Filling the Healthcare Void and Trying to Prevent the Conversion to Type 2 DiabetesFriday, May 18, 2012
The YMCA’s Diabetes Prevention Program is helping overweight Americans with prediabetes change their lifestyles and aid them in preventing the conversion to type 2 diabetes by losing a modest amount of weight. The well-known non-profit community organization has positioned itself to address a missing, but sorely needed preventative continuum in the U.S. healthcare system.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
In the 20th century, obesity was a major contributing factor to heart disease. However, thanks in part to statin treatment and medical intervention directed at cardio-related ailments, recent studies have shown the U.S. is beginning to fare a bit better with lowering cholesterol and triglycerides, and helping the country see a decrease in cardio-related deaths. And, if the 20th century was about heart disease, this century is about type 2 diabetes.
In terms of proportion and scale, everywhere you look, there are signs the United States is headed for a major health crisis related to obesity and type 2 diabetes—if the country is not there already. The U.S. is already spending $190.2 billion per year, or 20.6 percent of national health expenditures on obesity, according to a study by researchers at Cornell University.
Additionally, cases of type 2 diabetes are happening more frequently to Americans of all ages including children. The disease has taken hold as a major medical corollary to obesity. And with the inclusion of potentially hideous complications associated with type 2 diabetes—peoples’ nerves, eyes, kidneys, and heart—this can be a very sick and costly patient population who takes more medical resources in treating them.
Combine this with the way the current U.S. healthcare paradigm is delivered today, and things will likely worsen.
Traditionally, American healthcare has done a very good job at addressing acute ailments, but it is still finding its way with learning how to provide preventative healthcare. As healthcare has struggled with this, the YMCA or the Y as it has been widely known, has stepped in with its YMCA’s Diabetes Prevention Program.
Known nationally for an array of activities from camping, to group exercise to child care to swimming to craft classes, the public has a distinct comfort level and familiarity with the Y. The YMCA has developed this program to help overweight, adults with prediabetes prevent diabetes. People who participate in the YMCA’s Diabetes Prevention Program go through a year-long program that includes 16 one-hour classes with a trained lifestyle coach who helps participants learn how to eat healthier and increase their physical activity, plus 8 monthly one-hour sessions to help them maintain their progress.
This program looks to help participants lose 7 percent of their weight, and engage in 150 minutes of physical activity per week. While these are ambitious goals, they are evidence-based as the Y’s program has metrics based on the results of the National Institutes of Health (NIH)-funded landmark study done in the late 1990s and early 2000s, which showed losing that amount of weight combined with a specified amount of physical activity was more effective than using metformin to delay the conversion to type 2 diabetes.
The effort to scale the YMCA’s Diabetes Prevention Program is nearly two years old now and it is already in 27 states and more than 50 communities. In addition, the well-known non-profit organization is working with the country’s largest insurer, United Healthcare, the Centers for Disease Control and Prevention as well as the American Diabetes Association. While the Y has created a national program it is being delivered on a grassroots, local level. This allows regional employers and health systems to get involved in the program as well.
The man responsible for stewarding this unique, trend-setting program is Jonathan Lever, YMCA vice president for Health Strategy and Innovation. Understanding that overweight people with prediabetes are being seen and cared for by primary care providers, and that preventative healthcare measures are missing in the present primary care paradigm, Lever has been working with the American Academy of Family Physicians National Research Network (AAFP) to identify promising practices to support family doctors in referring prediabetic patients to the YMCA’s Diabetes Prevention Program.
DiabetesCare.net sat down with Lever (pictured, lower left) to discuss the specifics of how the program works, future plans for the overall program, and his expectations for the YMCA’s burgeoning relationship with AAFP.
DiabetesCare.net: Why did the YMCA get involved in this program?
Lever: The Y got involved in this program as a larger strategic move to increase its efforts to become one of America’s leading non-profits improving the nation’s health. The Y has been typically known for doing youth sports and camping, and primary prevention programs for families.
For several years we have been focused on adding secondary prevention and tertiary types of programs for people who are at risk for certain conditions or have a condition and trying to reclaim their health in living with it.
This was part of a larger effort to really put the YMCA in the forefront of helping to address America’s growing chronic disease crisis.
DiabetesCare.net: Can you talk about who the YMCA has partnered with on the program?
Lever: There are two layers of partnerships—both national and local. From the national level, we are partnering with key public health institutions. For example, we are working with the diabetes division of the Centers for Disease Control and Prevention, and we have worked with national health insurance companies like United Healthcare. We have also worked with the American Diabetes Association and the Diabetes Advocacy Alliance on policy efforts.
Locally, the way it translates is in more of a micro fashion. Often there are local health departments or non-profits like the local chapter of the American Diabetes Association. We are also working with doctors’ offices and federally qualified health centers. Any place where there is likely to have a referral for someone who is qualified for the program.
We have developed a relationship with the National Research Network of the American Academy of Family Physicians (AAFP) to navigate people from primary care in the community setting into the YMCA. This is a good example of what we want to do, which is taking a national partnership and trying to work locally with clinicians and YMCAs.
DiabetesCare.net: How would you characterize your partnership with AAFP?
Lever: We are just beginning. The paradigm of the doctor and his or her relationship to the community, and navigating the patient through the YMCA program is really just in its infancy.
Where we have most of our challenges is not that doctors don’t want to refer patients to community-based programs like the YMCA’s Diabetes Prevention Program; rather, it’s just that the systems are not set up to facilitate these kinds of interactions. However, it is happening in various pockets across the U.S. in certain YMCAs. We are making progress nationally, but we are in the very beginning stages of seeing the results of all of this work.
DiabetesCare.net: So the AAFP is receptive to communicating this program to it members?
Lever: Our work with the National Research Network of the American Academy of Family Physicians is very focused on finding out what are the correct levers to facilitate the pathway from the doctor to the community-based prevention program. As best practices are developed, the American Academy of Family Physicians is going to create tools that it can disseminate throughout its network.
It is a learning process now and will develop into more of a best practice document in the next six to eight months.
DiabetesCare.net: Turning to the specifics of the YMCA’s Diabetes Prevention Program itself, what type of training do the lifestyle coaches have?
Lever: The people who lead the class go through an extensive two day training where they learn the intricacies of the program, and they have a chance to practice delivering the program and learn about issues most people are not familiar with—such as laws related to HIPAA.
There are also other classes for the trainers that will eventually become a part of the required training. These classes include such things as: motivational interviewing; facilitating learning in small groups; and supporting behavior change. These classes will help our lifestyle coaches to be successful beyond delivery of the curriculum.
DiabetesCare.net: What is the professional background of the lifestyle coaches?
Lever: Generally speaking, they are health and wellness oriented professionals with educational backgrounds in this field, but not everyone is. We do have some lifestyle coaches that are certified diabetes educators but it is not a requirement.
Whether they be medical providers or come to the Y with either a strong background in nutrition or physical education, the biggest challenge we have for all of our lifestyle trainers is teaching them that this program is not about dictating to people what to do. Rather, it is about people discovering—for themselves—what steps they can take to make healthy choices on their own. The reason the program works is that it is about facilitating peoples’ own sense of self-efficiacy around what steps they can take.
DiabetesCare.net: Losing 7 percent of body weight and having people be able to exercise 150 minutes a week are both impressive goals. Why these particular goals?
Lever: These are goals that are established in the science and in the literature as being ways in which people can prevent the conversion to type 2 diabetes. This is not something the YMCA created. It is what comes out of the original NIH study. In the late 1990s, the NIH’s Diabetes Prevention Trial focused on whether lifestyle change through seven percent weight loss with and 150 minutes of physical activity was more effective than a drug [metformin] from preventing type 2 diabetes. The lifestyle intervention with weight loss combined with physical activity was more effective—almost twice as effective as using just metformin.
DiabetesCare.net: What are the sizes of the classes and are they held at a local YMCA facility?
Lever: There are 8-15 participants in a class, and you won’t find a YMCA offering a class with more people than that. These classes are meant to be kept to a manageable size to facilitate group interaction and engagement.
They are not only held at the YMCA, but these classes can be held anywhere. This can include any place from a federally qualified health clinic to a local church to a library. This program is a classroom activity. It’s not like you put on gym shorts and go running at some point in the class. Ifa program site has a table and chairs, its are good to go. We encourage local YMCAs to make it accessible to what works best for people in their area.
DiabetesCare.net: What are the qualifications to be eligible for the program?
Lever: To be eligible, you have to have the following three things: you have to be at least 18 years old; you have to be overweight with a BMI greater than 24—although it is slightly different for Asian populations; and you have to be at risk of developing type 2 diabetes. Ideally, participants also have a confirmatory diagnosis of prediabetes from their healthcare provider
DiabetesCare.net: Can medical insurance companies be billed for the program? Are there any scholarships or way in which to mitigate costs?
Lever: Yes all of those things are available, but it varies by individual markets. Depending on the market, the YMCA are able to offset the cost of program delivery through local resource. They may charge a flat rate for enrollment, and if a person cannot pay that flat rate, they make scholarships available for people to get into the program.
In other markets, insurance companies and/or employers pay for the program as an insurance benefit or employee benefit. Some employers recognize that the conversion to diabetes is such a problem in their employee base, that they were going to pay for this intervention, and the Y has a third-party administrator who handles the claims. In these cases, if you show up at the Y and your employer has decided to make this a benefit, there is no out-of-pocket cost to you the employee.
DiabetesCare.net: For anyone who is interested in finding out more about the program or if there is one nearby, what is the best thing to do?
Lever: For those who have computers, they can go onto www.YMCA.net/diabetes-prevention, and there it gives an overview of the program, and has a “find a local YMCA” participant feature. It also allows someone to send an e-mail to the person who coordinates the program locally. For anyone without a computer, I would have them call their local Y to ask if the program is available.
DiabetesCare.net: Is the YMCA’s Diabetes Prevention Program filling a void in today’s healthcare paradigm?
Lever: Yes. I believe that the Y is on the cutting edge of how healthcare is going to be delivered in the future, and I believe this for several reasons. We now have insurance companies paying for prevention, which is a relatively new phenomenon; we are a non-medical provider delivering a prevention program in a group-based format. It is relatively unheard of for insurers or employers to pay for prevention in a group-based format. The last reason is that third-party payers are paying for the program based on participant performance. This means the YMCA is only compensated when certain performance metrics are met both in attendance as well as health outcomes. I think our approach is setting the stage for a new paradigm in how healthcare will be delivered.
DiabetesCare.net: Are you planning to grow out the program to more states and more YMCAs? And if so, what is your specific strategy to get there?
Lever: Yes we are.The demand within YMCAs right now is huge. Nearly everyday, we get calls from Ys saying that they want to offer the program. We are doing everything we can to keep up with the demand.
This is different from other programs with the level of fidelity that is required, including the fact that payment is based on performance, and that there are HIPAA laws that the YMCA is not used to dealing with. We are having to approach this from a very different way from other kinds of programs we have done nationally.
We believe we have a responsibility to keep the integrity of this program whole. This way, when people hear the YMCA is doing its diabetes prevention program, they know we have the right kind of training and the right systems, and that we have satisfied the legal compliance issues to know this is a quality program.
We are involved in a six month strategic planning process, where we have engaged an outside consultant to develop a further strategy around scaling the program. We have scaled the program from two to 50 communities in almost two years. And we know we have to go faster.
It is both exciting and daunting to do this in light of the mechanics of the program and the quality assurance that is required. And we are talking about saving peoples’ lives. We have to be very disciplined and careful about how we do that as we continue to scale it on a national level.