Assessing NC local health department diabetes education programs

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Assessing NC local health department diabetes
education programs

• Deborah Porterfield, MD MPH
• University of North Carolina-Chapel Hilland RTI
  International
• 3.08

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Access to diabetes self-management education

• 54 of persons in NC have ever had a formal
  diabetes education class
• Those with lower income or education even less
  likely to have access to formal diabetes
  self-management education
• Majority of diabetes educators are localized in
  hospitals and health systems
• Local public health has a potential role in
  access to self-management education for
  underserved populations

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Objectives of this study

• Determine the prevalence of and characteristics
  of diabetes education programs in local health
  departments in North Carolina
• Data from a larger study, which looked more
  broadly at a variety of services and programs
• Through site visits to four local health
  departments, understand barriers and facilitators
  to providing diabetes education and other services

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Project Partners

• UNC Chapel Hill SPH and North Carolina Institute
  of Public Health
• NC Division of Public Health, Diabetes Prevention
  and Control Branch
• Health Promotion Committee, NC Association of
  Local Health Directors

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Larger study survey objectives

• Measure capacity of NC LHDs to conduct diabetes
  prevention and control activities.
• Measure levels of performance in diabetes related
  prevention and control services and programs in
  NC LHDs.
• Assess characteristics of communities, such as
  population size or estimated diabetes prevalence,
  or of local health departments that may be
  associated with higher capacity and performance.

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• Examine differences in capacity and performance
  between LHDs that have received training and
  funds through a specific federal and state
  program, Diabetes Today, and those who have not,
  in order to assess if participation has increased
  capacity and performance.

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Survey administration

• Mailed survey
• Participants All local health departments in NC
  (n85)
• Instrument adapted from the Local Public Health
  System Performance Assessment
• 10 Essential Services

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Results

• 100 response
• 2 mailings, reminder postcards, phone follow up

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LHD characteristics

• Number of FTEs (median) 80
  (IQR 51-128)
• Expenditures, million (median) 4.81
  (IQR
  2.95-8.0)
• Accredited 31
• Diabetes Today funding 35
• Project IDEAL funding 4
• Full time medical director 20
• DM or chronic disease in mission 18.9

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Characteristics of LHD jurisdictions

• Single-county 93
• Population gt100k 31
• Urban 47
• population below poverty (mean) 14
  (sd 4.2)
• Any C/MHC or free clinic 71
• Physician/100k ratio (median)
  62.0 (47.8-89.0)
• Est. diabetes prevalence (mean) 9.1
  (sd 0.93)

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Capacity FTEs in diabetes

• Prevention FTEs (median) 0.05 (IQR 0-0.5)
• Control FTEs (median) 0.1 (IQR 0-0.5)
• 40 have no FTEs devoted to prevention or control
• 16 have a certified diabetes educator
• 21 have access to an epidemiologist

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ES 1 Monitor health status

• Access to data
• 87 prevalence of diabetes
• 34 quality of care
• 28 health status of persons with diabetes

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ES 4 Mobilize partnerships

• 52 have a coalition that focuses on diabetes
• 47 use communication strategies to strengthen
  linkages or inform constituents

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ES 7 Link persons to needed personal health
services

• Assessment
• 41 assessed personal health services
• 46 assessed diabetes education
• Provision of services
• 37 primary care
• 74 screening for diabetes
• 48 screening for pre-diabetes

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ES 3 Inform, educate

• Health education for persons with DM
• 58 (n48) sponsor health education for persons
  with diabetes
• 31 group 19 individual 50 both
• Mean of hours/person of 8 (range 1-52)
• Mean number of persons in last year 121 (range
  9-400)
• Mean cost/session 15 60 have a sliding scale
• Onsite in 75 offsite in 54
• 67 in languages other than English
• 23 have a CDE
• 15 (n7) claim ADA recognition

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Health education for persons at risk

• 62 sponsor health education for persons at risk
  for diabetes
• 68 of these in nutrition 66 in physical
  activity

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Conclusions from the survey

• Limited capacity (FTEs)
• Diabetes education is one of the more common
  diabetes practices in LHDs
• The number of patients and contact hours are
  significant
• Availability of offsite classes, the low cost,
  and availability in other languages suggest
  access for underserved populations

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Case studies 4 high performing local health
departments

• Based on total performance index
• Also chosen based on total population size of
  county (2 big, 2 small) and whether the LHD had
  ever received funding from the NC DPCP (Diabetes
  Today)(2 yes, 2 no)

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Overall goals of the case study

• What are the diabetes prevention and control
  services among small and large health departments
  with and without DT funding?
• What are the barriers and facilitators of
  diabetes prevention and control services?
• In addition to size and funding, what are
  additional facilitators of diabetes services?

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Summary of ES3diabetes self management education

• 3 of 4 provided diabetes education to individuals
• 2 of 4 were ADA recognized programs
• All described the importance of work with local
  providers, primarily for referrals
• Three LHDs provide patients education outside the
  LHD (other providers offices or industry setting)

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Lessons from ADA recognized programs

• Importance of the ECU fellowship
• Value of ADA recognition to the LHD or the
  patient
• Word of mouth, publicity for the program
• Can see patients from other counties without
  being perceived as stealing patients (since
  services are not universally available)
• Potentially lower cost to patient
• Funding

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Challenges!

• were going down roads that I dont think people
  ever intended health departments to go
• Variation in requirements of Medicaid, Medicare,
  private insurance
• Challenges with HSIS
• BC/BS requiring a medical director
• Need for more assistance from the state

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• Being perceived as competing with a nearby
  hospital
• Not covering costs with billing
• Payor mix would need to see 2 insured for one
  uninsured

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Conclusions/recommendations

• Lessons learned from these 2 ADA programs
• Increase number of scholarships to ECU
• Promote startup of more ADA-recognized programs
• Technical assistance
• Call for greater TA and for networking
  opportunities at a more advanced level

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Limitations

• Self-report of items in the survey
• Different types of persons responding in each LHD
• Not a validated survey
• Small sample size in the case study
• Case study cases were not selected specifically
  because of their self-management programs

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Acknowledgements

• Every local health department In NC
• The NC Association of Local Health Directors
  Health Promotion Committee Curtis Dickson and
  Beth Lovette
• NC Division of Public Health Janet Reaves, RN,
  MPH Marcus Plescia, MD, MPH
• UNC School of Public Health and the NC Institute
  for Public Health
• Ed Baker, MD, MPH Mary Davis, DrPH, MSPH
  Bob Konrad, PhD Bryan Weiner, PhD
• Data for this study were obtained from the 2005
  National Profile of Local Health Departments, a
  project supported through a cooperative agreement
  between the National Association of County and
  City Health Officials and the Centers for Disease
  Control and Prevention (U50/CCU302718).
• Work funded by the Pfizer Scholars Grants in
  Public Health

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• Full report is available at UNC NCIPH website
• http//www.sph.unc.edu/nciph/evaluation_services.h
  tml

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• Deborah Porterfield, MD, MPH
• Department of Social Medicine
• UNC School of Medicine
• CB 7240
• UNC Chapel Hill
• Chapel Hill, NC 27514
• dport_at_med.unc.edu
• 919/843-6596