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MARTHA PELAEZ, PH.D. HEALTHY AGING REGIONAL COLLABORATIVE OF SOUTH FLORIDA Diabetes and Multiple Chronic Conditions in a Geriatric Population.

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Presentation on theme: "MARTHA PELAEZ, PH.D. HEALTHY AGING REGIONAL COLLABORATIVE OF SOUTH FLORIDA Diabetes and Multiple Chronic Conditions in a Geriatric Population."— Presentation transcript:

1 MARTHA PELAEZ, PH.D. HEALTHY AGING REGIONAL COLLABORATIVE OF SOUTH FLORIDA Diabetes and Multiple Chronic Conditions in a Geriatric Population

2 Agenda Complexities of managing multiple chronic conditions in a geriatric population The three legged stool for managing diabetes in older adults The Stanford Patient Education Center model for Diabetes Self Management

3 I want you to quit smoking and lose 35 pounds. Then I want you to come back and tell me how the hell you did it. Caption adapted from Bizarro, Universal Press, 1997.

4 PREVALENCE RISK FACTORS HEALTH CARE COST Complexities of managing multiple chronic conditions in a geriatric population

5 PREVALENCE

6 Number of Chronic Conditions per Medicare Beneficiary 63% 95%

7 Percent of Adults Reporting Diabetes Mellitus by Age and Sex, Percent (%) Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007

8 Diagnosed and Undiagnosed Diabetes Among Persons Age 65 and Over (age-adjusted) by Sex, Percent (%) Data source: Trends in Health and Aging web-site, National Health and Nutrition Examination Survey, accessed July 2007

9 Percent of Persons Age 65 and Over (age-adjusted) Reporting Diabetes Mellitus by Sex and Race/Ethnicity, Percent (%) Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007

10 Distribution of Age at Diagnosis of Diabetes Among Adult Incident Cases Aged 18–79 Years, United States, 2008 In % of the adult incident cases (i.e, cases diagnosed within past year) of diabetes were diagnosed between the age of 40 and 64 years. About 15% were diagnosed before the age of 40 and about 17% were diagnosed at age 65 or older.

11 Percentage of Civilian, Non-institutionalized Population with Diagnosed Diabetes, by Age, United States, 1980–2009 From 1980 through 2009, the percentage of diagnosed diabetes increased in all age groups. In general, throughout the time period, people aged 65–74 years had the highest percentage, followed by people aged 75 or older, people aged 45–64 years, and people younger than 45 years of age. In 2009, the percentage of diagnosed diabetes among people aged 65–74 (19.9%) was over 11 times that of people younger than 45 years of age (1.7%). CDCs Division of Diabetes Translation. National Diabetes Surveillance System available at

12 People with Chronic Conditions Suffer 79% 71% 64% 50% 49% Americans Speak Out about Life with Chronic Conditions; National Survey of Americans Aged 44+ January 2009,

13 Wheres the Help? 38% Feel Abandoned 45% Feel Unheard 45% Not Connected Im tired of feeling on my own when it comes to taking care of my health problems. Im tired of describing same conditions or problems every time I go to a hospital or doctors office. Im not told about other people who can help with health problems (classes, dieticians, health educators).

14 RISK FACTORS

15 Percent of Persons Age 65 and Over (age-adjusted) Participating in Leisure-Time Physical Activity by Sex, Male Female Percent (%) Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007

16 Measured Obesity by Age, Selected Years Percent (%) Data source: Trends in Health and Aging web-site, National Health and Nutrition Examination Survey, accessed July 2007

17 HEALTH CARE COSTS

18 Health Care Expenditure for Medicare Beneficiaries Age 65 and Over (age-adjusted) With and Without Diabetes by Type of Service, Dollars Data source: Trends in Health and Aging web-site, Medicare Current Beneficiary Survey, accessed July 2007

19 Average Health Care Expenditure of Medicare Beneficiaries Age 65 and Over (age- adjusted) with Any Chronic Condition and Diabetes, Diabetes Any chronic condition 2003 dollars Data source: Trends in Health and Aging web-site, Medicare Current Beneficiary Survey, accessed July 2007

20 CHRONIC CARE MODEL TREATMENT, EDUCATION, SELF- MANAGEMENT SKILLS BUILDING The three legged stool for managing diabetes in older adults

21 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Informati on Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Improved Outcomes

22 Chronic Care Model for Diabetes Patient Diagnosis and Treatment Diabetes Education Self management Skills and Support Improved Outcomes

23 The Case of Maria Nancy is a 66 year old women, recently diagnosed with type 2 Diabetes and Hypertension. She suffers from chronic pain due to Osteoarthritis and has Depressive symptoms. Nancy lives with a younger sister who works full time; she is a loner and tends to isolate herself from social and physical activity.

24 Marys contact with health care providers…. The Physician prescribes four medications: Metformin; Benicar HCT; Glipizide and Lipitor. The diabetes educator teaches her about the disease and the need to monitor her glucose in order to prevent complications. Classes are very informative and she gets motivated to do everything she can to avoid loosing her sight or get very sick. The healthy eating classes are great and she even buys walking shoes to start a walking program.

25 What happens? Nancy becomes frustrated with the meds side effects. Changing eating habits is difficult and besides, no meal is complete without dessert. Her walking routine never gets going due to her arthritis and knee pain. Nancy has a low degree of self-efficacy so she is convinced that she just has to learn to live with diabetes - - there is not much she can really do to change this.

26 What else could you offer Nancy? Can a program designed to increase self-efficacy help improve Nancys diabetes? The Stanford Diabetes Self Management, in a randomized control trial program participants were able to show a decrease in HbA1c.

27 PROGRAM PHILOSOPHY PROGRAM APPROACH TO BUILDING SELF EFFICACY AND EMPOWER FOR SELF CARE MANAGEMENT PROGRAM OUTCOMES The Stanford Patient Education Center Diabetes Self Management

28 28 Stanford Chronic Disease Self Management Program: Background Self-Management: A Key to Effectiveness & Efficiency in Care of Chronic Disease The present health care system is neither effective or efficient in addressing chronic care because it was designed for acute disease. For effective treatment of chronic disease, the patient must engage continuously in different health care practices (Holman & Lorig, 2004) The Chronic Disease Self-Management Program (CDSMP) is based on self- efficacy theory (Bandura,1977) which states: Self-management skills are learned and behavior is self-directed. Person-centered definition of the problem and person-selected targets for improvement. Motivation and confidence in managing ones conditions dictate success. The social environment (work, family, health care provider) support or impede progress.

29 CDSMP is a patient self-management education course, designed for adults 18+ with any chronic condition(s), that has three underlying assumptions: patients with different chronic diseases have similar self- management problems and disease-related tasks; patients can learn to take responsibility for the day-to- day management of their disease(s); and confident, knowledgeable patients practicing self- management will experience improved health status and will utilize fewer health care resources (Lorig, el.al. 1999).

30 Diabetes Self-Management Program (DSMP) Based on the Chronic Disease Self-Management Program developed at Stanford. Content is based on focus groups with diabetes educators and people with diabetes and meets the content standards of both the ADA and the AADE. The DSMP was originally written in Spanish for a research project funded by the National Institute of Nursing Research.

31 DSMP Assumptions People with diabetes have similar concerns and problems People with diabetes must deal not only with their disease(s), but also with the impact these have on their lives and emotions. Lay people with diabetes, when given a detailed Leaders Manual, can teach the Program as effectively, than health professionals The process or way the Program is taught is as important, if not more important, than the subject matter that is taught.

32 DSMP Research Outcomes The study results demonstrated that participants, as compared with people who did not take the workshop, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits. At one year, the improvements were maintained.

33 Self efficacy is improved in the following ways… Goal setting, making an action plan, feedback and sharing on a weekly basis Modeling Reinterpreting symptoms Persuasion This is not a workshop to learn facts. It is a workshop designed to teach skills that will make people better self-managers.

34 Workshop Overview Overview of self- management and diabetes Making an action plan Monitoring Nutrition/healthy eating Feedback/problem-solving Preventing low blood sugar Preventing complications Fitness/exercise Stress management Relaxation techniques Difficult emotions Monitoring blood sugar Depression Positive thinking Communication Medications Working with health care professionals and system Sick days Skin and foot care Future plans

35 35 Stanford Diabetes Disease Self Management Program meets the standards for accreditation by the American Association of Diabetes Educators (AADE) and American Diabetes Association (ADA) The program is delivered during an eight week intervention including: Individual assessment conducted by the programs primary qualified instructor (PQI), a registered nurse. Based on the results of the individual assessment an education plan is developed. A key component of the individual assessment is the establishment of individualized goals and self-management support strategies. Group intervention. Series of 6 sessions, 1 session per week, 2-1/2 hours per session held in community settings and led by two peer leaders or health promoters. Ideally, at least one facilitator has a diabetes. Peer modeling is a core component of the Stanford model. The peer leaders are supervised by the PQI while they use a highly scripted manual with an established curriculum. Follow-up assessment by the PQI to review the effectiveness in achieving the goals of the individualized educational plan. This review provides the PQI the opportunity to augment and modify the participants disease self-management plan, if necessary.

36 Take Home Message Gaps in quality care lead to thousands of avoidable deaths each year. Best practices could avoid the accelerated increase in health care cost. Patients recognize the need to change behaviors but may not be feel that they are able to do anything about it. Increasing self-efficacy will decrease morbidity/frailty in older years. Diabetes Educators and Community Based Self- Management Programs are two key ingredients in supporting improved outcomes for persons with diabetes.


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