1. Meeting the Challenge of Patient-Centered Care: Diabetes Education
Roberta Eis, RN, MBA
Sr. Program Manager, Diabetes Initiatives, HFHS
Pamela Milan, RD, CDE, MBA
Operations Manager, Diabetes Care Centers, HFHS

2. What is Diabetes Self-Management Education?
Diabetes Self-Management Education (DSME) is a crucial element of care for all people with diabetes
DSME is necessary in order to improve patient outcomes
National Standards are designed to assist diabetes educators in providing evidence-based information
Henry Ford Health System has five “Diabetes Care Centers” offering DSME, using traditional educational approaches until 2008.

3. Why Change?
New national standards for Diabetes Self Management Education (DSME) were released in June 2007, new version expected in 2012.
The new standards challenged American Diabetes Association (ADA) Recognized Programs to develop a curriculum delivered in a creative, patient-centered approach, encouraging patients set the agenda for their education.

4. Aim
To shift from primarily didactic presentation model to a facilitator style.
To standardized DSME class format for all sites while allowing instructors to individualize the presentation to the groups as needed.
To maintain the programs’ high customer satisfaction rating while aligning to the new process.
To develop curriculum exemplifying the use of action-oriented, behavioral goals & objectives delivered in a creative, interactive and patient-centered method of education.
To maintain best practices from the established past curriculum: depression screening and education tool kits.

5. The Patient-Centered Education Model
Conversation Map® educational tool created by Healthy Interactions, Inc. in conjunction with the ADA and supported by Merck & Co., Inc. was adopted.
Map is a large tabletop display tool with colorful visual images & metaphors, with printed cards is used to initiate various discussion topics.
The diabetes educator engages a group of patients seated around the map in interactive discussions and exercises.
The map is navigated sequentially with content specific to the DSME educational curriculum for each session.
Patients are central part of the learning process, and through the group model they discover and share many challenges in managing the disease.
DSME – 9 hours of education

6. Diabetes Conversation Map ®

7. Conversation Map® Session

8. Teaching the Teachers
The change process evolved over time and required a tiered learning approach for the diabetes educators.
All diabetes educators attended a half-day workshop provided by Healthy Interactions representatives on the introduction and use of the Diabetes Conversation Map® in February 2008.
In the first groups attending this workshop, two educators embraced the new model and agreed to be early adopters. They piloted the curriculum at their site.
A meeting was held with the entire DSME staff to gain team acceptance of the new teaching method.

9. Educators Still Not Ready

10. Long Road to New Skills
The staff were encourage to attend the Taylor pilot site to observe classes which provided opportunity for on-site mentorship support.
In order to assist the staff with transitioning to facilitation of groups, a workshop on advance facilitation skills was conducted by a master trainer from Healthy Interactions, Inc.
The staff still struggled with adaptation to the facilitation model, so multiple training sessions were provided on motivational interviewing.

11. Standardization and Best Practices
The standardized curriculum blended the best practices of the traditional DSME class content like education tool kits, practice with labels & food models and other hands on activities with the new education style.
Training in health literacy was completed. This knowledge was used as the basis for revising standardized patient education materials.
Depression screening was a core component of DSME program that we wanted to maintain. After numerous iterations, we have now successfully incorporated depression screening in the initial assessment.

12. Maintain High Customer Satisfaction Scores
Satisfaction Survey Results Pre and Post
Diabetes Conversation Map® Implementation
Satisfaction Survey Results Pre and Post
Diabetes Conversation Map® Implementation
Satisfaction Survey Results Pre and Post
Diabetes Conversation Map® Implementation

13. Improved Patient Engagement in Classes
Sites were less than 1 year in operation – mixed model to start not totally didactic.

14. 15% Increase in Class Completion
Three years after change

15. Patient Centered Care Patients teach each other:
We can hold up a divided plate to discuss portion sizes, but when a patient shares his personal weight loss story by using the small plate his wife started a month ago, the impact is much greater.
Patients support/bond with each other:
At one site the group set up an based support group.

16. Participant Behavioral Outcomes 2010
# who Selected Goal
# Reporting Success
% Met Goal
Benchmark
Healthy Eating
248
181
73%
60%
Being Active
210
126
Monitoring 27 23
85%
Taking Medications 9 8
89%
Problem Solving 5
100%
Healthy Coping
63%
Reducing Risk 32
72%
Unknown 14 10
71%
Behavior goal categories based on AADE7 Self-Care Behaviors™

17. Self Reported Behavior Change 2010
Less Often
No Change
More Often
# of responses
% of more often
Testing your blood sugar level 21
137
146
304
48%
Handling your stress or coping 10
163
131
43%
Taking your medications as directed 5
173
108
286
38%
Caring for your feet
130
167
302
55%
Eating smaller portions 18 70
214
71%
Your amount of activity/exercise
152
301
50%
Your amount of smoking
109 6
133 5%
Yes No
# of responses
% of yes
Keeping doctor appt every 4 to 6 months
293 8
301
97%

18. Impact of Diabetes Education

19. Patient Feedback
“Learning from other patients with diabetes like myself and being able to discuss my concerns was very helpful.”
“The other participants made the classes fun and interesting. It’s good to know we are not alone.”
“These classes told and helped me learn about things that my doctor could not have done for me. Thank you!!”

20. Lessons Learned
Accept that change is evolutionary and takes time, especially when staff are entrenched in the current process. Communication and engagement skills, positive reinforcement and patience are crucial.
Realization that staff who have developed a lifelong teaching style need to be thoroughly trained in a new style of education.  “Early adopting” colleagues made the best trainers for the process.
Teamwork is essential in providing quality patient care. Collaboration between nurses, dietitians, behavioral nurse practitioners and management was essential to the development of appropriate evidence-based diabetes education curriculum.

21. Lessons Learned
The patient’s agenda for learning needs to be considered in the development of an education program. The Conversation Map® environment of learning, allows patients to learn from each other and results in more enthusiasm with the information delivered. 
Attempting a new approach that fostered engagement trumped the inclination to remain static, i.e., “We’ve always done it this way”.
A consistent, standardized approach results in more reliable, replicable outcomes and increased transportability of the program.

22. Continuous Improvements Since Implementation
Establish a Peer Review process to maintain consistency throughout the Diabetes Care Centers.
Share class completion rates to investigate trends for process improvement with DSME Staff each month.
The program has changed patient feedback surveys & program follow up to reflect the patient-centered, healthy behavior questions.
Continue to collect data to look for additional ways to improve diabetes outcomes.
Continue tracking race, sex, gender data to look for trends in healthcare disparities and possible program improvement.

23. Questions