Teaching Diabetes Self-Management— in 4 Hours (or Less) Linda S Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes.

Teaching Diabetes Self-Management— in 4 Hours (or Less) Linda S Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes Prevention and Control Program Delaware Division of Public Health 1 CEHD Colloquium, University of Delaware, February 28, 2013

Juvenile Diabetes Maturity-onset Diabetes Insulin dependent Non-insulin dependent Diabetes (IDD)Diabetes (NIDD) Type I Diabetes Type II Diabetes Type 1 Diabetes Type 2 Diabetes Types of Diabetes 2

Types of Diabetes (DM) Type 1  -cell destruction; autoimmune disease; complete lack of insulin 5-10% of total patients Type 2  -cell dysfunction and insulin resistance Gestational  -cell dysfunction and insulin resistance during pregnancy 3

There is no such thing as Borderline Diabetes or a “Touch of Diabetes.” Pre-diabetes is a diagnosis. 4

There is no such thing as Borderline Diabetes or a “Touch of Diabetes.” 5 Pre-diabetes

DM defects 6

Diabetes is a cardiovascular disease. The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program People with diabetes are twice as likely to suffer a heart attack or stroke compared to people without diabetes. 7

Natural history of Type 2 diabetes Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota. Obesity Diabetes Uncontrolled Hyperglycemia 50 100 150 200 250 300 350 50 100 150 200 250 Glucose (mg/dL) Relative Function (%) -10 -5 0 diagnosis 0 diagnosis 5 5 10 15 20 25 30 Years of Diabetes Post-meal Glucose Fasting Glucose Insulin Resistance Insulin Level  -cell Failure Insulin Resistance Family History Prediabetes

Why teach self-management? Patients must control their blood glucose (BG) levels to avoid complications Controlling BG is a complex, 24/7, life-long task – Rx’s change, increase; may not insure optimal BG control – Changes in dietary intake & physical activity necessary – And more… So much to learn and do (or stop doing) 9

PWD’s* everyday reality * “Diabetic” is not a noun 10

As teacher educators, how would you recommend teaching diabetes self-management? Here’s the challenge 14

Private schools 0.4 mil teachers 5.4 mil pupils $673 billion 15 FederalStateDistrictFederalStateDistrict Regulations Public schools 3 million 50 million Diabetes education??

$673 billion 16 FederalStateDistrictFederalStateDistrict Regulations Public schools 3 million 50 million Instruction Learning tasks Private schools 0.4 mil teachers 5.4 mil pupils Diabetes education??

Context: Exploding numbers 1 2012 Condition of Education, Table A-3-1. http://nces.ed.gov/pubs2012/2012045_5.pdfhttp://nces.ed.gov/pubs2012/2012045_5.pdf 2 For 1970, All Ages is interpolated from 1968 and 1973. http://www.cdc.gov/diabetes/statistics/diabetes_slides.htm.http://www.cdc.gov/diabetes/statistics/diabetes_slides.htm 3 For 1990 and 2010, All ages and 65+ derived from http://www.cdc.gov/diabetes/statistics/prev/national/tnumage.htm, and 18+ fromhttp://www.cdc.gov/diabetes/statistics/prev/national/tnumage.htm http://www.cdc.gov/diabetes/statistics/prev/national/figadults.htm 4 Boyle et al (2010), Projection of the year 2050 burden of diabetes in the US adult population. Population Health Metrics, 8(29).I averaged the results from their 4 models. Huang et al. (2009) estimated 34.2M for Type 2 alone: Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. 5 CDC’s Diabetes Data & Trends. http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx,http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx Just 5 years! Public schoolsDiabetes cases Number needing instruction Millions enrolled 1 Millions diagnosed with diabetes Type 1 or 2 (non-institutionalized civilians) Fall of Total Elementary (preK-8) HS (9-12) 1970 45.5 32.5 13.0 1990 41.2 29.9 11.3 2010 49.5 34.6 14.9 2020 52.7 37.3 15.4 All ages Adults (18+) Older (65+) 1970 2 3.6 1990 3 6.6 2.8 2010 3 20.9 20.7 7.8 2020 4 33.5 2004 % diagnosed adults > 20 years 5 2009 17

Average $/person 2 4,3107,92510,694 (2008) 11,0936,7451,834466 Context: Exploding costs 1 2011 Digest of Education Statistics, Table 28, http://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp. Table reports costs in current dollars, so inflation calculator used to bring up to 2010 values.http://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp 2 2011 Digest of Education Statistics, Table 194, http://nces.ed.gov/programs/digest/d11/tables/dt11_194.asphttp://nces.ed.gov/programs/digest/d11/tables/dt11_194.asp 3 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. Used inflation calculator to translate dollars from 2007 to 2010. http://www.usinflationcalculator.comhttp://www.usinflationcalculator.com 4 Huang et al. (2009) Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. Includes Type 2 only. Type 1 would be <5% of cases but higher per capita cost. Inflation calculator used to change costs from 2007 to 2010 dollars. 5 No 2020-2030 projections available for school expenditures, so just repeated % GDP from the prior 2 decades. Used Huang et al.’s total diabetes medical costs for 2007, together with 2007 GDP, to calculate costs as % GDP in that year (1.1%). Then used their Exhibit 3 (projected real growth as multiple of GDP) to estimate % GDP in 2010, 2020, and 2030. No data prior to 2007, so just took line toward asymtope. Students in public schools, K-12Diabetes cases, diagnosed and undiagnosed Total expenditures (2010 dollars) Medical costs only (2010 dollars) 1970199020102007 3 2020 4 Total $ (billions) 1 270415673 Type 1 11 Type 2 111 Undiag 12 Pre-diab 27 Total 160 Type 2 237 Diabetes Schools 18

Total medical costs, by age & diabetes type, 2007 $ (billions) 25.3 105.7 11.0 10.5 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars. 19 % (prevalence)

35,365 Average cost ($) Average medical costs per person by age & diabetes type, 2007 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars. 20

Context: Institutional resources Public schoolsDiabetes self-management education Dedicated spacePermanent buildingsVaries; hospitals, medical offices, community sites Guaranteed funding100% tax-supported 1 (local, state, federal) Varies by health plan; free community classes provided by DPH/DPCP. Mandatory attendance10-14 yearsNone, all voluntary. ~ 24% of Medicare patients attended DSMT class. Teaching force: Trained in content area Certified to teach Classroom teachers All (N=3.1 million) 1 99% 1 Many staff do DSME: medical (e.g., MD, RN, RD, NP, PA, RPh); non-medical (e.g., CHW, CHES, peer educators). DSMP classes given by lay trainers. Trained in disease management: MD, RN, RPh, RD, NP, CDE. Trained to educate: Only CDEs (N=8710), national credential; possible state licensure too. Curriculum content & Teacher lesson plans State national standards (CCSS 2 ) Always. Vary by teacher common planning Curriculum content: ADA and AADE certify Recognized Programs. DSMP has evidence-based curriculum. Lesson plans: vary with ADA & AADE programs. Fidelity agreement for DSMP. 1 2012 Condition of Education, Tables A-19-1 (2008-2009), A-17-1 & A-17-2 (2007-2008) 2 http://www.corestandards.org/ = trend towards 21 More variable for DSME

5 levels of diabetes educators* o Level 1, non-healthcare professional, o Level 2, healthcare professional non-diabetes educator, o Level 3, non-credentialed diabetes educator,  Level 4, credentialed diabetes educator, and  Level 5, advanced level diabetes educator/clinical manager. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 22

Context: Instructional resources op0Public schoolsDiabetes self-management education Hours of instruction in content area (average per year) State/district-mandated minimum hours: 1 G1-4: 418 read/write 194 math 292 science Varies greatly by health plan & site - Classes: 10-15 hrs - Individual DSME: varies Instructional strategiesSystematic use of pedagogical principles For individual patients: CDE’s assessment of patient’s needs. For groups: scripts for some non-medical educators (e.g., DSMP) Pace, sequencing, Bloom level not always considered. Special needs students Established protocols?Yes, legal obligation (IDEA)Currently, no DSME materials or curricula specifically for elderly or persons with disabilities. Age- and ability-differentiated instruction & materials Age grouping, preK-12 Elem: reading/math groups within or between classrooms, all with different lessons HS: Tracks None. Growing concern over low “health literacy” & age-related cognitive decline with PWDs, but -Diabetes education materials vary widely; content, but not complexity, matched to PWD’s learning needs. - PWDs are given pre-determined meters and supplies, regardless of their abilities. 1 Data for 2003-2004. Source: “Changes in Instructional Hours in Four Subjects by Public School Teachers of Grades 1 Through 4,“ May 2007, NCES report 2007-305 http://www.eric.ed.gov/PDFS/ED497041.pdf/http://www.eric.ed.gov/PDFS/ED497041.pdf/ 2 http://www.cdc.gov/diabetes/statistics/preventive/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf 23 Little differentiation Limited time Materials too complex

Example of required task for all PWDs: Glucose meters and lancet devices Demonstration !! 24

Our efforts 1.Describe job of self-care from patient’s perspective. – Collaboration with CDS: AUCD Conference – AADE Conference: “Cognitive Demands of DSME” – NACDD Teleconference: “Cognitive Demands of DSME” – AADE Conference 2013: “Psychometrics of DSME in the Elderly” 2.Identify the job’s most critical tasks 3.Trace (and limit) cognitive complexity of learning tasks 4.Differentiate instruction by ability (“literacy”) level 5.Provide scripts for providers that minimize complexity 6.Provide patient handout that reinforces learning 25

AADE’s description of DSM* Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that: Requires making and acting on choices, on a regular and recurring basis, that affect one’s health Includes  learning the body of knowledge relevant to the disease state,  defining personal goals, weighing the benefits and risks of various treatment options,  making informed choices about treatment,  developing skills (both physical and behavioral) to support those choices,  evaluating the efficacy of the plan toward reaching self-defined goals. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 26

AADE’s description of DSM* Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that: Requires making and acting on choices, on a regular and recurring basis, that affect one’s health Includes  learning the body of knowledge relevant to the disease state,  defining personal goals, weighing the benefits and risks of various treatment options,  making informed choices about treatment,  developing skills (both physical and behavioral) to support those choices,  evaluating the efficacy of the plan toward reaching self-defined goals. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf What Bloom level would you assign to each? Remember Understand Apply Analyze Evaluate Create 27 AADE7 TM curriculum content 1.Healthy eating 2.Being active 3.Monitoring 4.Taking medication 5.Problem solving 6.Reducing risks 7.Healthy coping

Objective: Maintain blood glucose within healthy limits to avoid complications Learn about diabetes in general (At “entry’) – Physiological process – Interdependence of diet, exercise, meds – Symptoms & corrective action – Consequences of poor control Apply knowledge to own case (Daily, Hourly) – Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner – Adjust food, exercise, meds in timely and appropriate manner Coordinate with relevant parties (Frequently) – Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support – Communicate status and needs to practitioners Update knowledge & adjust regimen (Occasionally) – When other chronic conditions or disabilities develop – When new treatments are ordered – When life circumstances change Conditions of work—24/7, no days off, no retirement Objective: Maintain blood glucose within healthy limits to avoid complications Learn about diabetes in general (At “entry’) – Physiological process – Interdependence of diet, exercise, meds – Symptoms & corrective action – Consequences of poor control Apply knowledge to own case (Daily, Hourly) – Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner – Adjust food, exercise, meds in timely and appropriate manner Coordinate with relevant parties (Frequently) – Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support – Communicate status and needs to practitioners Update knowledge & adjust regimen (Occasionally) – When other chronic conditions or disabilities develop – When new treatments are ordered – When life circumstances change Conditions of work—24/7, no days off, no retirement Our more patient-centered job description Self- management Training 28

Objective: Maintain blood glucose within healthy limits to avoid complications Learn about diabetes in general (At “entry’) – Physiological process – Interdependence of diet, exercise, meds – Symptoms & corrective action – Consequences of poor control Apply knowledge to own case (Daily, Hourly) – Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner – Adjust food, exercise, meds in timely and appropriate manner Coordinate with relevant parties (Frequently) – Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support – Communicate status and needs to practitioners Update knowledge & adjust regimen (Occasionally) – When other chronic conditions or disabilities develop – When new treatments are ordered – When life circumstances change Conditions of work—24/7, no days off, no retirement Objective: Maintain blood glucose within healthy limits to avoid complications Learn about diabetes in general (At “entry’) – Physiological process – Interdependence of diet, exercise, meds – Symptoms & corrective action – Consequences of poor control Apply knowledge to own case (Daily, Hourly) – Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner – Adjust food, exercise, meds in timely and appropriate manner Coordinate with relevant parties (Frequently) – Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support – Communicate status and needs to practitioners Update knowledge & adjust regimen (Occasionally) – When other chronic conditions or disabilities develop – When new treatments are ordered – When life circumstances change Conditions of work—24/7, no days off, no retirement Our more patient-centered job description Self- management Training 29 It is NOT just following a plan. It is also thinking and acting to minimize problems.

Our efforts 1.Describe job of self-care from patients’ perspective 2.Identify the job’s most critical tasks 3.Trace (and limit) cognitive complexity of learning tasks 4.Differentiate instruction by ability (“literacy”) level 5.Provide scripts for providers that minimize complexity 6.Provide patient handout that reinforces learning 30

UD survey: Criticality rankings 31

Bloom’s Taxonomy of Learning Objectives Latest (2001) revision Bloom levels = continuum of cognitive complexity Not just readability!! 33

* Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman. To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. “To be or not to be” Bloom’s taxonomy of educational objectives (cognitive domain)* Simplest tasks 1. Remember recognize, recall, Identify, retrieve 2. Understand paraphrase, summarize, compare, predict, infer 3. Apply execute familiar task,, apply procedure to unfamiliar task 4. Analyze distinguish, focus, select, integrate, coordinate 5. Evaluate check, monitor, detect inconsistencies, judge effectiveness 6. Create hypothesize, plan, invent, devise, design Most complex tasks 34

* Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman. Anticipate effect of exercise & foods on blood glucose. Coordinate meds, diet, and exercise. Manage sick days. Determine when & why blood glucose is out of control Monitor symptoms; assess whether action needed; evaluate effectiveness of actions Create daily and contingency plans that control blood glucose Recall effects of exercise on glucose. Remember to take BGs & Rx. Bloom’s taxonomy of educational objectives (cognitive domain)* Simplest tasks 1. Remember recognize, recall, Identify, retrieve 2. Understand paraphrase, summarize, compare, predict, infer 3. Apply execute familiar task,, apply procedure to unfamiliar task 4. Analyze distinguish, focus, select, integrate, coordinate 5. Evaluate check, monitor, detect inconsistencies, judge effectiveness 6. Create hypothesize, plan, invent, devise, design Most complex tasks Remember to measure foods, drinks & read labels. 35

What about reading nutrition labels? How important? How complex? Essential Extremely 36

Information is better because it’s in chart form Amount per serving But, it contains a confusing technical symbol. Can you spot it? “Amount/serving” 38

What’s the problem here? 39

And here? Organic Healthy No sugar added 40

Pros: Fewer items Single vertical list Major headings stand out Cons: Lots of irrelevant info Seemingly inconsistent info Better, but… 41

Food Label revision… counting carbohydrates 42

Bloom’s taxonomy of educational objectives (cognitive domain) Simplest tasks 1. Remember recognize, recall, Identify, retrieve 2.Understand paraphrase, summarize, compare, predict, infer, 3. Apply execute familiar task,, apply procedure to unfamiliar task 4. Analyze distinguish, focus, select, integrate, coordinate 5. Evaluate check, monitor, detect inconsistencies, judge effectiveness 6. Create hypothesize, plan, invent, devise, design Most complex tasks Distractors: CHOs vs Fiber vs Fat Carb vs non-carb ?? Sequence of label Total CHOs important, “Sugars” not Grams as volume vs wt Part of meal vs snack OK? CHOs in intended serving? CHOs vs Fat/Chol vs Na Location of relevant CHO (carb) gms How many CHO gms in 1 serving? Subtract fiber gms from CHO gms Plan a meal or snack 43

Our efforts 1.Describe job of self-care from patients’ perspective 2.Identify the job’s most critical tasks 3.Trace (and limit) cognitive complexity of learning tasks 4.Differentiate instruction by ability (“literacy”) level 5.Provide scripts for providers that minimize complexity 6.Provide patient handout that reinforces learning How different in ability can adults be? 44

Typical literacy items, by difficulty level National Adult Literacy Survey (NALS), 1993 NALS difficulty level (& scores) % US adults (age 65+) peaking at this level Simulated everyday tasks 5 (375-500) 3% ~ 0%  Use calculator to determine cost of carpet for a room  Use table of information to compare 2 credit cards 4 (325-375) 15% 4%  Use eligibility pamphlet to calculate SSI benefits  Explain difference between 2 types of employee benefits 3 (275-325) 31% 16%  Calculate miles per gallon from mileage record chart  Write brief letter explaining error on credit card bill 2 (225-275) 28% 33%  Determine difference in price between 2 show tickets  Locate intersection on street map 1 (0-225) 23% 47%  Total bank deposit entry  Locate expiration date on driver’s license Daily self-maintenance in modern literate societies 45

NALS difficulty level (& scores) % US adults (age 65+) peaking at this level Simulated everyday tasks National Adult Literacy Survey (NALS), 1993) 5 (375-500) 3% ~ 0%  Use calculator to determine cost of carpet for a room  Use table of information to compare 2 credit cards 4 (325-375) 15% 4%  Use eligibility pamphlet to calculate SSI benefits  Explain difference between 2 types of employee benefits 3 (275-325) 31% 16%  Calculate miles per gallon from mileage record chart  Write brief letter explaining error on credit card bill 2 (225-275) 28% 33%  Determine difference in price between 2 show tickets  Locate intersection on street map 1 (0-225) 23% 47%  Total bank deposit entry  Locate expiration date on driver’s license  level of inference (“connecting the dots”)  abstractness of info  distracting information  number of features to match Not reading per se, but “problem solving” Typical literacy items, by difficulty level National Adult Literacy Survey (NALS), 1993 46

Complexity & aging 47

g - Basic information processing (G F ) Basic cultural Knowledge (G C ) Age-related cognitive decline Learning & reasoning ability Age 8 48 Age 80

“Rx for Physical Activity” for a Rural Community Health Center Linda S. Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes Prevention & Control Program Delaware Division of Public Health Presented at the 2009 Diabetes Translation Conference of the Centers for Disease Control & Prevention (CDC). Long Beach, CA, April 24, 2009 50

Basic pedometer—just counts steps 53

Graduated Rx Basic Rx increases speed http://www.udel.edu/educ/gottfredson/Rx 54

Teaching the teacher: Script for CDE when prescribing “Rx for Walking” Provides the CDE with: Educationally sound teaching strategy Key ideas Content, sequence, and pace of instruction, etc. Implicit training Be concrete, personalize, use meaningful metaphors, etc. 56

Lesson plan: Don’t assume they know what’s obvious to you Can’t assume: That patient will know: What a pedometer is How to wear it The exact regimen of the Rx i.e., extra steps That the educator will know specific learning steps for: Aim of script (e.g., extra steps) How to adjust regimen 60

Thank you. Questions? Advice? 63

5 levels of diabetes educators* o Level 1, non-healthcare professional, o Level 2, healthcare professional non-diabetes educator, o Level 3, non-credentialed diabetes educator,  Level 4, credentialed diabetes educator, and  Level 5, advanced level diabetes educator/clinical manager. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 65

Teaching Diabetes Self-Management— in 4 Hours (or Less) Linda S Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes.

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Teaching Diabetes Self-Management— in 4 Hours (or Less) Linda S Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes.

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Presentation on theme: "Teaching Diabetes Self-Management— in 4 Hours (or Less) Linda S Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes."— Presentation transcript:

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