative health and social services that improve the quality of life of individuals and families in the community, with particular concern for people who are underserved and poor. ST. JOHN S MERCY HOSPITAL 901 E. 5th Street Washington, MO Phone:

31 ST. JOHN S REGIONAL MEDICAL CENTER CSI-Diabetes (Collaborate for Self-Management Improvement in Diabetes) St. John s Regional Medical Center, a Joint Commission accredited hospital, seeks to build collaborations and initiate community-integrated services in order to fill gaps in the healthcare delivery system that affect the citizens of Jasper, Newton, and McDonald counties. Many of these area residents do not receive quality medical care due to multiple barriers including chronic illness, poverty, Key Intervention Strategies: Provide 5 two-hour sessions of diabetes self-management education to all participants Set short-term and long-term goals with patients Make follow-up visits, phone calls, and correspondence every 6 weeks or as needed Develop and offer support groups Market program to Medicaid providers to increase referrals Monitor individual patient progress and reward success Hold a Diabetes Day that allows patients to get their annual eye and foot screenings and dental care transportation, and language. The area experienced a 354% increase in its Hispanic population between 1990 and 2000, and this number continues to grow rapidly. The area has also experienced a substantial increase in adults living below the poverty line. Having a low income combined with being underinsured or uninsured prevents patients from getting regular, high quality medical care. The area is predominantly rural, with most core services located in the city of Joplin. Due to the high cost or lack of transportation, many people needing health and social services do not have easy access to them. Through the Better Self-Management of Diabetes program, St. John s Regional Medical Center partnered with four outlying community clinics to form the Collaborate for Self-Management Improvement in Diabetes (CSI-Diabetes) program. The goals of CSI- Diabetes are to improve meaningful access to health care, increase the health literacy of patients with type 2 diabetes, and empower patients to make long-term lifestyle changes. The program aims to achieve its goals by providing diabetes education, training patients in self-management skills, and implementing diabetes case-management services. 27