Advancing Diabetes Self Management

Gateway Community Health Center, Inc.

As a result of ongoing quality improvement efforts, GCHC found several components to be integral to their diabetes self management system of care: provider use of self management principles; an infrastructure that supported patient input yet provided some choices regarding care; a system of referral, follow up, feedback, and documentation that produced integrated and consistently high quality self management clinical practice; a system that recognized and managed chronic illness related depression; and a community-based, culturally-sensitive approach.

A critical component of GCHC’s comprehensive approach involved the integration of promotoras (community health workers) into the care of patients with diabetes. Promotora-led interventions included a 10-week diabetes self management course tailored for the target audience, a subsequent 10-week support group that met on a biweekly basis, and weekly phone follow up and support. Knowledge and skills related to blood glucose monitoring, medication management, physical activity, healthy eating and healthy coping were taught by promotoras in the self management course. Goal setting and problem solving were practiced at each class and during the support groups that followed. Weekly telephone calls from the promotoras reinforced problem solving strategies and helped to keep participants motivated.

The program infrastructure supported and reinforced these interventions. There were appropriate job descriptions, extensive competency and skills training, performance monitoring and supervision for promotoras. Policies and procedures ensured coordination of patient care, and monthly promotoras provider conferences included discussion of patient self management issues. Assessment of patient behavior, collaborative goal setting, goal follow up, goal revision, and problem solving to overcome barriers occurred during all patient interactions (physician, promotora, and certified diabetes educator visits). Finally, the Patient Electronic Care System was used to collect and manage self management processes and outcomes.

By incorporating patient feedback and striving for quality, the Advancing Diabetes Self management program helped GCHC achieve its mission: “To improve the health status of the people in Webb County and surrounding areas by providing high quality medical and dental care, health promotion and disease prevention services in a professional, personal, and cost effective manner.”

Summary

Key Interventions

• 10-week promotora-led diabetes self management course that includes depression screening, referral and follow up promotora-led support groups
• Standard protocols for promotora follow up and support, including weekly phone calls to participants for problem-solving and support

Key Accomplishments

• Integrated promotora-led self management interventions into clinic protocols and usual systems of care for people with chronic conditions
• Developed a culturally-competent diabetes self management education curriculum that also addresses cardiovascular disease and depression
• Became certified by the State of Texas Health Department as a Certified Center for Health Promoters; developed curricula and increased spread of training workshops for promotora

Lessons Learned

• A comprehensive system of care and a team approach are essential for successful program outcomes
• Integrating a self management program into a primary care system results in high quality diabetes care
• Integrating promotoras into a healthcare delivery system results in more comprehensive services and better outcomes

Grantee Presentations

• The Road to Effective Patient Self Management: The Role of Lay Health Workers in Managing Diabetes (8/2007)
• Comprehensive System of Care for Patients with Diabetes (10/2006)
• The Role of the Promotora in a Comprehensive System of Care (8/2006)
• Enhancement of Promotora-Led Self-Management Class Improves Sustained Metabolic Control (8/2005)
• Improving Diabetes Self Management Education in Community Health Centers by Incorporating Promotores in the Health Care Team (5/2005)
• Benefit-to-Cost Analysis and Program Effectiveness Evaluation of the Gateway Diabetes Self Management Project (3/2005)
• Gateway Community Health Center Program Overview (8/2003)

Program Materials

• Certified Diabetes Educator Guidelines
• Depression Screening and Follow Up Flow Chart
• Goal Setting Form
• Goal Setting Form and Tips English/Spanish
• Health Belief Questionnaire English/Spanish
• Informed Consent Form English
• Informed Consent Form Spanish
• Mental Health Progress Report Form
• Participant Registration Form
• Participant Registration Form Spanish
• Patient Assessment Form
• Patient Assessment Form Spanish
• Patient Success Stories Interview Form
• Patient Education Material English/Spanish
• Patient Diabetes Knowledge Questionnaire English
• Patient Diabetes Knowledge Questionnaire Spanish
• Policies and Procedures for Referring Patients
• Promotora Policies and Procedures
• Referral Form

Program Publications

• Integration of a Promotora-Led Self-Management Program Into a System of Care (June, 2007)