CT FEATURE. By Valerie Barnes, Vincent F. Carr, Kareem Karara, James C. Welch and Crosby Amoah

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1 Barnes:Layout 1 10/17/ :24 AM Page 45 CT FEATURE By Valerie Barnes, Vincent F. Carr, Kareem Karara, James C. Welch and Crosby Amoah D iabetes is a national epidemic that has a profound impact on both patient well-being and health care expenditures across a variety of health care delivery systems. Each year in the U.S., 1.9 million new cases of diabetes are diagnosed in people ages 20 years and older, and the prevalence of diabetes in inmate populations continues to increase as well. Diabetes places a significant cost burden on health care systems in the community and in corrections, with the American Diabetes Association estimating that in 2012, $176 billion was spent on direct medical costs attributable to diabetes.1 A projection model of the prevalence of diabetes in the inmate population estimated that at any given time, nearly 80,000 inmates, or 4.8 percent of inmates in the U.S., have diabetes.2 In an effort to address the burden that uncontrolled Type 2 diabetes exerts on patient outcomes and health care resources, the Delaware Department of Correction (DDOC) has chosen to use an innovative, patient-centered approach to improve short-term and long-term health outcomes. Preventative health care strategies are an effective example of value-based decision-making to improve quality while reducing expenditures. DDOC has committed itself to a culture of providing high-quality health care services that address acute medical concerns and attempt to prevent the complications of disease. To accomplish its goal, DDOC partnered with its contracted pharmacy vendor, Correct Rx Pharmacy, to pilot a customized group education strategy for diabetes self-management. Correct Rx Pharmacy provides DDOC with three on-site clinical pharmacists who are experienced in providing diabetes education, to take the lead on the diabetes program initiative. Clinical pharmacists are medication experts with advanced training in pharmacotherapy and patient care, whose contributions to the health care team are well-documented in medical literature.3 Numerous studies have found positive impacts on both objective patient care measures and health care costs. 4 With the department s preventative health care strategy in mind, the clinical pharmacist created a comprehensive curriculum that addressed modifiable risk factors such as diet and exercise, which have been linked to diabetes outcomes. The next task was to identify a pilot site for the diabetes education program. DDOC is a statewide unified correctional system, with all detention centers and prisons falling under the jurisdiction of the state, and detentioners and sentenced inmates housed in the same buildings. The department supervises between 6,500 and 7,000 inmates within nine correctional facilities. Factors that influenced pilot program selection included: security level of the population; adequate facilities to host group classes; warden and health care team buy-in; and patients who would benefit from program outcomes. Based on these criteria, the pilot diabetes education group was hosted at Baylor Women s Correctional Institution (BWCI). DDOC found that females gained more weight during incarceration at BWCI compared to other facilities. Weight gain is a significant risk factor for the development of Type 2 November/December 2013 Corrections Today 45

2 Table 1. Patient Outcomes and Corresponding Explanation/Benefit Patient Outcomes Explanation/Benefit Improved A1C Decreased Hypoglycemia and Hyperglycemia Decrease/Delay Microvascular and Macrovascular Complications Decrease in Diabetes Related Mortality Improved Lipid Levels Improved Blood Pressure Weight Control Decreased Cost Source: American Diabetes Association Diagnosis and classification of diabetes mellitus. Diabetes Care, 36(1): Table 2. Patient Outcomes and Goals Patient Outcomes Source: American Diabetes Association Diagnosis and classification of diabetes mellitus. Diabetes Care, 36(1): 67-74; American Diabetes Association Diabetes management in correctional institutions. Diabetes Care, 36(1): Table 3. Weekly One-Hour Meeting Outline Class Specifics Welcome/Review of Previous Meeting Weigh in/measure Vitals Review of Commissary Journal Weekly Topic Discussion Questions/Answers Long-term average blood glucose high values are a sign of nonoptimal diabetes managment. Stable blood glucose readings extreme changes can lead to hospitalization. Lower risk for complications such as heart attack, stroke, vision and kidney problems. Improve survival Lower risk for cardiovascular complications such as heart attacks Lower risk for cardiovascular complications such as stroke Lower risk for blood glucose and cardiovascular complications Improved management Goal A1C <7% Blood Glucose <130 mg/dl LDL Blood Pressure Weight Antiplatelet Therapy Smoking Cessation Prevent Complications <100 mg/dl <130/80 mmhg Sustain weight loss Aspirin for increased CV risk (>10% 10-year risk) Counseling on risks associated with smoking Adherence to recommendations and regular screening diabetes, which can lead to patient microvascular and macrovascular complications and additional health care expenditures. Additionally, weight gain can be indicative of poor lifestyle choices that negatively influence diabetes control, such as a sedentary lifestyle or a high-fat or highcalorie diet. Appropriate care of patients with diabetes requires both a pharmacological and nonpharmacological approach. To address patient-controlled factors, the goal of the group education class is to help patients acquire 5 minutes knowledge, coping skills and attitudes required for the effective self-management of diabetes. The American Diabetes Association, the American Association of Clinical Endocrinologists and the Federal Bureau of Prisons all recommend diabetes education encompassing weight loss, diet and medication management as an integral component of care. Comprehensive therapy can result in cost-savings and improved outcomes. This is evidenced by the fact that poor diabetes management can lead to higher risk of heart attack, stroke, infection, impaired vision and kidney problems. 5 Group intervention is a common community approach to addressing the needs of patients in a manner that saves money, time and effort. 6 In corrections, group education courses for the most prevalent chronic diseases diabetes, hypertension and asthma are uncommon. When group classes are employed, they typically focus on mental health issues. The department s diabetes care group is tailored to a correctional environment and designed to encompass most things within an inmate s control. The overall goal of the diabetes education program is to improve objective patient outcomes such as A1C, the gold standard for measuring diabetes control (see Table 1). Patients eligible for inclusion in the education program are identified through the pharmacistmanaged disease state management clinic for diabetes, an ongoing initiative between DDOC and Correct Rx. Enrollees must have a diagnosis of Type 1 or Type 2 diabetes and at least one of the following: A1C>9 percent, fasting blood glucose >240 mg/dl, or have not previously attended a diabetes education group in the previous six months; and has any two of the following: blood pressure>130/80 mmhg, dyslipidemia, chronic kidney disease or obesity with a body mass index (BMI)>30 kg/m2. Once patients are determined eligible, an offer to enroll in the group is made by the clinical pharmacist during a face-to-face counseling session. Medical literature has established that a 1 percent drop in A1C, which is achievable Time through lifestyle modifications, can reduce the incidence of microvascular complications by 35 percent; myocardial infarction by 18 percent; and diabetes related death by 25 percent. 7 Specific goals for patients in the education group track the results from the medical literature, such as a decrease in A1C to a goal of <7 percent (see Table 2). The diabetes education group meets once per week and is moderated by a clinical pharmacist. The program follows an eight-week schedule with weekly topics including nutrition, education, exercise and medication that progress to a comprehensive understanding of diabetes care. The group meetings last 50 to 85 minutes per session and follow a structured meeting outline that provides consistency for participants (see Tables 3 and 4). Each meeting begins with a five- to 10-minute introductory welcome/review of the 25 minutes 46 November/December 2013 Corrections Today

3 previous week. Patients then have a number of measurements, such as weight and blood pressure, taken to track long-term progress through the program. Commissary journals are also reviewed to assess dietary selections. At this point in the meeting, the pharmacist starts a discussion on the weekly topic and the group then engages in a question-and-answer session. The pharmacist serves a key role in providing basic, educational information in a patient-friendly manner and in maintaining an atmosphere that is conducive to the beneficial exchange of information among group members. However, it is interaction among group members that maximizes the opportunity for increased knowledge and improved outcomes. 8 Weekly topics were carefully selected according to community and correctional clinical practice guidelines on the management of diabetes. In the introductory week of the program, patients take a written test to assess their baseline diabetes knowledge, and the group topic is an introduction to the disease state. Diabetes is defined, and patients develop a strong understanding of the signs, symptoms and risk factors associated with the disease. In the second week of the program, the focus moves to developing participant understanding of screening values (blood glucose, A1C, etc.) and the goals of therapy. Group members become familiar with how to interpret their screening values compared to recommended values and are subsequently equipped to be active participants in their own health care. This step is key in ensuring that the patients are compliant with getting lab values, such as finger stick glucose readings, attending chronic care visits and taking medication. The third week is committed to the topic of hypoglycemia and hyperglycemia. Dramatic excursions and rapid decreases in blood sugar can be life-threatening and frequently result in more expensive acute care. Patients are educated on the signs, symptoms, and some of the situations and behaviors associated with hypoglycemia and hyperglycemia. During the fourth week of the program, patients become familiar with some of the long-term complications of diabetes. In developing a foundation of knowledge on how diabetes affects the body over time, patients can place an emphasis on keeping the disease under control so that they can lead longer, healthier lives. At the five-week point of the program, there is a shift in group focus from background knowledge building to the transference of information and skills that patients will need to make good decisions about management of their diabetes. The group discussion focuses on how to make good nutrition choices, how to read food labels and the importance of exercise. The American Diabetes Association has repeatedly highlighted medical nutrition therapy as an evidence-based cornerstone of diabetes management. 9 In a correctional environment, managing nutrition can be challenging due to limited dining options and access to commissary items that have a high sugar and fat content. Through this discussion, inmates learn about their own nutritional needs. In week six, group participants learn how different diabetes medications work and the importance of Table 4. Weekly Outline Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Eight-Week Class Schedule Diabetes Competency Test Discussion Topic: Overview of Diabetes Discussion Topic: Know Your Numbers Discussion Topic: Define Goals of Diabetes Therapy Discussion Topic: Hyperglycemia and Hypoglycemia Signs and Symptoms Discussion Topic: How Diabetes Affects the Body (Microvascular and Macrovascular Complications) Discussion Topic: Nutrition, Reading Food Labels and Exercise Discussion Topic: Review of Antidiabetic Medications: Oral and Insulins Discussion Topic: A1C, Blood Pressure and Cholesterol Post Test Group Discussion taking medications as they are prescribed. Medication plays a key role in improving diabetes outcomes, and reinforcing this fact educates patients on the importance of compliance. Week seven focuses on the ABCs, or A1C, blood pressure and cholesterol. The group discusses how these measures correlate with healthy living and how smoking can contribute to serious complications for diabetics. During the final week, group members take a post-test to assess knowledge gained throughout the eight-week experience; this is followed by a final overview discussion. The knowledge imparted to inmate diabetics who participate in this course has been key in improving the management of this disease at BWCI. Patients who have completed the course have the opportunity to cycle through again as experienced group members who provide an invaluable peer perspective on how to successfully keep diabetes under control in a correctional environment. The success of the course has been evidenced by the full participation from inmates; as many as eight inmates participate in the group each cycle. The program began in January One year later, the results to date have yielded a facility total 1.6 point overall reduction in A1C. Throughout all sessions, 78 percent of patients have decreased their A1C value and 22 percent of patients achieved an A1C of less than 8 percent. These are clinically valuable results, as each single point drop in A1C results in large decreases in both complications and diabetes-related death. 10 Inmates who participate in the program report feeling empowered through the knowledge of how to control their diabetes. The success of the course is rooted in a structured curriculum, effective facilitation and peer teaching. Within this venue, the inmates who have experienced real success as a result of the program train the more junior inmates on how to manage their disease. The trainees become the trainers. November/December 2013 Corrections Today 47

4 Figure 1. A 1 Percent Drop in A1C Can Reduce the Incidence of Long-term Diabetes Complications Source: American Diabetes Association Implications of the United Kingdom prospective diabetes study. Diabetes Care, 26 (Suppl): Figure 2. Health Care Outcomes Continuum Source: American Association of Diabetes Educators Standards for outcomes measurement of diabetes self-management education. The Diabetes Educator, 29(5): A 1 percent drop in A1C can reduce the incidence of long-term diabetes complications. A 2012 meta-analysis published in BioMed Central Health Services Research that assessed group-based diabetes self-management education compared to routine treatment for Type 2 diabetes evaluated 21 studies including (n=2,833) participants. 11 For the main clinical outcomes, A1C was significantly reduced for patients receiving group-based diabetes education at six months (0.44 percent points; P=0.0006, 13 studies, 1,883 participants); 12 months (0.46 percent points; P=0.001, 11 studies, 1,503 participants); and two years (0.87 percent points; P< , three studies, 397 participants) and fasting blood glucose levels were also significantly reduced at 12 months. For the main lifestyle outcomes, diabetes knowledge was improved significantly at six months, 12 months and two years; and self-management skills also improved significantly at six months. For the main psychosocial outcomes, there was significant improvement for empowerment/self-efficacy after six months. There were also significant improvements in patient satisfaction and body weight at 12 months for the group receiving diabetes education. 12 The authors concluded that group-based diabetes self-management education in people with Type 2 diabetes results in improvements in clinical, lifestyle and psychosocial outcomes. - Another study evaluated group versus individual diabetes education to compare their effectiveness. 13 A total of 170 patients with Type 2 diabetes were randomly assigned to group (n=87) or individual (n=83) diabetes education. The education was structured as four sessions during a sixmonth period. Changes in knowledge, self-management behaviors, weight, BMI, A1C, health-related quality of life, patient attitudes and following a medication regimen were assessed at baseline and after the two-week, three-month and six-month education sessions. Both educational settings had similar improvements in knowledge, BMI, health-related quality of life, attitudes and all other measured indicators. A1C decreased from 8.5+/-1.8 percent at baseline to 6.5+/-0.8 percent at six months (P<0.01) in the study population as a whole. Subjects assigned to the individual setting had a 1.7+/-1.9 percent reduction in A1C (P<0.01), whereas subjects assigned to the group setting had a 2.5 +/-1.8 percent reduction in A1C (P<0.01). The difference in A1C improvement was marginally greater in subjects assigned to group education versus individualized education (P=0.05). The authors concluded that diabetes education delivered in a group setting, when compared with an individual setting, was equally effective at providing equivalent or slightly greater improvements in glycemic control. Group diabetes education was similarly effective in delivering key educational components, and may allow for more efficient and cost-effective methods in the delivery of diabetes education programs. Through the experiences of the parties involved, the benefits of offering group education classes in a correctional setting are evident. It was also revealed that there are significant challenges to the success of diabetes self-management training in a correctional setting. Patients can initially be reluctant to engage in open communication regarding matters they may consider to be private. Dissatisfaction with meals provided at the facility may be used as an excuse for making poor food choices. Additionally, commissary use may represent a freedom to the incarcerated. Asking patients to restrict their commissary use to healthier options can infringe on their perceived freedom. These challenges, however, can be overcome through dialogue, encouraging moderation and setting attainable expectations. DDOC and Correct Rx plan to continue the current diabetes group education program and possibly expand it to include male inmate diabetics in other facilities. The 1.6- point reduction in facility A1C percentage is a marker of significant progress to date. The high level of participation in the group program is evidenced by the fact that 78 percent of group participants experienced a reduction in A1C value. The pharmacist structured curriculum encompasses all recommended diabetes education components from the American Diabetes Association and tailors them to a correctional environment. Corrections can present unique challenges to the management of diabetes, from medication administration to nutrition; therefore, structuring the course content appropriately is key to patient success. The weekly course structure provides for new information to be presented at each session and fosters an environment of peer exchange and teaching. Group discussion encourages the introduction of new perspectives, creativity and a sense of teamwork. The 48 November/December 2013 Corrections Today

5 literature has shown that diabetes group education is superior to individuals who do not receive any education and that group education is as effective as individual education. The inclusion of a diabetes self-management education program in a correctional institution that manages diabetic patients is an essential component in achieving positive treatment outcomes, such as lower A1C, adherence to lab monitoring and medication administration, and improved patient knowledge. ENDNOTES 1 American Diabetes Association Diagnosis and classification of diabetes mellitus. Diabetes Care, 36(1): National Commission on Correctional Health Care The health status of soon-to-be released inmates: A report to Congress, volume 2. Chicago: Author. 3 Chisholm-Burns, M.A., J. Kim Lee, C.A. Spivey, M. Slack, R.N. Herrier, E. Hall-Lipsey, J. Graff Zivin, I. Abraham, J. Palmer, J.R. Martin, S.S. Kramer and T. Wunz U.S. pharmacists effect as team members on patient care, systematic review and metaanalyses. Medical Care, 48(10): Ibid. 5 American Diabetes Association Diabetes management in correctional institutions. Diabetes Care, 36(1):S86-S92. 6 Erdman, S.A Therapeutic factors in group counseling: Implications for audiologic rehabilitation. Perspectives on Aural Rehabilitation and its Instrumentation, 16(1): United Kingdom Prospective Diabetes Study Group Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. British Medical Journal, 317(7160): Erdman, S.A Edwards, L Managing diabetes in correctional facilities. Diabetes Spectrum, 18(3): United Kingdom Prospective Diabetes Study Group Steinsbekk, A., L. Rygg, M. Lisulo, M.B. Rise and A. Fretheim Group based diabetes self-management education compared to routine treatment for people with 2 diabetes mellitus. A systematic review with meta-analysis. BioMed Central Health Services Research, 12(213): Ibid. 13 Rickheim, P.L., T.W. Weaver, J.L. Flader and D.M. Kendall Assessment of group versus individual diabetes education: A randomized study. Diabetes Care. 25(2): Valerie Barnes, Pharm.D., MS, is director of clinical pharmacy at Correct Rx Pharmacy Services in Linthicum, Md. Vincent F. Carr, DO, FACP, is the medical director for the Delaware Department of Correction. Kareem Karara, Pharm.D., is a clinical pharmacist at Correct Rx Pharmacy Services. James Welch, RN, HNB-BC, is chief of the Bureau of Correctional Healthcare Services, Delaware Department of Correction. Crosby Amoah, RN, Pharm.D., is a clinical pharmacist at Correct Rx Pharmacy Services. November/December 2013 Corrections Today 49