Seniors, Diabetes, and the Art of Self-Management

Long before terms like “care coordination” or “patientcentered medical home” became common, the principles that govern the movement to value-based care were second nature to Meena Murthy, MD, FACE, when she set up the diabetes care unit in 2000 at Saint Peter’s University Hospital in New Brunswick, New Jersey.

Murthy, an endocrinologist with advanced training in geriatrics, who is Saint Peter’s chief of the Division of Endocrinology, Nutrition, and Metabolism, convinced the hospital to embrace a team-based approach to diabetes care, years before it became the thing to do—and before insurers understood that it makes sense for certified diabetes educators (CDEs), nutritionists, and social workers to collaborate with physicians on patient care.

Even with more help than was customary at the time, Murthy also knew that managing diabetes requires more hands than any hospital could ever afford. The most important “hands” needed to manage a chronic disease belong not to the provider, but to the patient—with plenty of support, of course.

As she described Saint Peter’s program in interviews with Evidence-Based Diabetes Management, she said, building a patient’s abilities was always part of the approach. Said Murthy, “It’s in our DNA.” Thinking that a patient can be handed a few prescriptions and a list of instructions to manage their disease is unrealistic, she said. “With diabetes, that will never happen.”

What’s true in diabetes, generally, is especially true among the senior population. Many have built up poor lifestyle habits over decades, but at the same time, Murthy said, they often resist accepting help. She’s seen it over and over—a person retires, the metabolism slows, and there’s more access to food with less activity—and soon a person has gained 10 pounds. It’s little wonder, then, that according to the American Diabetes Association (ADA), the disease affects 25.9% of the population over age 65, mostly type 2 diabetes.¹

Murthy is passionate about her mission—not just improving the numbers, which is important—but also in treating the whole patient. For her, diabetes care is both art and science; it’s unacceptable to declare success if the glycated hemoglobin (A1C) looks good on the electronic health record (EHR), but the patient is gaining weight or struggling with side effects. She has a clever description: “The e-patient is doing well,” but the real one, not so much.

Especially for seniors, she said, “if a regimen is beyond their self-management capacity, they’ll be miserable and they won’t stick with it.”

More and more, the experts agree. The ADA’s 2016 Standards of Medical Care in Diabetes, published in January, featured a lengthy update on care for persons over age 65, including a call for individual goals based on each patient’s medical, functional, and cognitive status, as well as social capacity. The update states: “Glycemic goals for some older adults might be reasonably relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients.”²

Translating this into better care for older adults means teaching them to work healthy habits into everyday life. Today, Murthy, and her team, work not only with seniors who have diabetes, but they also work to prevent disease among those at risk, which will be a greater focus of Medicare going forward.³

Over time, Murthy has trained a powerful army in her cause—the seniors themselves. Her face lights up as she describes the stories of people with diabetes who came for education, and later became peer leaders and finally “master trainers,” a certification of the Stanford Diabetes Self-Management Program⁴ used at Saint Peter’s.

THE STANFORD PROGRAM

Around the time that Murthy founded the diabetes unit, research going on at Stanford University School of Medicine, led by Katie Lorig, DrPH, laid the groundwork for the program used at Saint Peter’s today.⁵

At that time, Lorig’s work in chronic disease self-management did not involve persons with diabetes per se, but those with a range of conditions—patients who had suffered strokes, heart disease, lung disease, or had arthritis. Results, of a 2001 study, showed that after 2 years, patients trained in self-management experienced fewer than expected visits to the emergency department, fewer hospitalizations, had less health distress and perceived themselves as more capable of managing their condition.⁵

The same principles—that patients educated to work with their doctors will fare better—informed the development of the Diabetes Self-Management Program. Based on a 2.5-hour session offered over 6 weeks, the Stanford program trains those with diabetes to be active partners with their doctors, nurses, and other providers. Topics include techniques to deal with the symptoms of the disease, such as fatigue, pain, or hypoglycemia; how to handle the stress of managing diabetes every day; how to exercise to maintain strength and endurance; and what kind of foods to eat.⁴ Results from a clinical trial, published in 2009, found that participants had fewer symptoms of hypoglycemia, reduced depression, and better communication with physicians. Even after a year, patients were eating better and reading food labels more closely. Because the program was peer-led, it cost less to implement than alternatives.⁶

Murthy said Saint Peter’s works hard to understand to gain the “common cultural intelligence” needed to help the many ethnic groups, in central New Jersey, adapt their native diets to their health needs. Understanding the disease—why diet matters, and especially what each pill is for—is critical for adherence and long-term success, she explains. For providers, it’s a new way of thinking toward educating, and not just prescribing. “The patient needs to learn as much as you!” she said.

The core of the program is the weekly action plan, which lets each person with diabetes set goals and specific ways to achieve them. Patients discuss the roadblocks they encounter while trying to fulfil their action plan and gain problem-solving skills. “Action plans have to be very specific,” Murthy said. Patients can’t simply state a goal; they must spell out how they are going to achieve it, such as on which days they will exercise. Involvement from family members is critical, so there is support at home for dietary changes.

FROM TREATMENT TO PREVENTION

A follow-up visit to Saint Peter’s happened on a big day for those in diabetes care: that morning, HHS Secretary, Sylvia Mathews Burwell, announced that Medicare would start paying for the National Diabetes Prevention Program (NDPP),³ the evidence-based initiative piloted at the YMCA that had been shown to reduce care costs for persons over age 65.

About 20 members of the Saint Peter’s team from multiple sites—from endocrinologists and nurses to CDEs to social workers to dietitians—have gathered for a meeting to share data and ideas. They discuss strategies for getting seniors to show up for all 6 sessions of the self-management program, not just the nutrition classes. One team member reports progress in getting more patients to eye exams. Much of the talk involves breaking down barriers for populations struggling just to access programs, must less control diabetes.

Saint Peter’s team approach received a boost in 2013, when the health system received a $20.5 million, 5-year grant from New Jersey’s Delivery System Reform Initiative. The award was part of the state’s Medicaid waiver with CMS, and it called for Saint Peter’s to create a patient-centered medical home to deliver better diabetes education and preventive care for at-risk adults. The award followed a needs assessment that found that 56.2% of the adults on the region Saint Peter’s serves had at least 1 chronic condition, with diabetes and hypertension being most common.^7-8

As much as overeating gets attention for the nation’s diabetes crisis, the team meeting in March 2016 discussed how lack of food causes just as many problems, especially for patients on insulin. Saint Peter’s commitment to serving the poor in and around New Brunswick—including some who are undocumented—calls for creativity and partnerships with many agencies beyond its walls, from food pantries to the school system.

When the group hears the news about NDPP, there’s applause—and lots of questions. Like other safety net hospitals, Murthy said, Saint Peter’s could substantially reduce readmissions if it could do more to prevent diabetes. Reducing the barriers to prevention is just as important as reducing the barriers to good care; because there has been no tradition of teaching people self-management or prevention, “we have very low standards,” Murthy said.

But that also means the potential for improvement is enormous. So much of teaching people to eat properly and care for themselves is simple. “If it has a label, it is already suspicious,” Murthy says with a laugh. “A banana doesn’t have a label.”

The big challenge in diabetes is that on any given day, the obstacles change. There’s a birthday party, or food at the office. There’s a thunderstorm that makes walking outside impossible. The person with diabetes must constantly adjust, because on most days, there are no symptoms, only temptations.

Says Murthy, “The day is full of negotiation.” References

1. Statistics about diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/. Updated April 1, 2016. Accessed April 28, 2016.

2. American Diabetes Association. Standards of Medical Care in Diabetes: older adults. Diabetes Care. 2016;39:S81-S85. doi:10.2337/dc16-S013.

3. Caffrey M. Medicare to fund diabetes prevention, Burwell says. The American Journal of Managed Care website. http://www.ajmc.com/focus-of-the-week/0316/medicare-to-fund-diabetes-prevention-programs-report-says. Published and accessed March 23, 2016.

4. Diabetes self-management program. Stanford Medicine website. http://patienteducation.stanford.edu/programs/diabeteseng.html. Accessed April 28, 2016.

5. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001;39(11):1217-1223.

6. Lorig KR, Ritter PL, Villa FJ, Armas J. Community-based peer-led diabetes self-management: a randomized trial. Diabetes Educ. 2009;35(4):641-651. doi:10.1177/0145721709335006.

7. Saint Peter’s launches region-wide initiative to treat and reduce diabetes [press release]. New Brunswick, NJ: Saint Peters Healthcare System; Undated. http://www.saintpetershcs.com/News-and-Events/Press-Releases/2014/Saint-Peters-launches-region-wide-initiative-to-treat-and-reduce-diabetes/. Accessed April 30. 2016.

8. Delivery System Reform Incentive Payment. NJ Department of Health website. https://dsrip.nj.gov/. Published August 9, 2013. Accessed April 30, 2016.

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