Project targets diabetes in Latino community

'Secondary gains' affect willingness to accept help

The "yes-means-no" phenomenon was one of several challenges encountered by the team conducting a community case management pilot project for diabetes patients in Nogales, AZ, says Donna Zazworsky, RN, MS, CCM, FAAN, diabetes care center manager for the Tucson-based Carondelet Health Network.

The project — which targeted emergency department (ED) "frequent fliers" with diabetes — focused on establishing the care team and developing a case management toolkit for home diabetes education visits, she adds.

"Nogales is primarily a Latino community, with a very high incidence of diabetes," Zazworsky notes. "Carondelet Holy Cross Hospital 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


This helped people who were hospitalized, but the process missed those ED frequent fliers 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 in Nogales 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.

As part of the pilot project, the team used assessment tools from the Case Management Adherence Guidelines (, as well as a risk assessment tool already in place for Carondelet diabetes inpatients, Zazworsky adds.

The tools were translated into Spanish by a licensed translator from the area who works with the Carondelet system, Zazworsky says.

"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," she 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 handoff so that the patient was aware of the program."

To facilitate that process, Zazworsky notes, the ED nurse made 3x5 note cards explaining that the nurse case manager would call 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.

The project evaluation process showed that even with short-term nurse case management interventions in the home, the target goal of 4.5 out of 5 in confidence levels was met in these areas:

  • make healthy food choices (4.5);
  • identify foods with carbohydrates (4.5);
  • find diabetes information and support (4.5);
  • detect and take action for low blood sugar (4.8);
  • examine feet for problems and know how to care for them (4.6);
  • work with a health care provider (5).

(Editor's note: Donna Zazworsky can be reached at