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Interprofessional Student Delivered Diabetes Education for Low-Income and Uninsured Spanish-Speaking Patients: �A Quality Improvement Project

Kacy Aderhold, MSN, APRN-CNS, BC-ADM, CDCES

University of Oklahoma Health Sciences Center

Clinical Assistant Professor, Fran and Earl Ziegler College of Nursing

APRN Adult Endocrinology, Harold Hamm Diabetes Center

Doctor of Nursing Practice Student, Fran and Earl Ziegler College of Nursing

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Team Based Health and Wellness
Interdisciplinary Student Teams

Medicine/PA
Nursing
Nutrition Sciences
Social Work
Pharmacy
Dental
Occupational/Physical Therapy

Let me first tell you about our clinic. The Unity Clinic is the University of Oklahoma Health Sciences Center’s student-ran free-clinic.

We provide primary care to Oklahomans without insurance and of low-income status., 90-95% of Unity Clinic patients are Hispanic and Spanish-speaking.

We operate physically out of another free clinic in downtown Oklahoma City, the Crossings Community Clinic, and we have a mobile outreach vehicle as well.

The Unity Clinic sees patients in office about 3 days weekly. On those days, we have student teams led by faculty (either MD or APRN).

The student teams consist of 1-2 students from medicine, physicians associate (PA), nursing, nutrition sciences, social work, and pharmacy.

The dental team runs a separate clinic and occupational and physical therapy students join us just once weekly.

We also have optometry students who see our patients as well.

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Diabetes prevalence is higher in those with less education.

Diabetes prevalence is higher in those with less income.

Diabetes prevalence is higher in Hispanics compared to white and Asian adults.

(CDC, 2022)

(United Health Foundation, 2022)

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OKLAHOMA

45^th

in overall health

12^th highest

diabetes prevalence

5^th highest

age-adjusted diabetes mortality rate

25.7%

Hispanic Oklahomans uninsured

(CDC, 2022)

(United Health Foundation, 2022)

(Oklahoma Department of Mental Health and Substance Abuse, 2020)

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Problem Identification

Hispanic and low-income Oklahomans with diabetes are a vulnerable population.
Lack of access to diabetes self-management education (DSME)
How can we remove language and cost barriers and provide DSME to the patients who so desperately need it?

I mentioned I work as faculty and provider at the Unity Clinic, and we have pretty big interprofessional teams. That is many people in and out of a patient room in 1 hour. Our visits are very full.

Each discipline has about 10 minutes with the patient.

So, we can give them bite-sized bits of education to help them, but evidence shows patients are more likely to have improved health overall from diabetes self-management education and support (DSME) (CDC, 2022).

These classes are generally offered through health systems and are covered by insurance. We did not expect our low-income patients to have the funds to cover these classes. Occasionally, there will be a free course offered to patients without health insurance, but none were offered in Oklahoma in Spanish.

I am a diabetes educator, but again this is a student-ran clinic. Also, I do not speak Spanish.

How can we remove the language and cost barriers and provide these patients with DSME?

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�

Culturally appropriate
Appropriate health literacy level
The American Diabetes Care and Education Specialist 7 Self-Care Behaviors
Diabetes self-management education classes were delivered by bilingual interprofessional students

The Project

Kolb L. An Effective Model of Diabetes Care and Education: The ADCES7 Self-Care BehaviorsTM. The Science of Diabetes Self-Management and Care. 2021;47(1):30-53. doi:10.1177/0145721720978154

My initial thought was surely there are some nutrition or nursing students who eventually want to become diabetes educators. I knew there was a requirement of 1,000 hours of actually providing diabetes education to patients along with supervision from someone who is already a diabetes educator to sit for the exam, so I thought maybe we could get former students involved since the person would need to have a professional license and 2 years experience. Then I realized being involved in diabetes education delivery would be beneficial to the whole interprofessional team. We learn best through teaching, right?

Although I am a diabetes educator, I have never actually practiced in that role. I had never developed a DSME program. I decided to use the ADCES7 Self-Care Behaviors as a guide to develop objectives. I sent emails out trying to recruit Spanish-speaking students with an interest in diabetes and/or helping their community. I had a great response and was so fortunate to recruit an amazing team!

There are so many great resources already developed in Spanish out there. I have included my favorites in the resources on my last slide. The students were engaged, made sure we delivered the education in a culturally appropriate way, at a proper education level, and made the content interactive and fun.

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Our Interdisciplinary Team

Our team consisted of faculty and students from OUHSC Colleges

Nursing
Social Work
Nutritional Sciences

along with mentorship and support from the Office of Interdisciplinary Programs.

I originally wanted to include a future provider (APRN/PA/medicine), pharmacy, nursing, nutrition, and social work. I sent out emails to occupational therapy to see if they wanted to come and teach some about mobility and maybe chair exercises or bands, something most people would be able to do for exercise. Pharmacy had some issues with getting a faculty preceptor for the project, so we ended up with just 5 wonderful students.

This is Alicia and Elsa. Alicia is working on her RN-DNP degree which means she is already an RN and is going to school to become a Family Nurse Practitioner and Doctor of Nursing Practice. She is here holding up a diabetes bingo game, diabingo that she played with the participants to teach about complications and prevention. Elsa is a Social Work student. She is holding up a glucose tube to show what high amounts of glucose look like in an artery compared to euglycemia.

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Class Objectives

Day 1

What diabetes is and some of the most common myths about diabetes
The feelings that you can have about diabetes
What blood glucose and insulin are
Blood glucose targets
S/S or how you feel when your blood glucose is in and out of your target ranges
Monitoring and knowing your A1c
What can make blood glucose go up and down and preventing high and low blood glucose
Using your monitoring results to manage your diabetes and solve problems

Day 2

The relationship between glucose and food
Feelings about food and eating
The nutrients that make up food and how to read a nutrition label
How what you eat, how much you eat, and when you eat can affect your blood glucose
Meal planning and other strategies for healthy eating

Day 3

The natural course of diabetes
Recognizing the fact that it may become more difficult to keep your blood glucose within your target range
The potential long-term complications of diabetes
How to delay or reduce the risk of long-term complications by keeping your blood glucose on target
The importance of checking for long-term complications and knowing your ABCs
The importance of physical activity
What common diabetes medications work
The importance of engaging a support network for coping

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Patient Impact – Self Efficacy

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Patient Impact

Our project was implemented in November 2022. Although we only had 7 participants and data is not yet complete, we have observed improvements in hemoglobin A1c and body mass index following our project.

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Patient Comments

https://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

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Undergraduate Nursing Students & Questions Asked on Day 1 of Class

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Student Impact

Median Student Jefferson Teamwork Observation Guide score = 7.

https://www.jefferson.edu/academics/academic-centers/interprofessional-education/resources/jefferson-teamwork-observation-guide.html

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Conclusion

Impact: improved access and removed barriers to healthcare delivery, improved patient-perceived diabetes self-efficacy, fostered an environment of teamwork in an innovative environment.

IPEC Core Competencies

Community Partnerships and Resources : Oklahoma City Mobile Market food pharmacy and Good Shepherd Clinic

Quality Improvement: PDSA model for continuous improvement

Dissemination: seed grant application, presentations, hopefully publication

We did run into some issues. For example, issues with contracts with the free clinic the Unity Clinic practices out of prevented us from being physically in clinic to recruit participants the entire time the project was implemented. And of course, over the winter and holiday season is not the most ideal time for nutrition and diabetes education.

Strengths: Our process is replicable. We have a high rate of uninsured Hispanics with diabetes in Oklahoma, but this project could be replicated in the Vietnamese or Indian population for example, depending on each communities' demographics and needs. We have strong community partnerships. We were able to use the Harold Hamm Diabetes Center classrooms for free. We are hoping to include cooking classes if we get approved for a grant. We were able to offer free fresh produce and healthy foods via the food pantry and OKC mobile Market.

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Questions?

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Resources

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References

Centers for Disease Control and Prevention. (2022a, March 1). Stats of the states - diabetes mortality. Diabetes mortality by state. https://www.cdc.gov/nchs/pressroom/sosmap/diabetes_mortality/diabetes.htm
Health Navigator. (2022, July 12). PDSA cycle. Health Navigator New Zealand. Retrieved November 12, 2022, from https://www.healthnavigator.org.nz/clinicians/p/pdsa-cycle/
Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. https://doi.org/https://ipec.memberclicks.net/assets/2016-Update.pdf
Kolb, L. (2021). An effective model of diabetes care and education: The adces7 self-care behaviors™. The Science of Diabetes Self-Management and Care, 47(1), 30–53. https://doi.org/10.1177/0145721720978154
Lyons, K. J., Giordano, C., Speakman, E., Smith, K., & Horowitz, J. (2016). Jefferson Teamwork Observation Guide (JTOG): An instrument to observe teamwork behaviors. Journal of Allied Health, 45(1), 49–53.
State of Oklahoma. (2019). 2019 Oklahoma minority health at a glance [PDF]. https://oklahoma.gov/content/dam/ok/en/health/health2/documents/2019-oklahoma-minority-health-at-a-glance.pdf
United Health Foundation. (2022a). Summary of Oklahoma. America's Health Rankings. https://www.americashealthrankings.org/explore/states/OK
United Health Foundation. (2022b). Uninsured Hispanic. America's Health Rankings. https://www.americashealthrankings.org/explore/annual/measure/HealthInsurance/population/uninsured_hispanic/state/OK