This product was developed by the University of Missouri-Columbia Department of Family and Community Medicine for the Better Self Management of Diabetes Program, with grant support from the Missouri Foundation for Health.
Diabetes-related health outcomes and clinical staff perceptions about transformed roles in a rural primary care practices implementing the Chronic Care Model Joseph W. LeMaster, MD, MPH Tamara Day, RN, BSN University of Missouri Columbia AHRQ 2009 National PBRN Conference June 25, 2009
BACKGROUND There is a 17% higher rate of DM Type II in rural vs. urban Missouri. Rural areas have severely limited resources to support practice re-organization and/or help improve patient self-management skills.
QUESTION What is the effect of self-management behavior promotion on behaviors and selected health outcomes among rural Missouri patients with diabetes?
About the Study 6 rural clinics in two Mid-Missouri counties. All providers and selected staff from each clinic. 1,098 patients diagnosed with DM Type II.
INTERVENTION Interventions based on the Chronic Care Model technique (goal-setting, patient and provider reminders/prompts to ensure standard of care). Quasi-experimental intervention. Model uses practice nurse case-managers (LPNs) who identify patients at high risk of treatment failure. A simple electronic registry/reporting system is used.
OUTCOME MEASURES/DESIGN Mixed-method pre/post analysis including: Quantitative measures including HbA1c, LDL cholesterol, BP and reported self-care behaviors over one year of patient participation. Qualitative investigation of healthcare staffs (nurse, physician) perceptions related to practice transformation. Both approaches compare baseline to 1 year changes
RESULTS: INTERVENTION Participating clinics were able to: Increase promotion of self-care behavior changes Use of self-care goal sheets Nurses follow-up regarding self-care goals Integration into patient flow varies
RESULTS: QUANTITATIVE Blood pressure reduced throughout clinics compared to control (SBP -5, DBP -2 mm Hg). Neither LDL cholesterol nor HbA1c showed significant improvement. Mean LDL at baseline was 102.8 Mean A1C at baseline was 7.3 Proportion moving from poor to good control also minimal
RESULTS: QUANTITATIVE Self-care questions asked: 1. On how many of the last SEVEN DAYS have you followed your eating plan? 2. On how many of the last SEVEN DAYS did you eat five or more servings of fruits and vegetables? 3. On how many of the last SEVEN DAYS did you do any physical activity of moderate intensity (for example: brisk walking, swimming, biking, gardening, or any other activity that causes increases in breathing and heart rate)?
RESULTS: QUANTITATIVE Change in responses: 1) Followed meal plan 5+ days: (-) 17 to (+) 33% (varied by clinic) 2) Ate fruit and veg 5+ days: (-)5 to (+) 26% (varied by clinic) 3) Physical activity:
Limitations Data are not yet complete (some 1 year follow-up questionairres still coming in) Analyses so far are cross-sectional (i.e. we are comparing mean results of all reported data at each time point, but have not yet performed longitudinal analysis, which may differ
RESULTS: QUALITATIVE Qualitative analysis of providers during recorded patient visits revealed: emphasis on clinical measures minimal exploration of patient goals little physician collaboration with nurse regarding patient goals over-reliance on checklist approach
CONCLUSIONS Clinic-level interventions ALONE may not be enough to change outcomes What is the optimal role of patient/community engagement in the process?
WORKING ON WELLNESS (WOW) Contest Collaborative effort between project & grocery chain with locations in each county. Contest to focus on increasing daily exercise and intake of fruits and vegetables (NOT weight).
WORKING ON WELLNESS (WOW) Contest Teams of 2-5 people Contest lasted 6 months Grant provided educational activities. Grocery chain provided $250/team prize money per county. Overall winning team in both counties received and extra $250.
WOW Contest Results
Conclusions Programs need to be simple, small steps, with easily obtainable goals Community and/or social support are as/more important than medical support for behavior change ( for diet and exercise especially!) Amount of motivation is not driven by size of incentive
What s Next? Complete longitudinal analyses Future interventions: Include patients earlier in planning, development and content Focus on physician buy-in and support to promote positive self-care behaviors Increase cross-talk between clinic- and community-based patient advisory