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RNs offer diabetes support to underserved through Project Dulce

Scripps Whittier Diabetes Institute’s nurse-led program provides tools to help people manage the disease

Monday December 9, 2013
A Project Dulce group meeting at the Neighborhood Health Center in Escondido, Calif., led by Magdalena Hernandez, a romotora (peer educator). 
Photos Courtesy of Scripps Health
A Project Dulce group meeting at the Neighborhood Health Center in Escondido, Calif., led by Magdalena Hernandez, a romotora (peer educator). Photos Courtesy of Scripps Health
(Photos Courtesy of Scripps Health)
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Lisa Rivard, RN
By Karen Schmidt, RN

The sweet taste of success is familiar and even life-changing for thousands of individuals with diabetes because of innovative nurse-led clinics designed for underserved, ethnically diverse groups throughout San Diego County.

Project Dulce (dulce means sweet in Spanish) is a 16-year-old community-based program developed by Scripps Whittier Diabetes Institute. It puts nurses in charge of helping more than 20,000 people with diabetes successfully manage their disease.


Gail Tomsky, RN
Many hats

Lisa Rivard, RN, CDE, and Aurelia Stephens, RN, CDE, manage care, coaching, support and education for 1,869 patients in 13 community health centers and three additional sites in and around San Diego. Sixty-five percent of patients are Latino Americans, low income and often undereducated, Rivard said. The youngest is 14, the oldest 88.

“Our role is case manager and clinician, co-managing the patients with a provider,” Rivard explained. The nurses visit the health centers, meeting with patients one-on-one and
in groups.

“I follow specific protocols,” said Rivard, who’s been with the project since its inception. “I make medication changes as needed, gather information and look at the whole picture.” She then provides the data to primary care providers who regularly meet with patients.

Project Dulce’s nurse-led teams include a dietician, a medical assistant who acts as a health coach, and promotoras, lay peer educators who are usually Hispanic and have diabetes themselves. After six months of training, promotoras provide the crucial cultural element in patient education that’s necessary for patients to make lasting health improvements.

At group appointments held every eight to 10 weeks with eight to 15 patients, Rivard checks vitals and blood glucose levels, offers vaccines and makes a diabetic-friendly breakfast. She uses group activities to stimulate participants to think critically about topics such as exercise, food choices
and medications.

“It’s about them learning to manage [the disease] themselves, thinking critically about what to do,” Rivard said. “Groups are also great for support and education.”

One long-time patient told Rivard, “Groups hold me accountable for my self care. I love the fact that I have a team; I have a nurse who I can get a hold of.” Nurses communicate with patients between appointments, answering questions and keeping them on track.

“We get lots of positive feedback. We spend a lot of time with the patients, pushing them to do their best,” Rivard said.

Gail Tomsky, RN, MSN, works with those with diabetes at Neighborhood Healthcare, a Project Dulce site in San Diego. “This effort is very successful, as successful diabetes management depends on active patient involvement,” she said. “Patients become engaged in managing their disease by establishing and meeting health goals they establish with the [Project Dulce] RN.”

Sweet success

Project Dulce’s success has been measured by the Scripps Whittier Diabetes Institute, according to a fall 2012 Clinical Diabetes article: “Community-created programs: Can they be the basis of innovative transformations in our healthcare practice?” According to the article, Project Dulce proves that nurse-led clinics are “a culturally appropriate, clinically sound and cost-effective care model for managing diabetes.” Scripps partners with the County of San Diego, Community Health Centers and San Diego State University for Project Dulce, and initially identifies patients via a patient registry.

The nurse-led, community-based model has “improved objective and subjective outcomes, including improvements in health status and quality of life, such as a decreased incidence of diabetes-related complications and hospitalizations throughout a patient’s lifetime,” said Athena Philis-Tsimikas, MD, corporate vice president, Scripps Whittier Diabetes Institute, in the Clinical Diabetes article. It also is “especially cost-effective for underinsured and uninsured groups.”

Rivard, who trains nurses for roles like hers, added that Project Dulce, which has been implemented elsewhere — in Camden, N.J., Watsonville, Vallejo and Los Angeles, Calif., and in Tijuana, Mexico — works because “nurses are good teachers. We communicate at a level patients understand, we take the time and we’re available when they need us.”

She urges more nurses to take on this advanced role. “We can think critically and follow algorithms. I wish more nurses were doing this. We could make a bigger impact for patients.”

For more about Project Dulce, watch a You Tube video: http://www.youtube.com/watch?v=LnygZqml34I


Karen Schmidt, RN is a freelance writer. Post a comment below or email editorWest@nurse.com