LCDR C. Fredette, BSN, CCHP, RN CDR R. Hunter Buskey, DHSc, CCHP, PA-C
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LCDR C. Fredette, BSN, CCHP, RN CDR R. Hunter Buskey, DHSc, CCHP, PA-C
description
LCDR C. Fredette, BSN, CCHP, RN CDR R. Hunter Buskey, DHSc, CCHP, PA-C. OBJECTIVES:. Review unique characteristics of inmates with diabetes Highlight clinical practice guidelines for correctional diabetic management - PowerPoint PPT Presentation
Transcript of LCDR C. Fredette, BSN, CCHP, RN CDR R. Hunter Buskey, DHSc, CCHP, PA-C
LCDR C. Fredette, BSN, CCHP, RNCDR R. Hunter Buskey, DHSc, CCHP, PA-C
OBJECTIVES:Review unique characteristics of inmates with diabetes
Highlight clinical practice guidelines for correctional diabetic management
Discuss practical methods to increase active inmate participation in diabetes management that incorporate personal behavior change
Review glucose meter distribution program for inmates
DIABETES PREVELENCE:
438 million worldwide by 2030
25 million United States = 8% of US Population
7th leading cause of death 2007
International Diabetes Federation (IDF); Centers for Disease Control and Prevention (CDC); Bureau of Justice Statistics (BJS)
DIABETES RISK FACTORS:
Non-ModifiableAfrican American, Native American, HispanicFamily historyChronic illnesses
ModifiableFood choicesPhysical activityWeight
FEDERAL INMATE PROFILE
White 57.2
African-American 39.2
Other 3.2
Hispanic 32.2
Non-Hispanic 67.8
Bureau of Justice Statistics , 2009
CHALLENGES FOR INMATES WITH DIABETES
LifestyleHealth literacy and educationCultureHealth numeracyNon-formulary drugsMotivationHealth beliefs
SURGEON GENERAL’S National Prevention Strategy
Injury and violence free living
Tobacco free living
Preventing drug abuse and excessive alcohol use
Healthy Eating
Active Living
Mental and emotional well being
Reproductive and sexual health
COST FOR DIABETES CARE
US diabetes related costs 2007: 174 billion; 116 billion for direct medical care
Inmate average health care costs $7.15/day
Range from $2.74-$11.96
US Department of Health and Human Services, 2011
The Council for State Governments, 2004; 1998 survey
IDF AACE ADA ADA Inmate NCCHC FBOP
Evidenced based, cost effective levels of care
Aggressive, comprehensive Team based care
Well and sick care for diverse populations
Early assessment, staff training and coordination of resources
Emphasize self-management, Quality improvement
Primary care provider team, strive for target goals
6.5 6.5 7.0 7.0 7.0 7.0
Chronic disease management models for diabetesScreening, diagnostic, therapeutic Categories for increased riskTestingTarget goalsAssessment of glycemic control
All Guidelines
Guidelines
Glycemic control
HBA1C < 7.0%
Preprandial plasma glucose 90-130 mg/dl
Peak postprandial plasma glucose <180 mg/dl
Blood pressure < 130/80 mmHg
Lipids
LDL <100 mg/dl
Triglycerides < 150 mg/dl
HDL > 40/mg/dl
ADA Treatment Goals
Weight BMI Targets
FACILITY TIMELINE2004 – Medical record review revealed clinical
improvement opportunities for diabetic inmates (physical assessment, medication, patient education)
2005 – FCC Butner designation “Diabetes Center of Excellence” (DICE)
2006 – Committee launched diabetes awareness programs for staff and inmates, now annual
2007 – inmate education classes, re-established target clinical outcomes
2008 – initiation of inmate self monitoring blood glucose program
INMATE CHARACTERISTICS:
~20% known or at risk are in diabetes chronic care clinics
Disproportionate number of federal inmates are overweight; many take anti-psychotics which can cause obesity
Predominately Hispanic, African American
INMATE BARRIERS TO ACHIEVING TARGET GOALS
Inmate contributions to food choices – commissary, menuLockdownsInsulin timingLack of community supportComorbidities
Quality Improvement
The continual assessment of health care delivery to improve outcomes and reduce medical errors
Areas to improve include:Appropriate utilization of medical services based on evidence, reduce service variability, address disparities, improve communication, increase patient-centered care, incorporate technology
Agency for Healthcare Research and Quality (AHRQ), 2012
Performance Improvement Priorities
Monitoring Parameters for Control and Complications
Performance Improvement Priorities
Monitoring Parameters for Control and Complications
Every Visit
3-6 months
Annual
Blood PressureFoot ExamWeight, Waist Circumference
HBA1cEvery 3 months (for poor control ):
Initiate/change medicationEvery 6 months for stable control
Dilated Eye ExaminationLipid Levels*Microalbumin
* Every 2 years if levels fall in lower risk categoriesAmerican Diabetes Association. Clinical Practice Recommendations. Diabetes Care.
FACILITY DIABETES STATISTICS
Majority Type 2 25% at or below target goals*~500 insulin usersInsulin use inevitably rises
* estimated by random hemoglobin A1c review
FACILITY INSULIN EXPENDITURES
Increase in insulin expenditures from 2010 to 2011No significant change in Metformin or SFU costsSignificant decrease in TZD costs
46K42K
106141866
Sulfonyurea = SFU; Thiazolidines = TZD
PHARMACY COSTS FOR DIABETES MEDICATIONS*
Insulin is associated with the greatest staff resource**
Insulin is associated with increased risk for medical errors, medical emergencies and morbidity
*2010/2011 data; does not include lancets, needles, syringes, alcohol swabs, gauze, band aids
**insulin prep time, pill line time, triage and emergency interventions
Federal Bureau of Prison Inmate Self monitoring program
Agency glucose meter distribution program initiated in 2008 for inmate insulin users
Considerations:Staff apprehensionOversightEducationCostAccountability Continuity during transfers
Hundreds of glucose meters issued since program inception
Noticeably Less Medical EmergenciesD 50
PROGRAM REVIEW OUTCOMESHemoglobin A1c (HBA1c) Values by groups
Minimum Maximum Mean Std. Deviation
Group one n=10 Target Glycemic Control
Pre baseline 5.9 6.8 6.4 0.3 Ø Post baseline 5.9 6.9 7.0 1.0
Group two n=29 Mild-Moderate Glycemic Control
Pre baseline 7.1 9.5 8.1 0.7
Post baseline 7.1 9.5 8.7 1.4
Group three n=22 Poor Glycemic Control
Pre baseline 9.6 14.8 10.7 1.2
Post baseline 9.6 12.2 10.0 1.1
N=61 HBA1c expressed as %
CLINICIAN BARRIERS
Definition of good glycemic control (treatment complacency)
Accountability for glycemic monitoring and interventions
Complexity: BS, BP, lipids, weight, personal behaviors for the incarcerated
Specialist and expert availability
GOALS FOR PATIENT CENTERED CARE
Education
Nutritional support
Physical activity
Medications
Self-monitoring blood glucose (SMBG)
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NEXT STEPS-TIME TO WORK TOGETHER
Health Services
Unit Management
CustodyMarshalls
Food ServiceCommissary
Recreation
INMATE 1500
1200
1800
2100
MOVING FORWARD Group medical visits
Group session for education; train the trainer
Staff and inmate lead physical activity sessions
Quality of life groups for psychosocial support
Foot clinic – Best Practice
Self-Management clinic (food, activity, medication and insulin)
Certified Diabetic Educator resources; Bureau of Prisons has issued an announcement for regional diabetic nurse consultants
Inmate self referrals (dental, eye, foot care)
Community partnerships – health fair, education for credit
What we learned is we cannot manage diabetes without a strategic self-management plan
Thank You…
FCC Butner, Diabetes Center of Excellence Committee (DICE)
Quality Management Department
QUESTIONS?
