Community Benefits Proposals -- Diabetes Among African Americans

African Americans with diabetes have more than a three times higher mortality rate than the overall diabetes population, and diabetes has an increasing overall mortality rate over the last 10 years in King County.

Clinical Rationale

Definitive studies have shown recently that controlling blood sugar to maintain near-normal levels can reduce complications by 25% to 50% for patients with both Type I and Type II diabetesⁱ. The type of patient self-management required to successfully sustain near-normal blood sugar levels can be achieved with the support of outreach workers, health education professionals or nurse managers, working in association with primary care physicians and specialistsⁱⁱ. Several studies currently show inadequate use of effective interventions, e.g. fewer than 20% of diabetic patients have foot exams.

Two Program Descriptions

1. COMMUNITY DIABETES INITIATIVE

This is an existing comprehensive and collaborative project among area community and health department clinics emphasizing the achievement of measurable health outcomes among low-income King County residents. The clinics are participating in a 13-month collaboration with the Institute for Healthcare Improvement, through their Chronic Disease Breakthrough Series. The clinics along with other participating health care systems across the country, the Institute for Healthcare Improvement, and the Robert Wood Johnson Foundation national program Improving Chronic Illness Care are working to implement a model of care for people with diabetes. Participants are learning and implementing an organizational approach to caring for people with chronic disease in a primary care setting. "The system is population-based, and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team". (Institute for Healthcare Improvement, 1998). The objectives of the program are to:

1.	Identify the diabetic population and proactively manage. A database for each diabetic is established and used for clinical tracking and patient follow-up.
2.	Cardiovascular risk reduction: document and track smoking, offer cessation courses, use evidence-based guidelines for aspirin use, offer weight loss and exercise programs, blood pressure tracking.
3.	Microvascular: modify adverse consequences of microvascular risks: establish retinal screening protocols, track micro-albuminurea, track hypertensive medications, foot exams, reminder system.
4.	Glycemic control: track HbA1c levels with routine measurements, use a clear plan of care.
5.	Self-management: emphasize patient's ability to achieve improved clinical outcomes, ask patient about approprite self-management opportunities, offer support and educational materialsⁱⁱⁱ.

Local Program Structure

For the community and health department clinics, a team of four staff is responsible for the overall system leadership, clinical expertise, and day-to-day direction of the project. The team includes one medical director, two clinic executive directors, and a diabetes initiative coordinator. A steering committee of 14 members representing the clinics provides oversight. The collaboration with the Institute for Healthcare Improvement provides three intensive breakthrough learning sessions and a final conference, as well as informational support throughout the 13 months. The state Department of Health is providing audit and computer programming assistance to help create the core patient registry.

Three work groups are creating the means to improve diabetic care for the clients of the community clinics and the health department. The Resource Workgroup is charged with establishing a consistent source for diabetic supplies for the uninsured patients of all the clinics. The Registry Workgroup is designing and will establish a core diabetic registry that will be used to track and monitor the care of patients over time and provide patient data to health care professionals. The Self-Management Support Workgroup is assisting clinics to develop a defined system to support the self-management by patients.

King County Health Action Plan and Community Benefits Focus

Additional resources are needed to fund supplies for low-income patients and self-management support by registered nurses.

Supplies
$5,000 will fund 11 patients? annual supply costs. This figure assumes that the patient would not need to buy a glucometer (either the patient has one or can get one at low or no cost) and needs strips to test two times per day. One box of 50 strips costs around $30, which totals $438 per year.

It is estimated that 1,050 patients need help paying for supplies. In the first year, funds for 500 patients could be efficiently disbursed. A total of $225,000 could be spent. Any fraction of that figure would be valuable in assisting with supply costs for these low-income patients.
Self-Management Support
$20,000 will fund a half-time registered nurse dedicated to diabetes self-management support. Individual sessions are conducted using social work components, covering blood sugar management, diet, foot care, eye care, and referrals to other resources. The half-time nurse can oversee self-management services for 15 patients per week or, with bimonthly visits, 120 patients per year. In the first year, 500 additional patients will need self-management services. A total of $83,300 could be spent, but any fraction thereof could help a smaller number of patients.

Target Population

The clinics are able to target services to low-income residents and to a disproportionate share of African Americans compared with the population as a whole. Nine community clinics plus the health department clinics treated 98,400 patients in 1998. Clinic users were twice as likely to be African American than the general population, while 5.8% of the King County population is African American, 11% of clinic patients are. The vast majority of clinic users are low-income, 93% of clinic patients have incomes below 200% of poverty. About 2,000 patients have been identified and are currently being actively treated for diabetes (about two percent of all patients).

Outcomes

In addition to several clinical outcome statements related to blood sugar control, eye care, foot care, etc. the following goals have been established for supplies and self-management programs:

100% of community clinic patients will have access to glucose monitoring supplies: glucometers, strips and medications
50% will have access to self-management support programs such as group of individual diabetic education and counseling.

Benchmark Measures

The strongest evaluation component of the program will be the before and after measurement of diabetes clinical measures, and the supply and self-management support outcomes measures. These measures can be compared with results from other health care centers currently participating in the Institute for Healthcare Improvement program.

2. AFRICAN AMERICAN ELDERS PROGRAM

A smaller and more highly targeted program for African Americans in King County is the African American Elders Program. Under Mayor Norm Rice, the Mayor?s Council on African American Elders was initiated. The Council oversees an interdepartmental social and health services program called the African American Elders Program. The program was established in July 1997, and in the past year and a half has enrolled 140 isolated African Americans living in specific target zip codes.

Individually customized services are provided by three City agencies: Aging and Disability Services, Senior Services, and the Seattle-King County Department of Public Health. Staff are donated by each of the three agencies. Currently, a case manager, an outreach worker and a half-time public health nurse are delivering services. All are African Americans familiar with the primarily Central Seattle target area. Project oversight is provided by the Mayor?s Council. The staff are working at full capacity with the current caseload of 140, though they believe additional resources could serve many more seniors in similar situations.

Provided services include home repairs, financial management, health assessment, health education and health care services. Participants are also connected as needed to community resources for legal services, meals on wheels, nutrition information, chore services, counseling, transportation, food stamps, utility bill assistance, and rent assistance^iv.

King County Health Action Plan and Community Benefits Focus

The African American Elders Program could more effectively identify, help manage, and refer participants with diabetes or suspected diabetes with the following additional funds:

Health services and education

An additional half-time public health nurse, at a cost of $25,000 per year could see 10 patients per week, or including follow-up visits every two months, 80 patients per year. These services will be used by the diabetic patients identified in the current caseload, plus any additional eligible elderly with diabetes that capacity allow.

Nutrition Counseling

Currently, nutrition counseling services are not available through the African American Elders Program. To address this service gap, a short-term pilot program is being developed using the Nutrition Screening Initiative Tool and other indicators to identify seniors at high nutritional risk. The identified seniors will be visited twice by student interns during the current academic year.

On-going nutrition services, including follow-up visits and more intensive diet modification work, will be needed for high risk elderly with diabetes. Assuming 40 such high risk seniors are identified, a dietitian working part-time could visit the seniors once a month for the first six months and once every two months or as needed thereafter. The dietitian would be needed at 0.5 FTE for the first six months and 0.25 FTE afterwards, for a total annual cost of $15,000.

Target Population

African Americans over age 60 who need help with basic services in eight target zip codes primarily in Central Seattle are the target population. Home and community visits by outreach workers identify isolated African American seniors and recruit them for the program.

Outcomes Measures
The following measures will be collected:

Number of diabetic patients identified
Number of diabetic patients referred for health services (currently health services are provided by the Central Area Health Center)
Pre- and post- blood sugar levels, annual measure
Number of individuals referred for nutrition counseling
Pre- and post-nutrition counseling brief diet survey.

Benchmark Measures

There are no other known programs locally that specifically target low-income, homebound African Americans, so comparable outcomes benchmarks are not available. Similar programs in other locations can be researched to obtain general outreach, enrollment and service measures. In the first year, one of the most revealing evaluation measures for the addition of a diabetes component to the African American Elders Program will be number of participants using specific services. After the first year, changes in clinical measures will become more important.

i	September 1998 studies in Lancet and the British Medical Journal, as referenced in "Studies point way to lowering diabetes dangers," Seattle Post-Intelligencer, September 11, 1998, A7; and "The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus," The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-86.
ii	Aubert RE, Herman WH, Waters J, et al. "Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: a randomized, controlled trial" Ann Intern Med. 1998; 129: 605-12.
iii	Institute for Healthcare Improvement, 1998, pLS1-1, LS1-12.
iv	African American Elder Project brochure, a partnership of Senior Services, Seattle Department of Housing and Human Services, Seattle-King County Department of Public Health, and the Mayor's Council on African American Elders, 1601 Second Avenue, Suite 800, Seattle, WA 98181, (206) 674-9271.