SAN DIEGO -- Over the past 15 years, more than 18,000 San Diegans with diabetes have been involved in a focused care management program that has proven to be both clinically and cost effective, according to recent findings.
A study published in the fall issue of the journal Clinical Diabetes compiles research that was conducted over the course of 15 years to explore health and economic benefits of diabetes treatment through the Scripps Whittier Diabetes Institute's Project Dulce.
Project Dulce began in 1997 in response to "an identified need for improved diabetes care in underserved diverse ethnic populations in San Diego County," said Athena Philis-Tsimikas, corporate vice president at Scripps Whittier Diabetes Institute and lead author of the study.
As part of a collaborative effort with San Diego County, the Community Health Centers network and San Diego State University behavioral health scientists, Scripps Whittier Diabetes Institute designed a model aimed at improving diabetes patient care and clinical outcomes at a time when little information was available about effective care models that could be integrated into the primary care setting.
The Project Dulce model is based on teams of a trained diabetes registered nurse, a registered dietician and a health coach. They're deployed to community health centers throughout San Diego to support medical staff, monitor diabetes management and provide patient education.
"Project Dulce gives us an extension of what we're doing in the exam room. The difference between our regular [medical] team and what the [Project Dulce nurse] does, is she's focused like a laser beam on diabetes and all its complications," said Jim Schultz, chief medical officer of Neighborhood Healthcare, a community health center that contracts with Project Dulce. Schultz is also an author of the study.
Project Dulce teams include a peer educator -- an individual with diabetes who has successfully managed his or her own illness. Diabetes patients identified as having leadership skills are selected to undergo a 40-hour training curriculum that includes techniques in behavior-modification, group instruction and mediation methods. Peer educators cover topics such as diet, exercise, medication and diabetes complications. The goal is to have peers share the same cultural background as the group of patients they are teaching. In San Diego, 65% of Project Dulce patients are of Latino/Hispanic descent.
Creating a culturally appropriate program is critical for a number of reasons, experts say. Diabetes is more prevalent among Hispanics, blacks and Asians than in non-Hispanic whites, and cultural barriers often prevent people from getting optimal care.
Learning from someone who has successfully managed the illness and also comes from a shared cultural background can positively affect patients' ability to make lifestyle changes, according to Schultz. "The whole barrier of cultural understanding and language goes away," he said.
"If patients have a peer telling them, 'You can manage this,' that is powerful. It gives people hope, inspiration and a good role model in addition to education. Hope and inspiration are just as important to the educational component," according to Schultz.
The latest of three studies conducted over the project's 15-year history specifically examined the impact of peer educators. Results show that groups receiving peer coaching demonstrated greater improvement in blood glucose levels, blood pressure, total cholesterol, HDL cholesterol and LDL cholesterol at the end of 10 months, compared with the control group.
These results follow those from a study conducted after the first few years of Project Dulce's existence that demonstrated improved clinical and behavioral outcomes, as well as higher rates of satisfaction with treatment among patients enrolled in the program.
"That was sort of the step that proved, yeah, this is probably something that is valuable to have in a primary care home environment," Philis-Tsimikas said.
A study published in 2005 showed the program also had a positive impact on the economics of diabetes treatment. Although expenses were higher during the program's first year because of implementation costs and greater patient adherence to medication, a dramatic reduction in both emergency department visits and hospital admissions reduced costs overall.
Broader Implications of Project Dulce's Success
Project Dulce is ahead of its time, having adopted a medical home model before the Affordable Care Act and its provisions pushing for similar models of care took effect.
The health reform law emphasizes a number of changes to the way health care is delivered and paid for, including the creation of medical homes that incorporate chronic care management methods such as patient education and community resources and support for better self-management. Project Dulce staff members have been asked by health systems around the country -- including the program's parent organization, Scripps Health -- to help design and implement culturally appropriate disease management programs. "Everyone is trying to consolidate their care and build primary care home sites," Philis-Tsimikas said.
What's more, the program has demonstrated how non-physician experts -- nurses, health coaches and peer educators -- can take on the lion's share of a disease management program, thereby freeing up the time of overworked primary care physicians, while simultaneously improving clinical outcomes and reducing spending.
"For a third or a quarter of the cost you can now have [diabetes education] done by a peer educator, and the study we did proved it's effective clinically. If the nurse can actually assist the physician with the management so that they achieve better clinical outcomes, well that's a lower cost than using your physician," said Philis-Tsimikas.
She pointed out that the physician remains the leader of the entire process, but with this model has a little army working to help manage the patient population.
Preventing Diabetes as Part of Health Reform
The health reform law has also identified diabetes as a major threat to public health and in response calls for a National Diabetes Prevention Program headed by CDC.
While programs like Project Dulce help to address the clinical needs of the nearly 26 million Americans currently affected by diabetes, the National Diabetes Prevention Program aims to prevent illness in the 79 million Americans estimated to have pre-diabetes -- people with blood glucose levels higher than normal but not high enough to be classified as diabetes.
"This is an urgent health issue facing the country and the projections are frightening," said Ann Albright, director of the Division of Diabetes Translation for CDC.
The CDC program is the outgrowth of a 2002 study funded by NIH, which found that moderate weight loss -- 5% to 7% of one's body weight -- along with lifestyle changes involving diet and at least 150 minutes of weekly exercise can reduce the diabetes incidence by 58%. National Diabetes Prevention Program participants work with a lifestyle coach in a group setting for one year and attend six follow-up sessions, all led by trained lifestyle coaches teaching small groups about behavior change.
CDC partnered with the Diabetes Prevention and Control Alliance, a business unit of United Health Group, which functions as a third party administrator. The DPCA is also working to establish a network of community-based organizations, employers, insurers, health care professionals, and other stakeholders to broadly implement the program. Currently, the National Diabetes Prevention Program is available in 42 states, mainly through the YMCA, which administers the program at 68 of its locations nationwide. In addition, CDC has funded five other organizations to help expand the reach and sustainability of the program across the country.
"It's imperative to move the work into a scalable implementation," Albright said.
It is clear that through evidence-based programs such as Project Dulce and the National Diabetes Prevention Program, significant progress can be achieved toward reducing the incidence and impact of diabetes, a major national health concern.
But experts say widespread success hinges, at least in part, on shifting the U.S. health care system away from traditional fee-for-service payment to budget-based reimbursement that rewards health care providers for the quality of care, rather than the quantity of care, they provide.
"We would do a lot more of this but are limited by our current payment structure," Schultz said.