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The PRISM Project

VIEWS: 5 PAGES: 24

									              PRISM Project:
       Promoting Realistic Individual
       Self-Management for Diabetes
                    Billings Clinic
     Center for Clinical Translational Research

                                    September 1, 2009
* Supported by funding from NIDDK

                                                   Health Care, Education and Research
Health Care, Education and Research
                         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.

                                 Health Care, Education and Research
                                     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



                                        Health Care, Education and Research
                         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.


                                 Health Care, Education and Research
                                  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.

                                                                           Health Care, Education and Research
           Study Sites




Health Care, Education and Research
                        Patient-Centered Care


    Traditional Care                       PRISM

• Content driven             • Patient driven
  education                    education

• Provider recommends        • Motivational
  preferred course of          Interviewing
  action                       techniques (Patient
                               decides action)

                               Health Care, Education and Research
                             Patient-Centered Care

       Traditional Care                            PRISM

• Patient is either “compliant”   • Readiness for change
  or “noncompliant”

• Passive Patient                 • Active Patient

• Expert providers work           • Team working for
  separately                        improved healthcare,
                                    including patient

                                      Health Care, Education and Research
                          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.

                                Health Care, Education and Research
Health Care, Education and Research
           Perceived Challenges

• Establishing trust

• Nonverbal communication

• Difficulty discussing sensitive issues

• Managing the technology

                               Health Care, Education and Research
           Services Provided

• Individual and Dual Sessions

• Patient Care Conferences

• Education and Support Groups

• Create Your Weight Group
                             Health Care, Education and Research
Education Groups




           Health Care, Education and Research
Support Groups




            Health Care, Education and Research
                            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

                                     Health Care, Education and Research
                Results




Health Care, Education and Research
                                         Figure 1. MMSE Score Mean Differences (Remote vs. In-Person)
                                                     and 95% Confidence Intervals (n=73)
                     0.2

                    0.15

                     0.1

                    0.05

                       0
Score Differences




                    -0.05

                     -0.1

                    -0.15

                     -0.2
                                                                                                                            Upper Confidence Limit
                    -0.25                                                                                                   Difference
                                                                                                                            Lower Confidence Limit
                     -0.3

                    -0.35
                            * 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
                                                                   and Care, Education and Research
       State Examination: Assessment from a distance. TelemedicineHealth e-Health, 2009;15(4): 325-327.
                                                                Patient Satisfaction with
                                                                         PRISM Program

Diabetes Care Patient Satisfaction (n=141)
                                                                                         Tx-Urban           Tx-Rural           Control
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




                                                                                       Health Care, Education and Research
                           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


                                      Health Care, Education and Research
                              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
                                     Health Care, Education and Research
            Self-Reported DM Self-Management Behaviors (n=287)

70%
            65%
                                  61%          Pre-PRISM       Post-PRISM
60%



50%
                                              46%


40%   37%

                           31%
                                                                            29%
30%



20%
                                        19%



10%                                                                 8%



0%
      Tx-Urban               Tx-Rural   Tx-Urban                     Tx-Rural

        Checks BG correctly, > 6 mo     Follows diet as instructed, > 6 mo
                                                    Health Care, Education and Research
                                         Proportion of patients with Controlled LDL Cholesterol (<100
                                            mg/dL) one-year post-PRISM who were uncontrolled at
                                                            baseline (n=118; p=.03)
                                   60%
Percent patients LDL < 100 mg/dL




                                   50%


                                   40%


                                   30%
                                               53%
                                                                      45%
                                   20%

                                                                                                        27%
                                   10%


                                   0%
                                              Tx-Urban               Tx-Rural                          Control

                                                                                Health Care, Education and Research
                          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


                            Health Care, Education and Research

								
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