Addressing Self-Management in a Primary Care PracticeFriday, July 08, 2011
Sensing the need for an alternative in self-management education in her local area, nurse practitioner Jacqueline Hudson, ARNP-BC, CDE, (pictured) has developed a program to help serve the needs of patients at her primary care practice and is also looking to gain AADE accreditation for it.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
Primary care practices maintain a lot of responsibility in caring for people with diabetes. The sheer numbers of people with the disease have primary care practitioners on the frontlines everyday treating these patients to help them navigate disease management. While the need to address self-management through education is a pressing need, often it is being underutilized in these practices. In an effort to change this common perception, one primary care practitioner is trying to make the difference and fill this void at her practice by offering a self-management education program.
Nurse practitioner Jacqueline Hudson of CFP Physicians Group in Casselberry, Fla., was not only encountering an influx of patients coming in with type 2 diabetes but many of them were uncontrolled. When she referred these patients to a local hospital for education classes, Hudson’s patients told her the hospital wanted an additional $1,200 co-pay even for those patients who had insurance to pay for the classes.
For a short time, CFP Physicians Group was able to utilize computer diabetes education classes for their patients, but the company that offered the classes went out of business. Looking for a self-management resource for her patients, Hudson was introduced to another education class. However, after learning more about the class, she felt it could use some restructuring in terms of its curriculum and was again left without much recourse for self-management for her patients.
With all these variables and not much in the way of adequate or affordable self-management education in her area, Hudson decided to do the next best thing; she started her own program. For the uninitiated, creating a self-management class from scratch is a lot of work in and of itself, but trying to get the program accredited by the American Association of Diabetes Educators (AADE) takes a completely different level of commitment including being creative in developing a program, meeting specific criteria, and demonstrating results by showing data of positive patient metrics.
Hudson began working on this project in August of 2009, utilizing the AADE’s Seven Core Concepts as well as some other Internet sources. After several long months working on this project alone and mostly at night, she unveiled her program in January of last year.
Along the way, Hudson has modified the program, including bringing in guest speakers to help present certain parts of the curriculum. For example, she has been working with a physical therapist who has spoke at her classes and helped her modify the exercises for the program. She acknowledges that exercise can be a challenging element to education with finding the right exercises and understanding the nature of some limitations for people with diabetes due to existing co-morbidities or obesity.
In addition, Hudson earned her CDE and has become a very active member of AADE serving as the current president for the central Florida region.
She has presented a poster of her program at the Volusia Flagler Advanced 5th Annual Sunshine Conference in Daytona Beach last year, which is an educational seminar for Florida-based nurse practitioners, and also presented the poster at the national American Academy of Nurse Practitioners conference this past June.
If she does earn AADE accreditation, Hudson believes she may be the first family primary care practice in the central Florida area to do so. She hopes to achieve this goal by the end of this year.
Hudson recently sat down with DiabetesCare.net to discuss her program and the work that is involved in getting accredited.
DiabetesCare.net: Can you provide an overview of what your diabetes education program encompasses?
Hudson: My education program utilizes the seven core concepts the AADE recommends. What I do is teach a five-week course for two hours a night for the first four weeks, and then in the fifth week we do a one-hour recap. We go over everything we learned in the first four weeks.
DiabetesCare.net: Do you provide these patients with any follow-up opportunities after they take the program?
Hudson: We tell them they can call me anytime with any questions. Right now all the patients participating in our program are from our office.
DiabetesCare.net: How are you measuring metrics like A1c?
Hudson: We do data collections in all of our charts. For every time patients have labs we include A1c, blood pressure, weight, body mass index, total cholesterol, LDL, and triglycerides. We check to see if they should be on an angiotensin-converting enzyme inhibitor (ACE) or an angiotensin receptor blocker (ARB). It reminds us if they have had appointments with other specialists like ophthalmologists, or if they have had their flu or pneumonia vaccines.
It is a nice flow sheet, and in trying to get accreditation, I have bought a program through the ADDE (the AADE 7 system), and I am inputting all the data. I just started looking into the accreditation about a month or two ago. There is a lot of paperwork involved.
DiabetesCare.net: Have you been working on the program with any of your colleagues?
Hudson: Venkatesh Nagalapadi, MD, is our medical director and he provides approval on everything I do. I do have a dietary technician who is actually going to school to become a dietitian who talks in my nutrition class. She is mainly a guest speaker and she does offer me some information.
I also have a physical therapist that comes and speaks. When he comes to speak, he demonstrates exercises and has patients try them.
DiabetesCare.net: Can you provide some specific features about your program?
Hudson: I have a walking plan that teaches people how to go from nothing in week 1 to carrying out a general walking plan of 35 minutes a day by week 8.
In our nutrition class, we have food models. We divide the food up into breakfast, lunch, and dinner. They put together each meal so they know what a normal serving size should look like. Unfortunately, a lot of times people with diabetes think all they have to do is watch their sugar.
I use these little cards that look like food. For example, I’ll use a card that represents a plate of spaghetti. On the back of the card, it will tell you how many carbs, salt, and protein are in it. We teach them that they need a certain amount of carbs, protein, and fat with each meal.
Some of my patients realize they are not eating enough and some realize they are eating too much. After they have done that, we switch up. Whoever did breakfast does dinner and those who did dinner do breakfast.
They also have labels where they have to decide from these labels which item they are going to pick and why.
DiabetesCare.net: Do you have a timeline for when AADE will accredit the program?
Hudson: I am working on the paperwork in the evenings, and in my spare time between patients (laughs). I am hoping to have it done by the end of this year. It is mainly coming up with organizational structure, job descriptions - things I never thought to do before. I know what I do and what my guest speakers do, but I didn’t know I had to write all this up.
I also need continuous quality improvement (CQI), which I have always done, but I have never written out before - they need the data.
DiabetesCare.net: In the paper you presented at the Sunshine Conference you had 30 participants. Have you had more people go through the program since then? What is the latest update on the program?
Hudson: Right now I have had 61 people go through the class. Like everything else, you will have 10 people scheduled for the class, and only 4 or 5 show up. However, the people that are going are telling their friends. I had one guy tell his ophthalmologist, and his ophthalmologist wants to start sending me patients, but I want to wait to take on more patients until after I am accredited.
DiabetesCare.net: What was the process in developing the program?
Hudson: I spent a number of months doing Powerpoints first, then took AADE’s core concepts course, which helped me further decide how to proceed. I joined the American Diabetes Association (ADA) so that I could get their up to date recommendations. The ADA puts out a book of clinical recommendations every single year. I also went online and downloaded pictures and slides that I could use.
My physical therapist wants to make some changes to my slides, and he can as long as I review and approve them first.
I also have to teach which exercises to avoid when you have conditions like diabetic retinopathy, so I can gain my accreditation. This is an important consideration.
DiabetesCare.net: Is the education program done in conjunction with medical appointments?
Hudson: In this office, as soon as a patient is diagnosed with diabetes they are asked to go to my class. When someone is diagnosed with diabetes we make him or her learn from the beginning, including doing things like sticking themselves with the blood glucose monitors for the first time in my office. I was shocked to find a new patient of ours who had diabetes for quite sometime didn’t know how to use a monitor. She said that her doctor had handed her the box and told her to do it. I don’t believe in that. People are not going to stick themselves for the first time. I also give them a little packet until they can get into one of my classes, because sometimes they have to wait 3 or 4 weeks before they can get into one.
If we have a patient who is a long-term diabetes patient, and their A1c is out of whack or their blood pressure or risk factors are getting worse than we will send them to classes.
And some people when you tell them they have diabetes, they get upset because they think they are going to die, because a loved one have the disease. I tell them, ‘no, you are not going to die, we’ll teach you how to control it so you are in control of the disease.’
DiabetesCare.net: Why it is important for primary care practices to get involved in diabetes education?
Hudson: Because almost all people with diabetes are treated by their primary care doctors. Only a few are sent to endocrinologists, like when they are unable to be controlled by their primary care doctor. People think endocrinologists mainly treat people with diabetes, but really it is the primary care practices that see more people with diabetes.
DiabetesCare.net: What kind of feedback are you getting from your patients?
Hudson: My patients love the class, and they have told me they like my classes because we make them fun. If the patient is not involved then he or she is not really going to learn.
They also learn because we try to do a lot of interactive things. I provide them with a notebook of information that has a total of 325 pages. This is their notebook that they have everything they have learned in it plus some additional information that if they go through the class, they can look at the notebook and review things.
DiabetesCare.net: What are you hoping to accomplish with the development of this program?
Hudson: I’m hoping my patients will get better control of their diabetes. As a practitioner, I can provide them with medication and education, but they are the ones who are there everyday with diabetes who have to check their feet, they have to know the symptoms of stroke and heart attack, and if they are having a problem with a medication they have to know to tell us.
I try to teach them as much as possible so they can control their disease.
DiabetesCare.net: Have you found having this education program to be beneficial to the practice overall?
Hudson: Yes, we are getting more people with diabetes that want to become patients at our practice. However, if I do get referrals from other doctors, I want them to realize that I’m not going “steal their patients.” I don’t want to do that. I just want people to learn how to take care of their diabetes better.
To find out more about Hudson’s program or her practice, visit: www.cfpphysiciansgroup.com.