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Improving diabetic foot care in a nurse-managed safety-net clinic

Peterson, JoAnn M. DNP, ARNP, FNP, WHNP1; Virden, Mary D. MSE, RN2

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Journal of the American Association of Nurse Practitioners: May 2013 - Volume 25 - Issue 5 - p 263-271
doi: 10.1111/j.1745-7599.2012.00786.x
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Scope of the problem

According to the 2010 Centers for Disease Control and Prevention (CDC) Prevalence Data, type 2 diabetes mellitus (T2DM) affects nearly 24 million people in the United States and an estimated 57 million American adults are at increased risk of developing diabetes. As the number of persons living with T2DM continues to increase, providing primary care services to a more socioeconomically, culturally diverse population is necessary to reduce associated morbidity, and mortality (CDC, 2010). In addition, with the passage of the Affordable Care Act of 2010, the increase in the insured population and the rapid increase in racial and ethnic minority groups who have traditionally faced obstacles in accessing health care will demand that care be designed for a more socioeconomically and culturally diverse population (Institute of Medicine [IOM], 2011). Consistent with extensive research, the Agency for Healthcare Research and Quality (AHRQ) 2010 National Healthcare Disparities Report found that disparities related to race, ethnicity, and socioeconomic status still pervade the American healthcare system and are observed in almost all aspects of health care including preventive care, treatment of acute conditions, and management of chronic diseases. These at-risk populations are at increased relative risk or susceptibility to adverse health outcomes, more health problems, premature death, and diminished quality of life (AHRQ, 2010). Furthermore, these underserved populations suffer from significant disparity in the quality of care they receive (AHRQ, 2010).

Nurse-managed clinics and health centers are poised to meet the challenge of providing primary care services, especially to diverse patient populations and individuals experiencing disparate and inadequate health care, especially those with chronic diseases. Hansen-Turton, Bailey, Torres, and Ritter (2010) referenced a National Nursing Centers Consortium study of 11 nurse-managed health centers (NMHCs) in Pennsylvania, which found that the centers are of critical importance as safety-net providers by providing high-quality, cost-effective care to vulnerable populations. Fiandt, Doeschot, and Lanning (2010) reported that nurse practitioner (NP)-led safety-net practices provide a model of care designed to increase access to quality health care and to improve health-related outcomes including patients with chronic diseases such as T2DM.

The American Diabetes Association's (ADA, 2010) Standards of Medical Care in Diabetes reported that diabetes is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk for long-term complications. Furthermore, diabetes care is complex and requires that the primary care provider address many biophysical and socioeconomic issues beyond glycemic control. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes (ADA, 2010).

A standard of care to improve diabetes outcomes is a yearly comprehensive foot exam (ADA, 2010). For clarification, a yearly comprehensive foot examination and risk assessment differs significantly from a general inspection and sensory examination of the foot. The comprehensive examination includes the following components: (a) history; (b) general inspection (including footwear); (c) dermatological assessment; (d) musculoskelatal assessment; (e) neurological assessment; (f) vascular assessment; (g) risk classification; (h) referral and follow-up; and (i) patient education (Boulton et al., 2008). The general inspection and sensory examination of the foot involves two primary steps: (a) visually inspecting the foot for abnormalities; and (b) testing sensations using a 10-g (5.07 Semmes-Weinstein) nylon filament on various areas of each foot.

Nationwide, more than 60% of nontraumatic lower-limb amputations occur in people with diabetes (CDC, 2007). Locally, Wyandotte County of Kansas (location of this project) has the highest nontraumatic lower extremity amputation rate in the state of Kansas (Kansas Department of Health & Environment, 1999). Comprehensive foot care programs can reduce amputation rates by 45%–85% (CDC, 2007). According to the Amputee Coalition of America (2009), diabetes-related amputations cost approximately $3 billion per year or $38,077 per amputation procedure. The monetary cost is evident, but the cost to patients in terms of quality of life is a significant reason to detect early signs of tissue damage, or better yet, to identify risk factors and implement preventive strategies through a routine annual comprehensive foot examination.

This article describes the development and implementation of a Comprehensive Diabetic Foot Care Program and assessment tool in a nurse-managed, multidisciplinary, safety-net clinic. The assessment tool parallels parameters identified in the Task Force Foot Care Interest Group of the ADA's report published in 2008, “Comprehensive Foot Examination and Risk Assessment”(Boulton et al., 2008).

Clinic and diabetes quality improvement team

Silver City Health Center (SCHC), located in Kansas City, Kansas, has been managed by KU HealthPartners, a clinical enterprise operated by the University of Kansas School of Nursing and School of Health Professionals, since July 2006 (prior to 2006, the clinic was operated by the Kansas School of Medicine). SCHC is an academically affiliated, nurse-managed, primary care safety-net clinic that offers care for the medically underserved in Wyandotte County in Kansas City, KS. The clinic provides primary care, health promotion, and health maintenance services (including community education) to individuals in need of medical care through the use of registered and advanced practice nurses, supported by a staff physician, other allied health providers, and support staff.

The SCHC's 2009 Annual Report indicated that over 50% of the patients seen at the clinic in 2009 were uninsured (total number of patients in 2009 = 1906). Of these, 83% had incomes that were less than the 100% federal poverty guidelines. Federal poverty guidelines are issued yearly by the Department of Health and Human Services and are used for administrative purposes, such as determining whether a person or family is financially eligible for assistance or services (United States Social Security Administration, 2009). According to the Federal Poverty Guidelines of 2009, single individuals would be considered at 100% of poverty if they made equal to or less than $10,830 per year; a family of four would have earned income equal to or less than $22,050 to be at 100% of poverty level.

Many of SCHC's patients access the clinic's services with minimal or no previous chronic disease management. Compared to insured nonelderly adults with diabetes, those who are uninsured are less likely to receive appropriate standards of care, which can lead to uncontrolled blood sugar levels, greater risk of hospitalization, and increased risk of additional chronic disease and disability (Tu & Cohen, 2009). Among nonelderly adults with diabetes, lack of insurance is associated with less glucose monitoring and fewer foot and eye exams (Tu & Cohen, 2009). Therefore, it is SCHC's primary goal, as in many safety-net clinics, to prevent unnecessary complications and disabilities, which potentially create even more burden on the health system, employers, taxpayers, and family dynamics.

The SCHC is committed to improving the care of patients with chronic diseases and uses the Chronic Care Model (CCM; Improving Chronic Illness Care, 2010) to guide design and improvement strategies. The CCM identifies the essential elements of a healthcare system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise (Improving Chronic Illness Care, 2010). In addition, the comprehensive, multisystem approach of the CCM makes it ideal for working with the vulnerable populations often seen in NP practices (Fiandt, 2006).

Delivery system design, a specific CCM element, provided the framework in the development of the Diabetic Comprehensive Foot Care Program at SCHC. Improving the health of people with chronic illness requires transforming a system that is essentially reactive—responding mainly when a person is sick—to one that is proactive and focused on keeping a person as healthy as possible. That requires not only determining what care is needed, but also spelling out roles and tasks for ensuring the patient receives evidence-based care using structured, planned interactions (Improving Chronic Illness Care, 2010).

SCHC recognizes the essential use of metrics to support data-driven improvement efforts and uses the Chronic Disease Electronic Management System (CDEMS), a software application developed by the Washington State Diabetes Prevention and Control Program in 2002, to track the management of care and outcomes of patients with chronic medical conditions (Washington State Diabetes Prevention & Control Program, 2010). Since 2008, SCHC has had a robust Quality Improvement (QI) plan and metrics. The plan identifies a QI team for each clinical program (e.g., diabetes, obesity, asthma, health literacy), which is comprised of primary care providers, support staff, and an administrative representative. For each clinical program, established metrics and targets, based on evidence-based standards of care, are reviewed quarterly.

T2DM has been and remains in the top five diagnoses for patients seen at SCHC (KU HealthPartners, 2009). As a result, a Diabetes Quality Improvement Team (DQIT) was established in late 2007. The metrics and targets established by the DQIT have been and continue to be based upon the most current ADA Standards of Medical Care in Diabetes. The DQIT meets quarterly to review monitoring and evaluation data, determine opportunities for improvement, and assess opportunities for clinical QI initiatives.

Deficits identified

In May 2006, an analysis of CDEMS was conducted for SCHC. Sixty-four patients with T2DM were registered in CDEMS and only 18% of those had received a foot check (defined as visual and/or sensory examination with a 10-g [5.07 Semmes-Weinstein] nylon filament of both feet). Zero percent of the patients received a comprehensive foot examination and risk assessment. In addition, a manual review of the records revealed that four of the 64 patients had been hospitalized for preventable, diabetic, foot-related complications in 2005–2006; two patients were uninsured; and one patient had Medicare insurance coverage. In addition, there were multiple patient record entries indicating a foot or nail abnormality needing specialized foot care management. Furthermore, there was limited documentation of follow-up or ongoing foot care for specified abnormalities.

Each of the primary healthcare providers (physicians, residents, NPs, nurses) and support staff at SCHC were asked, via electronic mail, to identify barriers in performing appropriate diabetic risk assessments and routine foot care and management. Three barriers were identified. The first barrier was not having a documentation tool that clearly identified the steps in a comprehensive foot examination and risk assessment that was concise and easy to use. The second barrier was the lack of training for providing appropriate care with skin and nail disease of the foot. The third barrier was the lack of specialty care for uninsured patients needing further testing or intervention.

QI plan developed

Based on this information, the DQIT identified a three-step process for improvement: (a) find or create a documentation tool that reflected the parameters identified in the Task Force Foot Care Interest Group of the ADA (Boulton et al., 2008); (b) implement provider team training for management of common skin and nail diseases of the foot; and (c) establish referral resources for diabetic foot conditions that are beyond basic care.

As a first step, the authors conducted a literature search for existing tools that reflected the parameters identified in the ADA's Task Force Foot Care Interest Group (Boulton et al., 2008). Multiple assessment tools were identified; however, none of the tools incorporated all of the components of the comprehensive foot examination as recommended by the ADA's Task Force of the Foot Care Interest Group. As a result, the DQIT drafted a tool that included the nine components established by the ADA's Task Force, that is, history, general inspection (including footwear), dermatological assessment, musculoskelatal assessment, neurological assessment, vascular assessment, risk classification, referral and follow-up, and patient education.

The tool was pilot tested at SCHC for approximately 6 months at which time the DQIT reevaluated the tool's effectiveness and ease of use. After minor revisions, the tool was reviewed by healthcare professionals across the state of Kansas, including physicians, physical therapists, NPs, and diabetes nurse educators. In October 2009, the tool was one of three diabetic management tools featured as an example of a quality of care improvement tool at the Kansas Statewide Diabetes Quality of Care Project's annual meeting (see Figure 1). An algorithm for foot care follow-up or referral based on the patient's risk category assignment was also developed (see Figure 2).

Figure 1
Figure 1:
Annual comprehensive diabetes foot exam form. Reprinted with permission.
Figure 2
Figure 2:
Provider algorithm for diabetic foot care. Reprinted with permission.

The second step in the improvement process was to provide training on the treatment and management of common skin and nail conditions of the diabetic foot. To accomplish this, the NP developer of the foot care program attended a nationally recognized program for specialized training in care of common foot and nail problems followed by a brief internship with a local podiatrist. The NP then held a series of nail and skin care of the diabetic foot training sessions for members of the SCHC healthcare provider team and support staff. A recent polling of the SCHC provider team reveals that their comfort level has increased significantly in caring for common foot problems. The providers use affordable treatment interventions for common skin and nail conditions of the feet and the clinic has a pharmacy assistance program that can assist patients in obtaining necessary medications. The DQIT has made strides in acquiring donated footwear, creams, lotions, mirrors, and other tools to assist indigent diabetic patients in self-care of their feet.

The third step in the improvement process was to establish referral resources for diabetic foot conditions that are beyond basic care. This is an ongoing process. The quality of care team recognized that obtaining uncompensated specialized care is an issue and concern across the nation (Suwatee, Lynch, & Pendergrass, 2003). The SCHC has positive working relationships with local hospitals and physicians and continues to develop new relationships and foster existing relationships. We have been able to extend needed resources thru a multicounty specialty referral system developed specifically for the safety-net clinic network in Wyandotte and Johnson counties of Kansas. The referral system, a clearing house of sorts, gives area-wide physicians of various specialties the opportunity to participate in a program designed to provide gratuitous or reduced-rate specialty care for uninsured patients. We have been successful in recruiting wound care specialists, vascular surgeons, and podiatrist to the program.

Data and outcomes

August 2010, an analysis of CDEMS revealed 30% of 184 registered patients with a diagnosis of T2DM received a comprehensive foot examination in the past year and 64% had received a diabetic foot check (monofilament + inspection) in the 4 months preceding this analysis. A retrospective chart review of all patients with diabetes (n = 184) revealed no hospitalizations had occurred for diabetic foot-related complications since January 2008, the date of full implementation of SCHC's Comprehensive Diabetic Foot Care Program. Compared to 2006, this represents a 188% increase in the number of patients with diabetes and a 400% reduction in hospitalizations for diabetic foot-related complications.


The most important lesson learned from this QI project is that quality healthcare services can successfully be developed and implemented in a safety-net clinic despite the financial and staffing limitations often experienced in this type of setting. The development of the Comprehensive Diabetic Foot Assessment tool and the implementation of the Comprehensive Diabetic Foot Care Program have resulted in positive outcomes for the patients. We have demonstrated that the program has significantly reduced hospitalizations for diabetic foot-related complications despite the increase in the growing number of patients with diabetes being served at the clinic. Providing comprehensive, quality care to vulnerable populations can be challenging at best. As a nurse-managed clinic, we recognize and address social, demographic, and other risks that influence healthy outcomes. The Comprehensive Diabetic Foot Care Program also provides an opportunity to develop the patient/provider relationship. Many of our foot care patients routinely schedule their “pedicures,” that is, nail trimmings and other routine foot procedures. The staff utilizes the “pedicures” for ongoing diabetic teaching. The social and economic impact of doing so is evident to SCHC patients and to the healthcare providers who provide their care. Future studies will include comparing diabetic management interventions and strategies to disease control.

The DQIT plans to continue to develop improvement strategies in the care of SCHC's patients. The data collected through CDEMS will drive improvement strategies at SCHC as well as to assist the local, state, and national safety-net communities in diabetes QI programs.


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      Diabetes; early intervention; clinical decision making; evidence-based practice; nurse-managed clinics; nurse practitioners; risk reduction

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