* supported by funding from niddk

Health Care, Education and Research

PRISM Project: Promoting Realistic Individual Self-Management for Diabetes

Billings Clinic

Center for Clinical Translational Research

September 1, 2009

* Supported by funding from NIDDK


What is Translational Research?

Translational research examines how people access health care, how much care costs, and what happens to patients as a result of this care.

The main goals of translational research are to identify the most effective ways to organize, manage, and deliver high quality care, reduce medical errors, and improve patient quality.


CTR PRISM Team Members

• Valerie Caton, MN, FNP-C, Nurse Practitioner, Team Leader• Diane Kersten, LCSW, Social Worker• Stephanie Selzler, LD, RD, Dietitian• Karen Gransbery, RN, CDE, Diabetes Educator• Barbara Holloway, RN, CDE, Diabetes Educator• Jude Russell, MSN, CDE, Diabetes Educator• Patricia Coon, MD, Medical Director• Chris Sorli, MD, Endocrinologist Consultant


Study Objective

• Evaluate the effectiveness of an NP-led multi-disciplinary team approach to diabetes self-management on achieving American Diabetes Association (ADA) guidelines for diabetes disease control, patient satisfaction and patient self-management in the urban and rural primary care setting.


Methods: Study Participants

• Participants:– 259 adult patients– Type 2 diabetes mellitus (DM)– At least one uncontrolled risk factor (HbA1c, BP or LDL-C)1

– Seen by PCP in past year• Study Sites:

– One urban primary care clinic: • Billings Clinic with 48 PCPs who manage ~5,000

diabetes patients– Five rural community clinics in Eastern Montana

• 2 to 9 providers per site serving 30 to 300 diabetes patients

1Standards of medical care in diabetes--2009. Diabetes Care 2009;32 Suppl 1:S13-61.


Study Sites


Patient-Centered Care

Traditional Care

• Content driven education

• Provider recommends preferred course of action

PRISM

• Patient driven education

• Motivational Interviewing techniques (Patient decides action)


Patient-Centered Care

Traditional Care

• Patient is either “compliant” or “noncompliant”

• Passive Patient

• Expert providers work separately

PRISM

• Readiness for change

• Active Patient

• Team working for improved healthcare, including patient


All Team Members Responsibilities

• Empowerment of patient.• Determine barriers to self-management,

including psycho-social issues, teach problem solving skills.

• Help patients to develop and implement realistic self-management goals.

• Facilitate behavior change.• Participate in weekly team meetings.


Perceived Challenges

• Establishing trust

• Nonverbal communication

• Difficulty discussing sensitive issues

• Managing the technology


Services Provided

• Individual and Dual Sessions

• Patient Care Conferences

• Education and Support Groups

• Create Your Weight Group


Education Groups


Support Groups


Create Your Weight• 10 week Adult Weight Management Program based

on guidelines from the ADA* which encompassed nutrition education, physical activity and the role of behavioral therapy in weight management

• Adapted the class to PRISM participants and the use of telemedicine

• Provided two series and 18 urban, 21 telemedicine and 15 family members participated.

* American Diabetes Association


Results


Figure 1. MMSE Score Mean Differences (Remote vs. In-Person) and 95% Confidence Intervals (n=73)

-0.35

-0.3

-0.25

-0.2

-0.15

-0.1

-0.05

0

0.05

0.1

0.15

0.2

Scor

e D

iffer

ence

s

Upper Confidence LimitDifferenceLower Confidence Limit

* From left to right, MMSE items represented in this figure include time orientation, place orientation, registration of 3 words, serial 7s, world (spell backwards), recall 3 words, naming, repetition, comprehension, reading, writing, and drawing.

Ciemins EL, Holloway B, Coon PJ, McCloskey-Armstrong T, Min SJ. Telemedicine and the Mini-Mental State Examination: Assessment from a distance. Telemedicine and e-Health, 2009;15(4): 325-327.


Patient Satisfaction with PRISM Program

Diabetes Care Patient Satisfaction (n=141)

Satisfaction: ↑ OR ↓ % ∆ ↑ OR ↓ % ∆ ↑ OR ↓ % ∆Very satisfied with diabetes care I receive (n=144)** ↑ 97% ↑ 200% ↑ 44%The diabetes care I received last few years is just about perfect (n=141)** ↑ 54% ↑ 70% ↑ 25%Communication:I have been kept informed about next steps of diabetes care (n=136)** ↑ 85% ↑ 57% ↑ 50%Other health care provided has been up-to-date, current tx and test results (n=102)* ↑ 67% ↑ 30% ↑ 16%Satisfied w/ communications different health care providers (n=128)** ↑ 49% ↑ 52% ↓ -6%Self-Efficacy:Know who to ask when I had questions about my health (n=135)** ↑ 52% ↑ 54% ↓ -7%Feel good to excellent about managing my diabetes (n=111)** ↑ 74% ↑ 68% ↑ 4%Symptoms:Past 6 mos., diabetes symptoms somewhat/ much better (n=131)** ↑ 115% ↑ 74% ↓ -7%* p <.10; limited to subjects with data in both time periods** p <.05; limited to subjects with data in both time periods

Tx-Urban Tx-Rural Control


Patient Satisfaction with Technology

• 111 patient surveys– 100% were satisfied with their telehealth sessions– 100% felt comfortable with learning health information

using this technology and said they understood as if it were in person

– 99% felt picture and sound were clear– 99% felt equal comfort with in-person encounters and

felt comfortable discussing personal information – 96% felt their privacy was protected


Staff Satisfaction with Technology

• 177 staff surveys– 98% felt telehealth equipment worked properly and with

clear sound– 95% felt they had a clear picture– 96% felt they had adequate access to patients’ medical

records and tests prior to appointment– 99% felt patients’ privacy was protected– 98% felt patients were satisfied– 96% were satisfied with the consultations– 97% felt telehealth was a useful tool for teaching patients

about Diabetes management


Self-Reported DM Self-Management Behaviors (n=287)

37%

31%

19%

8%

65%61%

46%

29%

0%

10%

20%

30%

40%

50%

60%

70%

Tx-Urban Tx-Rural Tx-Urban Tx-Rural

Checks BG correctly, > 6 mo Follows diet as instructed, > 6 mo

Pre-PRISM Post-PRISM


Proportion of patients with Controlled LDL Cholesterol (<100 mg/dL) one-year post-PRISM who were uncontrolled at

baseline (n=118; p=.03)

53%45%

27%

0%

10%

20%

30%

40%

50%

60%

Tx-Urban Tx-Rural Control

Perc

ent p

atie

nts

LDL

< 10

0 m

g/dL


Pending Projects

• Expansion of Diabetes Care to Rural Communities via Telehealth

• Using Telehealth to Enhance Shared Diabetes Medical Appointments in Rural Communities

• Supporting Rural Caregivers Using Telehealth Technology

* supported by funding from niddk

Documents