AZ project targeted ED 'frequent flyers'

'Secondary gains' a factor

Education challenges faced by the organizers of a pilot project in Nogales, AZ, aimed at emergency department (ED) "frequent flyers" involved secondary gains experienced by patients who didn't participate and the cultural phenomenon known as "yes means no."

The project — which targeted diabetes patients who often received care in the ED — took place in what is primarily a Latino community, says Donna Zazworsky, RN, MS, CCM, FAAN, diabetes care center manager for the Tucson-based Carondelet Health Network.

"Carondelet Holy Cross Hospital in Nogales had started an inpatient case management program, where anyone hospitalized with diabetes would be seen by a nurse case manager/diabetes educator and referred to diabetes self-management classes held in the community," she notes.

This helped people who were hospitalized, but the process missed those ED frequent flyers with diabetes, Zazworsky says. "These individuals were not making their way to the classes.

"Many of these patients said that it was just too hard to get to the classes," she explains, "or there was a secondary gain they had. In one case, a gentleman wanted to get on disability and needed to get documentation, so he didn't want to get any better.

"Others wanted to [use their disease to] get attention from family," Zazworsky says. "They had the wherewithal to get to classes, but just didn't go."

Another barrier identified by the team was "the concept of 'yes means no,'" she points out. The phrase, used as the title of a book written in regard to Native Americans, also applies to Latinos, Zazworsky says. "It's not polite to tell you, 'No, I don't want to do that,' so they say yes."

Carondelet Holy Cross Hospital received a grant from the Arizona Department of Health Services to conduct the pilot project in March 2007, she says, and had to complete it by June 30. "We had to use [the funds] by the end of the fiscal year.

"We already knew the community nurse case management program would be funded beginning July 1, but we got the grant to fund the nurse to identify the tools, test them, and put them in place," Zazworsky adds.

"We had a tracking system in place for inpatients and were building a database for why we needed a program to extend beyond the walls of the hospital," she explains. "When the grant came along, it gave us the opportunity to put the structure in place for that program."

The program was promoted to the hospital's ED nursing supervisor, care manager, and social worker, each of whom was involved in shaping the pilot, Zazworsky says. "The program targeted only patients who came through the ED for a diabetes-related episode."

One of the objectives of the project was to reconvene the Nogales Diabetes Partnership Team, which had already been instrumental in establishing a number of programs and services related to diabetes for the Nogales community. The team met every other Thursday from noon to 1 p.m. over a period of seven weeks.

In addition to Zazworsky, that team includes a diabetes nurse practitioner with the Carondelet Diabetes Care Centers; the diabetes nurse case manager and several other clinicians and administrative staff with Holy Cross Hospital; and three representatives from the Mariposa Community Health Center in Nogales.

The behavioral health specialist from the Mariposa center was an active member of the partnership team, Zazworsky notes, attending the biweekly meetings and available to coordinate visits to his counseling program.

As part of the pilot project, the team used assessment tools from the Case Management Adherence Guidelines (www.CMSA.org), as well as a risk assessment tool that was already in place for Carondelet diabetes inpatients, she adds. "We were targeting everybody and trying to get a baseline on readiness, knowledge, and motivation."

The tools were translated into Spanish by a licensed translator from the area who works with the Carondelet system, Zazworsky says. "This is important to guarantee that we are using the appropriate terminology specific to our Latino region."

"The bottom line was that we were able to get patients into the program and agree to have a nurse case manager make a home visit," Zazworsky says. "The key was the ED nurse, who provided patient referrals to the community nurse case manager and explained the program to patients. There had to be some kind of hand-off so that the patient was aware of the program."

To facilitate that process, she notes, the ED nurse made 3 x 5 note cards, explaining that the nurse case manager would be calling to set up a time for a home visit in order to see how she could help the patient.

The nurse case manager would call within 24 hours to set up the visit, and would then make the visit within 48 hours, Zazworsky says. During the visit, she adds, the nurse case manager would use the tools to gauge the patient's knowledge, readiness, motivation and literacy level in regard to the diabetes.

Of 36 patients contacted about participating in the pilot, 20 — ranging in age from the 40s to over 70 — became part of the project, she explains. Fifteen patients actually completed the project, Zazworsky says.

Short-term outcomes, she adds, showed that "the tools worked, and helped guide the case manager on how to do her work, and there was immediate improvement in patients' levels of confidence."

As a result of the pilot, she adds, the partnership team will continue to monitor numbers to determine appropriate cutoffs for risk level, adherence level, and intervention strategies.

"We still have those outliers that refused services from the nurse case manager and continued to use the ED," she says. "We know as case managers that we are not able to convince everybody that they could benefit from our help."

One of the team's observations in regard to the outliers, Zazworsky says, was that high knowledge/high motivation does not equal better self care, and that, in fact, modifiers — such as the desire for more attention from the family — have a greater effect on patient behavior.

"When we realized that, we really wanted those patients to have some behavorial health [intervention], but they weren't willing to get the appointment, and it wasn't the kind of scenario in which we could have [therapists] come into the home."

One possibility for addressing that issue, she adds, is to look at "telebehavioral health" — a video phone setup that allows the therapist to work with the patient remotely.

"That can open the door to other modalities," Zazworsky says. "What it's about is building the trusting relationship."

(Editor's note: Donna Zazworsky can be reached at donnazaz@aol.com.)