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Program aims to close diabetes care gaps

Sunday June 19, 2011
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Nurses are helping to drive the Proactive Managed Intervention System for Education in Diabetes program, which is delivering much needed education to adults with type 2 diabetes.

Primary healthcare providers refer patients to PROMISED, an outpatient diabetes group education program, offered at the Montefiore Clinical Diabetes Center at Montefiore Medical Center in the Bronx, N.Y. PROMISED encompasses five weekly two-hour sessions. A nurse practitioner and dietitian use those 10 hours to educate and empower patients to take better care of themselves, and interact more productively with their healthcare providers, said Sharon Movsas, RD, CDE, PROMISED program coordinator.

“These group sessions are interactive, very informal and fun. This is an American Diabetes Association-recognized program, which means that we hold up to the ADA’s education standards of care,” Movsas said.

Arming patients with education

Helena Duffy, RN, NP, CDE, presents the sessions with Movsas. While Movsas covers nutrition, Duffy talks about diabetes management, long-term complication prevention, hypoglycemia management and monitoring, sick day management and diabetes medications. The nurse practitioner reviews the ADA’s recommendations for tests and follows up with patients about getting them. She also talks with participants about the impact of stress on diabetes management, and depression associated with diabetes.

PROMISED doesn’t offer direct patient care because its aim is to return more educated and empowered participants to their primary care providers. However, Duffy does more than educate. When patients come to class, Duffy reviews their blood sugar logs, measures blood pressures and performs foot exams. “If I find anything on the [log,] blood pressure or foot exam that needs attention, I talk to the patient or directly to the doctor,” Duffy said.

Duffy also is part of an expert team in the PROMISED program that reviews each patient’s health profile, history and lab results, to come up with recommendations — especially addressing cardiovascular risk factors. These recommendations are sent as an individual consultation report to the patient’s primary care provider. The teams include not only a nurse practitioner and registered dietitian, but also an endocrinologist and lipid specialist.

An inpatient staff nurse, who is a diabetes specialist, serves as the expert on the acute care side, referring patients whom she identifies as needing education and empowerment.

“The appropriate candidates are [but not limited to] patients newly diagnosed with diabetes type 2; [patients who] have a poor understanding of their disease, despite having it for years; have little or no family support related to their diabetes; and women wanting to get pregnant,” said Iris Carrasquillo, RN, MSN, CDE, diabetes clinical nurse specialist for the Weiler Division of Montefiore.

Carrasquillo said others who benefit from PROMISED include motivated acute care patients who request referrals for education in diabetes management; patients with laboratory values that are moving in the wrong direction; and those who are in the hospital because they self-medicate with insulin, without the appropriate knowledge of how to adjust their insulin dose.

Witnessing change

Duffy said she receives satisfaction from seeing what patients get out of PROMISED. People who first walk into the program often have their arms crossed, expecting a lecture. They quickly learn that’s not the case, Duffy said.

“The first thing we say is, ‘You can take the perfect plan and forget it. It’s self-defeating to believe that you’re always going to have the perfect blood sugar; you’re always going to eat perfectly.’ We work on setting realistic goals,” she said.

The goal is to give participants a sense of empowerment. They become engaged in the process of their own care, Duffy said.

“We give patients knowledge; then, as part of the standards of care, spend time teaching them how to use this knowledge to change their behavior,” Movsas said.

More than anecdotal

Studies on PROMISED outcomes are showing positive results. Last year, Duffy and Movsas analyzed low-density lipoprotein cholesterol levels of 112 patients. To determine whether the program helps patients achieve LDL levels below 100 mg/dL, they compared patients’ LDL levels at baseline for four to six months after the program.

“Before the class, 49% had LDL below 100 mg/dL,” Movsas said. “After the class 63% had an LDL below 100 mg/dL.”

In a 2003 study, researchers looked at patients’ hemoglobin A1C stats. The patients were followed for four years with a significant improvement in A1C after the first year. “Although there was a slight rise in A1C in the following three years, much of the improvement was sustained throughout the four years and never went back to [pre-program] baseline,” Movsas said.

Nurses pivotal

“Management of any chronic disease, such as diabetes, is meaningless without proper education and patient empowerment and participation,” said PROMISED creator Joel Zonszein, MD, CDE, professor of clinical medicine, endocrinology, at Albert Einstein College of Medicine in the Bronx.

As director of the Clinical Diabetes Center at Montefiore Medical Center, the University Hospital and Academic Medical Center at Einstein, Zonszein started PROMISED in 1996 because he noticed that although primary care physicians were providing the bulk of diabetes patients’ medical care, those physicians were not providing proper patient education.

“A team effort has been shown to be a very good and fruitful model. The best people to provide education are RNs and RDs [who are certified diabetes educators]. The role of the nurse is pivotal, as they have the knowledge and experience for disease prevention and management,” he said. “[Nurses] often have more insight and learn more about patients’ day-to-day management, what their days are like, how they’re functioning and what their barriers are.”

Lisette Hilton is a freelance writer.

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