Diabetes care program addresses specific needs

Program addresses cultural differences

Project Dulce, a diabetes care management program housed at Whittier Institute for Diabetes in La Jolla, CA, has successfully addressed not only the difficult challenge of helping patients manage their diabetes, but also another issue of growing concern to quality managers: improving outcomes among minority populations.

Using a combination of trained diabetes educators, endocrinologists, and peer educators (minority individuals who have successfully managed their own diabetes), the program has achieved impressive results.

Project Dulce, partially underwritten by Scripps Health (which owns the Whittier Institute), has cared for more than 4,000 individuals at 17 sites since its inception in 1997. In its initial 18-month pilot program alone, Project Dulce was able to reduce the average hemoglobin A1c in 300 patients from nearly 12 to eight.

"We developed an approach we thought would work," recalls Chris Walker, MPH, director of strategic planning and development at the Whittier Institute. "We brought together endocrinologists, plus people who had worked in the community setting and knew how to approach diabetes patients. The program combines clinical expertise and community-based knowledge about how to reach [minority] populations."

Originally designed to serve Spanish-speaking patients, Project Dulce has expanded to include Vietnamese and Filipino patients. As a hospital-sponsored program, officials of the American Hospital Association and others believe it may offer a valuable model for other hospitals.

Pilot sets model

"The New Jersey Hospital Association has called and asked us to present to their groups; they're thinking of doing something similar there," shares Athena Philis-Tsimikas, MD, executive director and chief medical officer of the Whittier Institute.

The staffing in the original pilot program created the model for the full-blown program, says Walker. "We had one team — a diabetes nurse educator, a dietician, and a peer health educator," she explains.

"They provided clinical management, and the nurse educator and dietitian developed the whole curriculum to train people with diabetes to deliver diabetes education," she says.

The peer educator curriculum involves a 10-week course. The peer educators also are complemented in-hospital by the nurse educators, who use handouts from the course in Spanish, English, Vietnamese, and Filipino, Walker adds.

"The nurses and dietitians we work with are all certified diabetes educators; each has had about 10 years' experience in managing diabetes," Philis-Tsimikas adds.

When a patient is identified as having diabetes by a physician in one of the participating health centers (the community clinic system and primary care physicians are part of the program), they are referred to the project. "We explain the program to them in their native language, set them up for an appointment with the nurse, and enroll them in group education classes," says Walker.

The nurse conducts an assessment, which takes about an hour. "The nurse works with the patient to develop a care plan and does the clinical management in collaboration with the physician; she takes charge of labs and medication judgment, under the physician's guidance," says Walker.

Specialization is key

Some of the nurses are not bilingual, but each has an assistant who is, Walker continues. "After all clinical exams are done, the patients come in as needed," she shares. "We collect all the data and put it in an electronic registry, which allows us to track clinical outcomes and also to track patient activities — which of them, for example, has not had a recent retinal exam."

The specialized knowledge of the educators and dietitians, as well as the experiences of the peer educators, are key to the success of the program, she says.

"Look at the ease with which [the nurse educators] use insulin," offers Philis-Tsimikas. "You have a lot of patients with type 2 diabetes, of lower income, ethnically diverse, and they have let their disease go for quite a while; many have had the disease for 10 years and have had minimal care. You have primary care physicians who are very motivated but who deal with a lot of different diseases and conditions, and their level of expertise in insulin is not that great. So when you put in a person who can teach someone to start insulin 'in their sleep,' — or any of the meds required, for that matter — the patient looks at that person as an expert in diabetes."

Their experience also enables them to recommend the best possible combination of medications, she adds.

"And they are able to educate the patient about why it is important to take your meds, test your blood sugar, alter your diet, and so forth," she notes. "They work with them; that's important to the patients."

The peer educators complete the "package" of care. "They connect with them culturally," says Philis-Tsimikas.

Walker agrees. "They are from all different cultures; different belief systems impact their ability and willingness to manage their diabetes," she says.

"There might be the whole concept that the disease is their fate — that they might have done something wrong and there is nothing they can do about it. Yet studies show the key to improved self-efficacy is feeling you can control the disease. We address these issues in a culturally sensitive way and complete their education so they have more accurate information," she says.

It is that complete package that is so key, adds Philis-Tsimikas. "It is very hard to treat type 2 diabetes and get people where they need to be with their goals just with the peer educator," she says. "You really need the combination, because they each attack things from a different perspective."

Hospital-based programs

Just as the Scripps health organization is underwriting Project Dulce, says Philis-Tsimikas, other hospitals and health systems can pursue a similar model.

"Hospitals need to know there's a program they can send their hospitalized patients out to," she explains. "They might be admitted with something else, but if their blood sugars are running around 200 to 300 you might have to keep them in the hospital an extra two to three days — unless you know you have someone you can send them out to with whom you feel comfortable. In our communities, we are the program. Other hospitals can have the same sort of program set up in their own location."

That's just what Scripps Health has done, she continues. "Yes, we are subsidized, but we are able to bill for services, and we have made a really good effort to try and get as much reimbursement as possible so as to be self-sufficient; and we are pretty darn close. Scripps does help us with a little bit of the rent."

Better outcomes

It's important to remember, says Philis-Tsimikas, that setting up such programs not only helps the community, but it also helps the hospital in the long run.

"For one thing, we conduct monthly professional education programs; we teach in-hospital nurses how to better care for diabetes patients," she says.

The ability to reduce LOS for patients with diabetes becomes even more significant, she says, when you realize just how many patients who are hospitalized also have diabetes.

"Our hospitals here have recently gained the ability to look at the percentage of patients who have diabetes," she shares. "It ranges from 12% of all admissions in one hospital all the way up to 35%." One cath lab, she continues, reported 40% to 45% of its patients had diabetes.

"So we're not talking about a small number of people, but a large percentage of those patients in a hospital who are affected," she emphasizes. "They have longer hospital stays — by a day and one-half on the average. If you have outpatient education plus better inpatient care, you will get better outcomes."


For more information, contact:

  • Athena Philis-Tsimikas, MD, executive director and chief medical officer; Chris Walker, MPH, director of strategic planning and development, The Whittier Institute for Diabetes, 9894 Genesee Avenue, La Jolla, CA 92037. Phone: (877) WHITTIER.