Presentation

Report
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
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-Modifiable
 African American, Native American, Hispanic
 Family history
 Chronic illnesses
Modifiable
 Food choices
 Physical activity
 Weight
FEDERAL INMATE PROFILE
White
African-American
Other
Hispanic
Non-Hispanic
Bureau of Justice Statistics , 2009
57.2
39.2
3.2
32.2
67.8
CHALLENGES FOR INMATES WITH
DIABETES
 Lifestyle
 Health literacy and education
 Culture
 Health numeracy
 Non-formulary drugs
 Motivation
 Health 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
Emphasize
selfmanagement,
Quality
improvement
Primary care
provider team,
strive for target
goals
6.5
6.5
7.0
Early
assessment,
staff training
and
coordination
of resources
7.0
7.0
7.0
Chronic disease management models for diabetes
Screening, diagnostic, therapeutic
Categories for increased risk
All Guidelines
Testing
Target goals
Assessment of glycemic control
Guidelines
ADA Treatment Goals
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
Weight
BMI Targets
FACILITY TIMELINE
 2004 – 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, menu
Lockdowns
Insulin timing
Lack of community support
Comorbidities
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
Every Visit
Blood Pressure
Foot Exam
Weight, Waist Circumference
3-6 months
HBA1c
Every 3 months (for poor control ):
Initiate/change medication
Every 6 months for stable control
Annual
Dilated Eye Examination
Lipid Levels*
Microalbumin
* Every 2 years if levels fall in lower risk categories
American Diabetes Association. Clinical Practice Recommendations. Diabetes Care.
FACILITY DIABETES STATISTICS
 Majority Type 2
 25% at or below target goals*
 ~500 insulin users
 Insulin use inevitably rises
* estimated by random hemoglobin A1c review
FACILITY INSULIN EXPENDITURES
1866
10614
46K
42K
Increase in insulin expenditures from 2010 to 2011
No significant change in Metformin or SFU costs
Significant decrease in TZD costs
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 apprehension
Oversight
Education
Cost
Accountability
Continuity during transfers
Hundreds of glucose meters issued since program inception
D 50
Noticeably Less Medical Emergencies
PROGRAM REVIEW OUTCOMES
Hemoglobin A1c (HBA1c) Values by groups
Minimum
Group one n=10
Maximum Mean
Std. Deviation
Target Glycemic Control
Pre baseline
5.9
6.8
6.4
0.3
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 %
Ø
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)
NEXT STEPS-TIME TO WORK TOGETHER
Health Services
1200
Marshalls
Commissary
Unit Management
Custody
2100
INMATE
1800
1500
Food Service
Recreation
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?

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