At the state of the science symposium on how to promote diabetes self-management, nurses from five different practice settings discussed their roles in advancing best practices. Maureen Shawn Kennedy, AJN news director, moderated the panel discussion, and then audience members were invited to ask questions or make comments. See page 78 for participants' affiliations.
Shawn Kennedy: Please describe your practice setting and talk about what works when promoting diabetes self-management.
Dawn Heffernan: I work in a federally qualified, accredited health center. Nearly all of our patients live 100% to 200% below the federal poverty level. Literacy rates are low, with most patients reading on a second-to-ninth-grade reading level. Most of our population speaks Spanish only and is of Puerto Rican descent.
We received funding from the Robert Wood Johnson Foundation to develop and implement a diabetes self-management demonstration project. We have found some of the hands-on strategies using low-literacy techniques to be very successful. Also, we've trained a cadre of patients who have been successful in controlling their diabetes to be community health workers [CHWs]. They've been very successful in serving as a link between the health center and the community.
Kelly Hudson: I'm a family nurse practitioner and care for a population of indigent working poor. Our patients have no insurance, and we accept none; if you have insurance, you can't come to our clinic. We have a significant language barrier, as most of our population is Mexican, with some Brazilians. Many of our patients are illegal immigrants.
Because I'm in a primary care setting, I manage comorbid conditions in patients with diabetes. I ask them to always bring their glucose monitor, blood sugar and pressure records, and medications. It's a telling sign when half of their medication is still in the bottle and their blood sugar levels are high.
We have a dispensary, and we use pharmaceutical companies' patient-assistance programs; otherwise, we couldn't provide the necessary medications.
I would like to have patients check their blood sugar levels a couple of times a day. But because of costs, that's impossible. I can give them 50 test strips every three months and hope that they monitor their sugar level three or four times a week. I tell them to vary the time of day when they do these checks, to identify trends. Despite the financial and language barriers, we're able to tightly control their diabetes.
Linda Haas: I'm an endocrinology nurse specialist at the Department of Veterans Affairs [VA]. Nurses run our diabetes program. We do have a physician who sees patients for one half day each week, but it's mainly the nurses who manage the patients and conduct the self-management education.
We try to incorporate diabetes self-management into primary care, not just the specialty practice, with the specialist serving as a consultant. All of the primary care nurses have participated in Choices and Changes: Clinician Influence and Patient Action in Diabetes Self-Management Training, a workshop on clinician–patient communication that was created by the Institute for Healthcare Communication and the American Association of Diabetes Educators.
We have an electronic medical record, which I cosign. The primary care nurses see and teach a patient, for example, and I can oversee their actions. Or they may send me a question about what they should do under particular circumstances.
I've included in our clinical reminders diabetes self-management goals. Patients can rate their conviction and confidence about completing these goals. These factors are very important to Choices and Changes.
We also have classes that are run by patients, in which we're the facilitators. There is no set curriculum. We give patients their laboratory reports at the beginning of the class and talk about what the numbers mean. When someone's glycosylated hemoglobin [HbAIc] has dropped from 10 to 7, we ask her or him to describe how she or he did that. The patients learn from each other, rather than the nurse or dietitian telling them what to do.
Jane Seley: I've been in an inpatient setting for the past two years. I started working in inpatient care, which at the time was where patients with diabetes received their training. Later, patients weren't allowed to stay in the hospital with newly diagnosed diabetes; they were sent home quickly or not admitted. So I did self-management training with outpatients. It's now come full circle, back to inpatient care, with emphasis on glycemic control.
I was hired to find a way to control hyperglycemia and hypoglycemia among patients in our institution. My role was to educate staff, not patients, and to put systems in place to control blood sugar levels. In the inpatient setting, it is difficult for nurses to stop what they're doing and teach patients how to administer insulin or how to check their blood sugar level. It's much easier for the nurses to do it themselves. The challenge is to get nurses to buy into their role as educators and feel comfortable doing it.
Marcia Draheim: My site is part of an 11-hospital center, the Iowa Health System. The community is a mix of technology and industrial workers. Many of our patients are well educated, and most have at least a high school education. Ours is primarily a white population, with a recent influx of East Indians because of a growing number of high-tech businesses in the area. We also have agricultural workers, many with degrees in horticulture or agribusiness.
To save money, we publish our own diabetes education materials. Therefore, we can quickly change the printed materials when innovations occur.
Our diabetes education program presents nine and a half hours of information. We start each session by asking patients what is most important to them, what they want to learn that day. We coach, rather than preach.
Kennedy: How do patients move among the inpatient setting, primary care, and the community setting? Is there a coordination plan?
Seley: I'm fortunate to have a counterpart in a primary care nurse. We try to communicate with each other as I funnel my patients to her. Knowing that there will be a continued effort in diabetes education takes the pressure off me. I only have to do survival skills; foot care is the primary care nurse's area. I think it's important that we identify what each of us has to do and where the resources are for the other pieces of the diabetes education puzzle.
Haas: We have an advantage at the VA in that we have an electronic medical record. If someone is admitted to my VA or to a VA anywhere in the country, I can pull up all the patient's records and see what was done.
We have a diabetes urgent care clinic, which we hold every Monday morning. The emergency department clerks and the inpatient clerks schedule patients directly into that clinic, without going through the consult process. So we see someone as an inpatient and see her or him again within a week after discharge.
The challenge is that we cover a five-state area. If someone from Alaska is admitted, how do we follow up? I work a lot by telephone and e-mail with the providers in Anchorage and other distant places to assure some continuity of care.
Hudson: We don't have an integrated system for our patients in crisis. Because many of them are illegal immigrants and don't have Social Security numbers, they can't even go to the county hospital without having to pay full price. If a patient has to be hospitalized or see a specialist who does not volunteer at our clinic and we have advance warning, we can use the financial assistance programs at the hospitals. But in a crisis, these folks go to the emergency department, and we often do not know about it until later.
In our primary care practice, we don't have a formal diabetes program—there is no certified diabetes educator [CDE] or dietitian on-site daily. The primary care providers do most of the teaching and manage treatment. Once a week we send patients in need of more intensive education to our four-hour diabetes clinic, which is run by pharmacists who are CDEs.
Heffernan: Because we have a transient population, coordination of care can be challenging. Our patients often have no phones, move often, and frequently travel between here and Puerto Rico.
We send CHWs to the home if a patient hasn't been seen in three or four months and can't be reached by phone The primary care provider is supposed to be notified when a patient is hospitalized, and then it's up to the provider to refer as necessary to the diabetes self-management team.
In one case, a CHW called from the home of someone who had just been discharged from the hospital. There was a horrible odor in the home. The health worker said the patient had a serious infection and was on antibiotics. His blood sugar level was more than 400. We sent a taxi to bring him to the clinic.
Kennedy: How much do nurses own the system? How much do you collaborate with physicians?
Hudson: Most of the time we manage our patients independently and autonomously. Because of the nature of our practice, we don't write many prescriptions. A family physician works in the practice with me, but I work autonomously.
Haas: Ours is a nurse-run clinic; there are no physicians involved. Two of us are advanced practice nurses, and another is a nurse who's a CDE. We also have a dietitian and a doctor of pharmacy. They all work under my supervision.
The VA recognizes the value of nursing in general and advanced practice nursing in particular. Reimbursement is not an issue at the VA, because we're on salary. That has been very helpful.
Draheim: We have a physician director, and physicians in the community refer patients to us. But we work autonomously. We implement the therapy that we feel is appropriate, based on assessment. A nurse practitioner writes prescriptions if we need them. We also have a diabetes educator who has a master's degree in psychology and behavior change, and we use her services.
Seley: I'd originally thought physicians would want to watch over everything I did, but I've had the opposite experience. I created an advisory council that includes two endocrinologists, among other physicians, but I run the show. The physicians know that, as a nurse, I understand other professions and I know how the hospital works. If I need something done, I know who can help me make this happen.
Heffernan: Our health center has a strong nursing presence at all levels, and nurses play a leadership role on our clinical teams—each chronic care team has at least one nurse. We have a physician executive director and medical director, but we function as a team, following the chronic care model. The team always resolves issues and questions.
Problems that cannot be resolved during day-to-day operations are brought to the attention of the diabetes collaborative, which has a representative from nursing, medical assistants, providers, technology services, and other support staff. A major problem is that providers sometimes want us or lay educators to do more than we can within the scope of practice. For example, we'll receive referrals for CHWs to teach patients about medications.
Kennedy: At this point I'd like to invite the audience to make comments and ask questions.
Andrea Zaldivar: Throughout my career, home care and visiting nurses have helped me to coordinate patient care. When I worked in an inpatient setting, they took care of my patients in their homes. Now that I'm in the outpatient setting, I do many referrals to them.
Haas: We have hospital-based primary care, with a team that travels to patients' homes, and we work very closely with them. A physician, several nurses, a dietitian, and an occupational therapist go in and evaluate the safety of the home. We also have people in nursing homes. The visiting nurses will call or e-mail me, and the nursing homes will too. They'll accept my management of patients, even though they're outside the VA.
Amparo Gonzalez: An area that I think needs a lot of work is the transition from one setting to another, especially from hospital to home. Patients who have been on insulin for days in the hospital may go home on nothing because the insulin was overlooked.
Draheim: You're right. Inpatient and outpatient care are completely separate, and we're trying to change that. One day each week, our diabetes faculty make rounds on specific units. They visit the nurses on those units to help them understand some of the latest things about diabetes management and to answer their questions. In addition, our diabetes center manager meets frequently with the managers of each of the Iowa Health System physicians' offices. They problem solve and talk about how we can improve our services. We now have hospitalists within St. Luke's, one of the hospitals in the Iowa Health System, and this has helped considerably.
Linda Siminerio: I think the state nurse practice acts are antiquated. For example, when I did clinical work at Children's Hospital of Pittsburgh, I managed insulin. That's what I taught families and 10-year-olds to do. But with the nurse practice acts in Pennsylvania, we now need a written protocol from a physician. Nurse practice acts should reflect the extent of our responsibilities in self-management, because they otherwise limit the scope of our work.
Robin Thompson: In the past two years, our division of diabetes treatment and prevention has been focusing on case management. We have 22 model programs, several of which use nurse case managers for patients with diabetes. Because our registries are huge, we're able to address only a small number of patients on a yearly basis. In our particular program, we're targeting newly diagnosed patients with diabetes and those who need intensive management. We have databases that allow us to track patients and see whether we're reaching the goal in our target population.
Carol Laws-Krause: I wanted to ask Dawn Heffernan about the training of your CHWs. What type of initial training do you provide? How do you keep them up-to-date and ensure that they're providing accurate information?
Heffernan: The CHWs are the cornerstones of our programs, and ongoing training and supervision are essential. Many of our programs are cofacilitated by nurses and CHWs. After the CHW does outreach in the home, we have a debriefing session. They chart in the progress note, which is reviewed by a supervisor before it becomes part of the medical record. There's constant feedback.
For initial diabetes education training, we used the Diabetes Empowerment Education Program from the University of Illinois at Chicago. Additionally, these workers have all been through Stanford University's Chronic Disease Self-Management Leaders' Training. Nutritionists and diabetes educators conduct regular—at least monthly—workshops for the CHWs. The supervision is very intense. The ability of the lay workers to reach out to patients, to link them to the community health center, is incredible. It's been a key to our success in lowering average HbAIc levels from 8.4 to 7.5.
Kennedy: I'd like to thank all the participants for their contributions and insights into promoting diabetes self-management.