Rules of Engagement

Apr 08, 2014 at 09:14 am by Staff

Diabetes, Chronic Disease Prevention & Management

Tight schedules make it difficult for primary care providers to spend as much one-on-one time as they would like with diabetic patients or those at risk for developing the disease.

Nashville, however, is home to a number of organizations with experts to help fill in the gaps and empower individuals to take control of their health. Demand for disease management professionals and health coaches is increasing as recent statistics from the Centers for Disease Control and Prevention showed the prevalence of diabetes doubled in Tennessee between 1995 and 2010.

Last month, MissionPoint Health Partners received an $80,000 grant to launch a chronic disease management pilot program serving the most challenging cases of uninsured patients with diabetes in Clarksville and nearby Fort Campbell, Ky. A medically underserved area, Montgomery County has the highest age-adjusted prevalence of diagnosed diabetes in the state. In addition to coaching, the grant will be used to connect patients with social services support, health system navigation and care coordination.

Wendy Wright, vice president of Clinical Integration for MissionPoint, noted the patients targeted for this grant had no other access to diabetes care except through the country health department. Health officials were concerned, she continued, because they felt they were continuously ‘putting a bandage’ on the problem instead of being able to get to the root of the diabetes self-management issue.

Using evidence-based standards of care and self-management guidelines, Wright said their model is all about problem solving … looking at how to achieve objectives in light of obstacles. “You can tell a person to quit smoking,” she pointed out. “Everyone knows that they should quit, that it isn’t good for them … but the how is a lot harder. That’s what we do … the how.”

Wright continued, “We try to get to the barrier and eliminate it.” She added that while others might write off particularly challenging patients, she doesn’t believe people are willfully non-compliant. “Life gets in the way,” she stated. “It takes enormous commitment to be able to care for oneself with diabetes,” she continued, adding it impacts every aspect of a person’s life.

Addressing challenges starts, she said, by employing the health-coaching model, which uses motivational interviewing to ask what an individual hopes to achieve. “Starting from that perspective is very different than being told what to do,” Wright pointed out. She continued, “We try to set small goals to achieve success. From small successes come even bigger successes.”

Specific data measures will be followed throughout the one-year grant from the Clarksville-Montgomery County Community Health Foundation to help assess the program’s effectiveness. Wright noted a similar program in Davidson County has already resulted in promising outcomes.

Nashville is also home base for international health and well-being company, Healthways, Inc., which partners with payers and employers in the quest to help individuals live healthier, happier lives as a value proposition for all parties involved. Ann Worf, senior clinical designer and family nurse practitioner, said the company has three decades of diabetes management experience.

Using a clinical algorithm to assess a diabetic individual’s acuity level and ability to self manage, the company’s health coaches then hone in on areas of greatest need and deliver support through a telephonic program. Worf noted there are several key areas that tend to trip people up and keep them from achieving maximum management.

“The area of medication adherence is one of our big areas – taking all of your medications, every day, exactly as prescribed,” Worf said. She added there are a number of reasons why someone might not follow their doctor’s orders. One such barrier, she noted, is a lack of understanding about a medication’s purpose and the health consequences of not taking it. Financial issues are also a major concern. Worf said Healthways has social workers to help connect individuals with assistance programs, provide conversation starters to discuss costs with a provider, or even directly contact the provider at the individual’s request.

Similarly, poor appointment adherence is another barrier to optimal diabetes management. “There are so many standard of care clinical guidelines that go with diabetes,” Worf said, adding regular checkups, labs, annual foot check, dilated retinal exams and blood pressure checks are just a few appointments that must be made and kept. “We send out lots of educational materials and quarterly reminders with checklists of what needs to be done when,” she noted of simple steps to make the overwhelming more manageable.

Under the larger umbrella of ‘self management,’ Worf said issues range from tobacco use and poor dietary choices to physical inactivity and depression. Although Healthways doesn’t handle depression management, they do screen and refer. “We do depression screening as part of all of our calls, and we do a larger depression screening every six months with anyone who has a chronic disease,” Worf explained.

Specific programs target each of the other areas such as QuitNet for tobacco cessation or Innergy, which was developed in collaboration with Johns Hopkins to help with sustained weight loss. “The coaches for each of these programs are very specialized,” Worf said, adding health coaches are selected for programs based on their backgrounds and then given additional training and tools to address their focus area.

“It’s absolutely individualized. There’s no cookie cutter here,” Worf said. “We’re going to work with the person where they are today.” She added coaches help each person set and achieve attainable goals based on their real life parameters.

She continued, “You can scare anybody into doing anything for a short time … but it’s not sustainable.” Instead she continued, “Feeling good, having hope, feeling like you can have a normal life … that is sustainable.”

Worf said success comes once an individual begins to own their health and make the connection between their actions and how they feel. “It’s like anything that’s good … you want more,” she concluded.

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