Diabetes and Multiple Chronic Conditions in a Geriatric Population Martha Pelaez, Ph.D. Healthy Aging Regional Collaborative of South Florida

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

“I want you to quit smoking and lose 35 pounds. Then I Caption adapted from Bizarro, Universal Press, 1997. And participatory research is not simply asking the patient to do the research for us… “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.”

Complexities of managing multiple chronic conditions in a geriatric population Prevalence Risk Factors Health care cost

PREVALENCE

Number of Chronic Conditions per Medicare Beneficiary Number of Conditions Percent of Beneficiaries Percent of Expenditures 18 1 19 4 2 21 11 3 12 5 7 6 13 7+ 14 Too often we organize our care around a certain chronic condition, like diabetes, or asthma. But the data show a different story. Well over half of those over age 65 have more than one chronic condition and they account for 95% of all health care expenditures. Almost a quarter of Medicare beneficiaries have four or more chronic illnesses, and they consume two-thirds of all Medicare expenditures. We can no longer think about disease management in the singular, given the prevalence of multiple conditions. Source, Partnership for Solutions, Johns Hopkins University, http://partnershipforsolutions.org/ 63% 95% http://partnershipforsolutions.org/

Percent of Adults Reporting Diabetes Mellitus by Age and Sex, 2004-2005 Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007

Diagnosed and Undiagnosed Diabetes Among Persons Age 65 and Over (age-adjusted) by Sex, 2001-2004 Percent (%) Data source: Trends in Health and Aging web-site, National Health and Nutrition Examination Survey, accessed July 2007

Percent of Persons Age 65 and Over (age-adjusted) Reporting Diabetes Mellitus by Sex and Race/Ethnicity, 2004-2005 Percent (%) Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007

Distribution of Age at Diagnosis of Diabetes Among Adult Incident Cases Aged 18–79 Years, United States, 2008 In 2008 68% 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.

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%). CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

People with Chronic Conditions Suffer Americans Speak Out about Life with Chronic Conditions; National Survey of Americans Aged 44+ January 2009, http://www.ncoa.org/improving-health/chronic-disease/healthier-lives.html 79% 71% 64% 50% 49% 12

Where’s the Help? 38% Feel Abandoned 45% Feel Unheard 45% Not Connected Themes from People with Chronic Conditions Diversity in many forms Struggles. Delaying care Hurting, tired, depressed and stressed Reliance on healthcare system that’s not working for many Real barriers to self-care Seeking realistic, practical, customized help “I’m tired of feeling on my own when it comes to taking care of my health problems.” “I’m tired of describing same conditions or problems every time I go to a hospital or doctor’s office.” “I’m not told about other people who can help with health problems (classes, dieticians, health educators).” www.ncoa.org/improving-health/chronic-disease/healthier-lives

RISK FACTORS

Percent of Persons Age 65 and Over (age-adjusted) Participating in Leisure-Time Physical Activity by Sex, 1998-2005 Male Female Percent (%) GAINESVILLE, Fla. — Structured exercise and physical activity programs should be covered by insurance as a way to promote health and reduce health care costs, especially among high health-risk populations such as those who have diabetes.   So says Marco Pahor, M.D., director of the University of Florida Institute on Aging, in an editorial Wednesday, May 4, in the Journal of the American Medical Association. Pahor’s paper accompanies an analysis of multiple clinical trials that examined the effect of exercise and physical activity on the control of blood glucose levels. “Cumulative work over the past few decades provides solid evidence for public policymakers to consider structured physical activity and exercise programs as worthy of insurance reimbursement,” Pahor said. A host of studies have linked exercise programs with improved health measures related to blood pressure, lipid levels — including cholesterol and triglycerides — cardiovascular events, cognition, physical performance, premature death and quality of life. People who take part in programs that contain both aerobic and resistance training are likely to get the greatest benefit, compared with people who do only resistance exercises. The study that Pahor’s editorial accompanied, conducted by Daniel Umpierre, M.Sc., of the Hospital de Clinicas de Porto Alegre, Brazil, and colleagues, compared the association between physical activity advice and structured exercise programs, respectively, and markers of diabetes. Analyses of interventions to promote physical exercise in adults have found that compared with no intervention, exercise programs are cost-effective and have the potential to improve survival rates and health-related quality of life. Some insurance providers already include a fitness benefit for members, such as monthly membership at certain fitness centers or access to personal trainers or exercise classes at reduced cost. Use of such health plan-sponsored club benefits by older adults has been linked to slower increases in total health care costs. In one study, older adults who visited a health club two or more times a week over two years incurred $1,252 less in health care costs in the second year than those who visited a health club less than once a week. Programs among people with lower incomes can also pay off, because people in that group are otherwise more likely to forego health-promoting physical activity because of economic constraints or safety concerns. “People are willing to invest in improved health, but if you have a fixed amount of resources then you want to choose where you get the most health for the dollar,” said Erik Groessl, an assistant professor of family and preventive medicine at the University of California, San Diego, and director of the UCSD Health Services Research Center. Groessl was not involved in the current analysis. Group training or walking programs, for example, can be cost-effective, sustainable forms of physical activity that don’t require expensive health care professionals or equipment. But more costly interventions that yield dramatic results might also be worth the expense. With respect to type 2 diabetes, Medicare reimburses for approved self-management education and medical nutrition therapy programs. But no specific reimbursement is given for any physical activity or exercise program, despite evidence that such programs can help improve health and cut costs. Questions remain as to what format reimbursable exercise and physical activity programs should take, what population group should be targeted, and at what stage of life or health status would a lifestyle intervention be most cost-effective to implement. Various studies, including the UF Institute on Aging Lifestyle Interventions and Independence for Elders, or LIFE study, are aimed at answering those questions through randomized controlled trials that can provide data about the efficacy and cost-effectiveness of structured activity programs with respect to a range of health outcomes. Funded by the National Institute on Aging, the LIFE study is the largest of its kind to examine physical activity and health education as a way to prevent mobility disability among older adults, and accounts for the largest federal award to the University of Florida. The institute will break ground on May 26 for a 40,000-square-foot complex within UF’s new $45 million, 120,000-square-foot Clinical and Translational Research Building, which will serve as headquarters for this research and others aimed at speeding scientific discoveries to patients. “There is a lot of evidence that physical activity works, and I think it’s time to start putting it into practice more widely,” Groessl said. Data source: Trends in Health and Aging web-site, National Health Interview Survey, accessed July 2007

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

HEALTH CARE COSTS

Health Care Expenditure for Medicare Beneficiaries Age 65 and Over (age-adjusted) With and Without Diabetes by Type of Service, 2003 2003 Dollars Data source: Trends in Health and Aging web-site, Medicare Current Beneficiary Survey, accessed July 2007

Average Health Care Expenditure of Medicare Beneficiaries Age 65 and Over (age-adjusted) with Any Chronic Condition and Diabetes, 1992-2003 Diabetes Any chronic condition 2003 dollars Data source: Trends in Health and Aging web-site, Medicare Current Beneficiary Survey, accessed July 2007

The three legged stool for managing diabetes in older adults Chronic Care model Treatment, education, self-management skills building

Clinical Information Systems Self- Management Support Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Self- Management Support Delivery System Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level. Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides. Improved Outcomes

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

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.

Mary’s 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.

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.

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

The Stanford Patient Education Center Diabetes Self Management Program philosophy Program approach to building self efficacy and empower for self care management Program outcomes

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 one’s conditions dictate success. The social environment (work, family, health care provider) support or impede progress.

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).

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.

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 Leader’s 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.

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.

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.

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

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 program’s 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 participant’s disease self-management plan, if necessary.

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. The magnitude of the problem: 45% of the U.S. population suffers from one or more chronic illnesses, and over 60 million (21% of the population) have multiple conditions.