Addressing Obstacles on the Road to Diabetes Control

Apr 08, 2014 at 12:00 am by Staff

What is the best way to get ... and keep ... diabetic patients actively engaged in the lifelong self-management of their condition?

The individual or institution that comes up with a definitive answer to that question will surely be remembered in the history books in the same manner as Jonas Salk. After all, diabetes is a pervasive condition of epidemic proportions in much of the world. According to the latest statistics from the National Institutes of Health, 25.8 million Americans have diabetes ... roughly 8.3 percent of the nation's population. Additionally, it is estimated another 79 million American adults have prediabetes, putting them at high risk for developing the condition without active intervention to stop the progression toward disease.

Keenly aware of the toll diabetes takes on the body, healthcare providers routinely talk to patients about the threat of comorbid conditions ranging from heart disease, stroke and kidney disease to blindness and amputation. Yet, there continues to be a disconnect from what a patient seemingly hears and understands in the office and what actually transpires on a daily basis.

"We talk about diabetes all day long with patients, but they have to go about their business of living with the disease," noted Elizabeth S. Halprin, MD, associate director of Adult Diabetes at Joslin Diabetes Center, an affiliate of Harvard Medical School.

A recent study conducted by Joslin researchers looked at obstacles present among patients with poorly controlled diabetes. Halprin, a board certified endocrinologist and instructor at Harvard Medical School, said the reasons for poor management vary hugely and are specific to individuals and their own personal circumstances. Are there financial issues that make office visits cost prohibitive? What about transportation or geographic barriers that make it difficult to get to an appointment? Perhaps an individual is working multiple jobs or caring for everyone else in the family with little time left over to address their own needs.

Halprin said the study also revealed some interesting perceptions about the healthcare system and providers. "They find the whole healthcare system impersonal," she said of the study participants. "They think we're not listening and that we suggest things that aren't practical."

To a physician, telling a patient to 'increase physical activity' seems like a highly appropriate, straightforward step toward better diabetes management. To a patient who struggles financially, a gym membership is out of the question and strolling through an unsafe neighborhood could be more dangerous to their health than the disease, itself.

"Diabetes is a very time consuming disease to have, but it's also a very time consuming disease to treat," Halprin pointed out. "The healthcare system doesn't always permit the time for exploring and looking at each person's individual needs."

To address that, Joslin is investigating the addition of care coordinators to work with high-risk patients. The coordinator becomes the point person who initiates a follow-up call after an appointment to see if the patient understood recommendations and to make sure prescriptions are being filled. The coordinator might also reach out to remind the patient when it is time for their diabetic eye or foot exam. This is the individual who is more likely to know about medication assistance programs, area outlets for safe activity, and other resources to overcome obstacles.

Although the concept isn't novel in healthcare, it is one that has been difficult to fund under the current payment system. Changes in reimbursement models, such as the patient-centered medical home, make it more feasible to add a care coordinator to the team approach that Halprin used at Joslin. In addition to the physician, the team includes a nurse practitioner, nutritionist, exercise physiologist, registered nurse, psychiatrist and diabetes educator. Through a joint project with Beth Israel Deaconess Medical Center, Joslin has launched the Diabetes Practice Liaison Program to share collaborative strategies with primary care providers and their office staff in the region.

Just as one provider doesn't hold all the answers, it's unlikely one approach will meet everyone's needs.

Halprin pointed to another study among Joslin's older patients that had encouraging outcomes. "A highly structured education program with specific tasks and cognitive behavior strategies resulted in better A1c control, which was maintained for at least a year," she noted of the intervention that worked well with older patients up to age 75. However, she continued, that program didn't show the same promise among middle-aged patients.

Race and ethnicity are also important variables in how information is received, perceived and acted upon. Joslin has initiatives for Asian, African-American and Latino patients that take into account social and cultural traditions. Considering the risk of diagnosed diabetes in comparison to non-Hispanic whites is 18 percent higher among Asian Americans, 66 percent higher among Latinos, and 77 percent higher among non-Hispanic blacks, reaching these specific populations in a meaningful way is critical.

Halprin, a member of Joslin's Latino Diabetes Initiative, noted there is a support group that meets regularly at the diabetes center to knit and chat. A staff psychologist joins the group to guide conversation and answer questions.

"They bring food so that's an opportunity to discuss what is a good choice or a not-so-good choice," Halprin said. "Nutrition is a huge part of diabetes care, but it's also a huge part of the Latino culture," she noted, adding nutritionists on staff try to make suggestions that are culturally appealing or that revamp traditional meals to lighten the carbohydrate load.

Additionally, education classes are conducted in Spanish and materials have been translated. Providers with the Latino program also are piloting group medical visits with four-eight participants. All of these efforts combine to make the healthcare clinic less intimidating and more welcoming of natural conversation and questions about living with diabetes.

In fact, Joslin hosts a number of programs in a group setting including DO IT, a four-day intensive outpatient program designed for those who have gotten off track with their self-management; Why WAIT, a combined weight reduction and management program with a focus on nutrition, physical activity and behavioral support; and interactive games like CarbChallenge where participants test their knowledge of carbohydrate containing foods.

"Diabetes can be a very isolating condition," Halprin said. "It's good for people to be in a group and know other people are struggling with similar issues."

What's good for patients is also good for providers. Halprin's colleague, Robert Gabbay, MD, the chief medical officer for Joslin Diabetes Center, is slated to give the keynote speech at The American Journal of Managed Care annual meeting. "Patient-Centered Diabetic Care: Putting Theory into Practice" is the 2014 theme of the April 10-11 conference in Princeton, N.J.

"Our meeting will occur as the first waves of newly insured consumers are accessing the healthcare system, including many who will learn for the first time they have diabetes or other cardiometabolic conditions," said Brian Haug, president of AJMC. "This is an important time for healthcare professionals to be engaged with leaders in this field."

By working collaboratively, utilizing diverse technologies and education offerings, and leveraging the theories embedded in new reimbursement models, the hope is patients and providers will work together to overcome the obstacles to effective diabetes self-management.

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