Inner-city clinic succeeds at diabetes control
Inner-city clinic succeeds at diabetes control
The secret: A team that includes the patient
Editor's note: Diabetes Management visited the Grady Diabetes Detection and Control Center in Atlanta for a first-hand look at how teamwork and patient involvement can help an underinsured, high-risk, urban population.
It’s tucked away, somewhere behind Grady Hospital’s updated main building, a shabby brick building that saw its best days more than 80 years ago.
Grady’s Diabetes Detection and Control Center, serving more than 80 patients a day, the vast majority of them on Medicare or Medicaid or uninsured, is a poor stepchild to a poor public hospital.
But the less-than-luxurious facilities belie the beehive of activity inside as hundreds of diabetic patients from the surrounding community flock to the center to learn how to manage their disease.
It’s simple. There’s nothing fancy or presumptuous about Grady’s diabetes clinic. It’s just a handful of people who care and who are willing to take the time to be sure their patients understand what they need to do to be in charge of their disease rather than letting the disease run them, says clinic manager Kris Ernst, RN, CDE.
The classes are working
It’s working. The numbers prove it.
The 9,000-plus patients in the Grady clinic’s database have an average HbA1c of 7.2%.
The team of nurses, nurse educators, physicians, pharmacists, dietitians, and support staff are confronted with working with a budget of only about $1 million a month. Ernst offers these statistics of the clinic’s clientele:
- Their population base is high-risk; 88% are African-American. Most of the rest are Hispanics, Asian-Pacific Islanders, and Africans, with only a smattering of Caucasians.
- Most are poor; 50% are on Medicare B, 28% are uninsured, 12% are on Medicaid, and the remaining 10% have some type of insurance.
- Many are homeless.
- About 60% are illiterate.
Yet, despite seeing patients with HbA1c levels as high as 21, staff are achieving results that many clinics can only dream of. How do they do it? "It works because we have a whole team, and they are all sending the same message all the time," Ernst says. "And we back each other up. Everybody on the team looks out for problems."
Patients get the same message over and over as they circulate through the clinic’s various stations. The messages are verbal and nonverbal, says Ernst, and patients spend a great deal of time with professionals.
Newly diagnosed patients and patients who have been hospitalized get a full-day work-up at the clinic and enter the clinic’s six-week program of classes and follow-up. By the end of that six weeks, Ernst says, diabetic patients have learned a great deal. (See class curriculum, p. 97.)
All patients are encouraged to visit the clinic quarterly to have HbA1c levels checked, visit the foot clinic, and see the doctor and nurse-educator. Microalbumin levels, lipids, other blood work, and retinal and neuropathy exams are done once a year. But there are no reminders when it’s time for a visit. There’s no staff to handle that chore.
On the first day of the all-day program, patients arrive fasting, get lab tests, and eat breakfast.
At 9:30 a.m., Barbara Boyd, RN, CDE, one of nine nurse educators at the clinic, is just finishing her early morning class where new patients familiarize themselves with their monitors, and those using insulin are checked on their injection techniques.
She uses illustrated flip charts and explains carefully what causes diabetes and emphasizes the importance of monitoring and achieving desirable HbA1c levels. She asks her students to parrot back what they understand. They get it.
It takes teamwork
She asks one woman how she felt when she was told she had diabetes. The woman shyly says, "It took something out of me." Boyd assures her that many people have those feelings and says there is help available if those feelings persist.
Before she sends her off to her podiatry appointment, Boyd reminds the woman, "We are a team. And you’re the most important member of the team; we can do this together."
The elderly woman shuffles away using a walker and pauses to read a bulletin board lauding the achievements of the clinic’s star patient of the month: a woman in her mid-40s who has lost 152 pounds, walks five miles a day, and goes to aerobics classes twice a week.
At the podiatry offices, a somewhat confused man confides he isn’t doing too well while Audrey Carter, RN, manager of the foot section, trims his calluses. A few questions uncover the problem: He hasn’t had any medication in four days. He says there was no one to pick up his prescription. Carter calls the pharmacy and the lab. The man seems to relax. "Every time I talk to you, I get good information," he says.
Downstairs, the waiting room is crowded. Sometimes staff make use of the waiting time to instruct patients and answer questions about nutrition or other aspects of diabetes. Down the hall, Linda K. Mann, RN, CDE, nurse educator at the clinic, is just finishing a typical half-hour appointment with a young autistic woman and her mother, both diabetics.
"Now Laura, your sugar is a little low this morning," she says looking at the lab report and handing the young woman a packet of crackers. "I don’t feel so good," Laura agrees as she begins to munch on the crackers. Based on Laura’s escalating blood glucose levels, Mann decides to increase her insulin dosage.
In the kitchen, nutritionist Carol Brazier, RD, shows two patients how to adjust their cooking and eating habits to accommodate their nutritional needs. "You can have the things you like," she tells them as she reviews a chart on high-sugar and high-fat foods and gives directions on alternative ingredients. "There are so many nice things on the market now that are made with reduced sugar and fat."
From her tiny office in the clinic’s maze of corridors, clinic pharmacist Diane Erdman, PharmD, checks blood pressure and pulse and scans the lab sheet for a woman asking for refills on her medications for diabetes, hypertension, and cholesterol. "How often do you check your sugar?" Erdman asks and nods when the woman replies how she tries to check it every day. "And do you check your feet?" The woman says she likes the clinic to trim her toenails.
Long wait times are standard
"You’re doing great," Erdman tells her patient. "Your blood pressure is 130/60, and your cholesterol and sugar are good." She hands her three prescriptions — for which the patient may have to wait as long as an hour. "We’re just not fast enough," Erdman says. "They simply have to wait too long."
David Ziemer, MD, one of four endocrinologists at the clinic, agrees with her assessment. As he ushers a woman from the stuffy waiting room into the examining room, he asks how long she has been waiting. "Only about two hours," she answers, clearly exasperated. Then she smiles at the bow-tied doctor. "It’s worth it," she says. "You’ve really helped me.
Ziemer scans her chart, as the last in the series of professionals who’ve looked at it today. "I know I’ve gained weight," the patient says, "but you know, the holidays, all those cakes and pies." Ziemer repeats what the patient has already heard several times today. "I am concerned about your weight, but I am more concerned about your blood sugar. It’s over 300."
"It needs to be lower than this, much, much lower." The endocrinologist continues, "You know the problems this can cause."
The patient nods her agreement. "If we can’t get this down considerably in the next month, we’re going to have to seriously consider putting you on insulin injections," Ziemer adds.
"I don’t want that, doc," the woman says. "I’ll try harder." She leaves his office clutching her prescriptions and a new batch of literature, promising to stop for a talk with the dietitian on her way out.
For more information, contact: Kris Ernst, Grady Hospital Diabetes Detection and Control Center. Telephone: (404) 616-7417.
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