Chronic care program helps diabetics manage

One-stop clinics, community health workers key

A chronic care program for diabetics at St. Elizabeth Health Center in Tucson, AZ, provides recommended care at a reduced cost and copay, helps them develop self-management goals, and supports them when they go back into their communities.

The program includes proactive care through planned visits and group visits, as well as education and follow-up by promotoras, or community health advisors. The clinic is able to offer the reduced costs by using local health taxes for safety net programs and accessing pharmacy assistance programs.

The clinic provides a wide range of medical, dental, and community services to more than 19,000 new patients each year and a total of 60,000 patient visits a year, according to Sr. Janet Sue Smith, ACS, RN, MAPS, director of community outreach, St. Elizabeth Health Center.

Patients who are eligible for treatment at the clinic are uninsured or underinsured. About 80% are Hispanic.

"We work to identify people with diabetes who are not getting consistent care and get them into the system. Our patient load changes frequently, because the Medicaid contracts change and people find themselves without coverage," Smith says.

The clinic is staffed by two physicians, two nurse practitioners, a dentist, and 150 volunteer providers.

To develop the chronic care program, the clinic worked closely with the Carondelet Health System and became a satellite center for that organization's group diabetes classes, according to Donna Zazworsky, RN, MS, CCM, FAAN, director of network diabetes care, faith community nursing and telemedicine for Carondelet Health Network also in Tucson, AZ.

The clinic staff tapped into the local YWCA's promotora program and trained the promotoras to work with diabetes patients.

A key component of the program is diabetes group visits, a one-stop monthly clinic during which patients see an ophthalmologist, podiatrist, and dietician as well as a primary care provider. They receive all the recommended tests and procedures for diabetes and receive diabetes supplies.

"Diabetics are referred to at least one diabetes group visit a year to ensure that they get foot checks, eye checks, and other tests. We encourage them to come to the clinic regularly to see a primary care practitioner," Smith says.

During the group visit, patients receive annual podiatry and retinopathy exams, recommended laboratory tests such as cholesterol and hemoglobin A1c tests, a pharmacy review, and a review by a primary care provider. They attend a group class and work with a promotora to set self-management goals.

Patients pay considerably less for a diabetes visit than for a typical fee-for-service visit for the same services. Funding sources that allow St. Elizabeth to offer the low rates include grants and donations.

The clinic also provides glucometers and glucometer strips at no charge or at a reduced cost. Insulin and syringes and oral medications are provided while patients are being coordinated into a pharmacy assistance program.

A year after the chronic care program began, the percentage of patients with a hemoglobin A1c of less than seven had increased from 18% to 38%. The target is 70%. The percentage of patients with an LDL cholesterol of less than 100 rose from 40% to 74%, exceeding the goal of 70%. The percentage of patients who develop self-management goals have increased from 78% to 98%.

"The key to success is an aggressive multi-dimensional approach through reminder calls, newsletters, and clinical flow sheets," Zazworsky says.

When patients are enrolled in St. Elizabeth's diabetes program, they receive a diabetes risk assessment that stratifies them as to their risk for diabetes.

The clinic provides care that fits with the patients' cultural backgrounds and in ways that they can understand, Zazworsky says.

All individuals with diabetes and pre-diabetes received a quarterly newsletter in English and Spanish and reminders of the diabetes days.

Patients who have diabetes come for quarterly visits with a primary care provider who refers them to a nurse and a dietician. The physicians also refer patients to diabetes self-management classes and diabetes group visit clinics.

Promotoras follow up with the patients either face to face, on the telephone, or in the home and help them work on their self-management goals.

"Communication is an important component. The patients need outreach between visits to help support them in meeting their goals," she says.

The clinic created a "Passport to Better Health" that shows the patient's actual and targeted hemoglobin A1c levels, blood pressure, cholesterol, and weight along with boxes to be checked off when the patient receives his or her pneumonia and flu shots.

The passports, available in English and Spanish, also include key target laboratory values for people living with diabetes along with advice such as getting regular exercise, seeing their provider every three months, taking medication as directed, and checking their feet daily.

"The passports are patients' report cards that provide consistent messages. They assess where the patients are in their disease process and help them learn what they need to do to control their disease," Zazworsky says.

The clinic's clinical information protocol form has built-in guidelines that trigger physicians when gaps in care occur.

During the diabetes group visit, the patients meet with promotoras who help choose goals to work on, such as walking three times a week or eating smaller portions.

The promotoras have been trained in motivational interviewing and help the patients develop goals that they are willing to meet.

They use a tool that helps patients measure their readiness to change on a scale of one to 10. For instance, they might ask "How ready are you to start working on portion control on a scale of one to 10."

If the patient rates him or herself at an eight, the promotora knows he or she is ready. If it's a five or less, ask what it would take to get the patient to an eight and maybe suggest trying portion control just for breakfast.

The promotoras make follow-up calls to support the patients in meeting their goals, she says.

"The follow-up calls by the promotoras are very important because they coach the patients and problem solve with them to help them continue to work on their goals. They relay any information they discover in the follow-up calls to the providers so they'll know what's going on with the patient. The promotoras help facilitate the whole process," she says.