Teaching Diabetes Self-Management—in 4 Hours (or Less)

Teaching Diabetes Self-Management—in 4 Hours (or Less)

Linda S Gottfredson, PhDSchool of Education

University of Delaware

Kathy Stroh, MS, RD, CDEDiabetes Prevention and Control Program

Delaware Division of Public Health

1CEHD Colloquium, University of Delaware, February 28, 2013

Juvenile Diabetes Maturity-onset Diabetes

Insulin dependent Non-insulin dependentDiabetes (IDD) Diabetes (NIDD)

Type I Diabetes Type II Diabetes

Type 1 Diabetes Type 2 Diabetes

Types of Diabetes

2

Types of Diabetes (DM)

Type 1 -cell destruction; autoimmune disease; complete lack of insulin

5-10% of total patients

Type 2 -cell dysfunction and insulin resistance

Gestational -cell dysfunction and insulin resistance during pregnancy

3

There is no such thing as Borderline Diabetes

or a “Touch of Diabetes.”

Pre-diabetes is a diagnosis.

4

There is no such thing as Borderline Diabetes

or a “Touch of Diabetes.”5

Pre-diabetes

DM defects

6

Diabetes is a cardiovascular disease.

The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program

People with diabetes are

twice as likely

to suffer a heart attack

or stroke

compared to people without diabetes.

7

Natural history of Type 2 diabetes

Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

Obesity Diabetes Uncontrolled Hyperglycemia

50100150

200250300350

50

100

150

200

250

Glu

cose

(mg/

dL)

Rel

ativ

eFu

nctio

n (%

)

-10 -5 0diagnosis

5 10 15 20 25 30Years of Diabetes

Post-meal Glucose

Fasting Glucose

Insulin Resistance

Insulin Level-cell Failure

Insulin ResistanceFamily History

Prediabetes

Why teach self-management?

• Patients must control their blood glucose (BG) levels to avoid complications

• Controlling BG is a complex, 24/7, life-long task– Rx’s change, increase; may not insure optimal BG control– Changes in dietary intake & physical activity necessary– And more…

• So much to learn and do (or stop doing)

9

PWD’s* everyday reality

* “Diabetic” is not a noun 10

11

12

13

As teacher educators, how would you recommend

teaching diabetes self-management?

Here’s the challenge

14

Private schools

0.4 mil teachers 5.4 mil pupils

$673 billion

15Federal

State

District

Federal

State

District

Regulations

Public schools

3 million 50 million

Diabetes education??

$673 billion

16Federal

State

District

Federal

State

District

Regulations

Public schools

3 million 50 million

InstructionLearning tasks

Private schools

0.4 mil teachers 5.4 mil pupils

Diabetes education??

Context: Exploding numbers

12012 Condition of Education, Table A-3-1. http://nces.ed.gov/pubs2012/2012045_5.pdf2 For 1970, All Ages is interpolated from 1968 and 1973. http://www.cdc.gov/diabetes/statistics/diabetes_slides.htm. 3For 1990 and 2010, All ages and 65+ derived from http://www.cdc.gov/diabetes/statistics/prev/national/tnumage.htm, and 18+ from http://www.cdc.gov/diabetes/statistics/prev/national/figadults.htm4 Boyle et al (2010), Projection of the year 2050 burden of diabetes in the US adult population. Population Health Metrics, 8(29).I averaged the results from their 4 models. Huang et al. (2009) estimated 34.2M for Type 2 alone: Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. 5CDC’s Diabetes Data & Trends. http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx,

Just 5 years!

Public schools Diabetes casesNumber needing instruction

Millions enrolled1 Millions diagnosed with diabetes Type 1 or 2(non-institutionalized civilians)

Fall ofTotal

Elementary (preK-8) HS (9-12)

197045.532.513.0

1990 41.229.911.3

201049.534.614.9

202052.737.315.4

All agesAdults (18+)Older (65+)

19702

3.619903

6.66.62.8

20103

20.920.7 7.8

20204

33.5

2004 % diagnosed adults > 20 years 5 2009

17

Average $/person2 4,310 7,925 10,694 (2008)

11,093 6,745 1,834 466

Context: Exploding costs

12011 Digest of Education Statistics, Table 28, http://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp. Table reports costs in current dollars, so inflation calculator used to bring up to 2010 values.22011 Digest of Education Statistics, Table 194, http://nces.ed.gov/programs/digest/d11/tables/dt11_194.asp3 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. Used inflation calculator to translate dollars from 2007 to 2010. http://www.usinflationcalculator.com4Huang et al. (2009) Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. Includes Type 2 only. Type 1 would be <5% of cases but higher per capita cost. Inflation calculator used to change costs from 2007 to 2010 dollars. 5 No 2020-2030 projections available for school expenditures, so just repeated % GDP from the prior 2 decades. Used Huang et al.’s total diabetes medical costs for 2007, together with 2007 GDP, to calculate costs as % GDP in that year (1.1%). Then used their Exhibit 3 (projected real growth as multiple of GDP) to estimate % GDP in 2010, 2020, and 2030. No data prior to 2007, so just took line toward asymtope .

Students in public schools , K-12 Diabetes cases, diagnosed and undiagnosedTotal expenditures

(2010 dollars)Medical costs only

(2010 dollars)

1970 1990 2010 20073 20204

Total $ (billions)1 270 415 673Type 1

11 Type 2

111 Undiag

12 Pre-diab

27Total160

Type 2237

1970 1980 1990 2000 2010 2020 20300.0

5.0

10.0

15.0Costs as % of GDP1,5

Diabetes

Schools

18

Total medical costs, by age & diabetes type, 2007$ (billions)

25.3

105.7

11.0

10.5

Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars. 19

%(prevalence)

18–34 35–44 45–54 55–59 60–64 65+0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

3,567

4,775

6,387

8,198

11,722

3,837 3,7144,561

5,077 5,359

9,061

5,425

1,3742,327 2,063

4,763

579210 305 391 488 537 716

Type 1Type 2UndiagnosedPre-diabetes

II

Ages:

Average

35,365

Average cost ($)

Average medical costs per person by age & diabetes type, 2007

Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.20

Context: Institutional resources

Public schools Diabetes self-management educationDedicated space Permanent buildings Varies; hospitals, medical offices, community sites

Guaranteed funding 100% tax-supported1

(local, state, federal)Varies by health plan; free community classes provided by DPH/DPCP.

Mandatory attendance 10-14 years None, all voluntary. ~ 24% of Medicare patients attended DSMT class.

Teaching force:

Trained in content areaCertified to teach

Classroom teachers

All (N=3.1 million) 1

99%1

Many staff do DSME: medical (e.g., MD, RN, RD, NP, PA, RPh); non-medical (e.g., CHW, CHES, peer educators).DSMP classes given by lay trainers.Trained in disease management: MD, RN, RPh, RD, NP, CDE. Trained to educate: Only CDEs (N=8710), national credential; possible state licensure too.

Curriculum content &

Teacher lesson plans

State national standards (CCSS2) Always. Vary by teacher common planning

Curriculum content: ADA and AADE certify Recognized Programs. DSMP has evidence-based curriculum.Lesson plans: vary with ADA & AADE programs. Fidelity agreement for DSMP.

12012 Condition of Education, Tables A-19-1 (2008-2009), A-17-1 & A-17-2 (2007-2008) 2 http://www.corestandards.org/

= trend towards

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More variable for DSME

5 levels of diabetes educators*o Level 1, non-healthcare professional,o Level 2, healthcare professional non-diabetes educator,o Level 3, non-credentialed diabetes educator,

Level 4, credentialed diabetes educator, and Level 5, advanced level diabetes educator/clinical manager.

*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf

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Context: Instructional resourcesop0 Public schools Diabetes self-management education

Hours of instruction in content area (average per year)

State/district-mandated minimum hours:1

G1-4: 418 read/write 194 math 292 science

Varies greatly by health plan & site - Classes: 10-15 hrs - Individual DSME: varies

Instructional strategies Systematic use of pedagogical principles

For individual patients: CDE’s assessment of patient’s needs. For groups: scripts for some non-medical educators (e.g., DSMP)Pace, sequencing, Bloom level not always considered.

Special needs studentsEstablished protocols? Yes, legal obligation (IDEA) Currently, no DSME materials or curricula specifically for elderly or

persons with disabilities.

Age- and ability-differentiated instruction & materials

Age grouping, preK-12 Elem: reading/math groups within or between classrooms, all with different lessonsHS: Tracks

None.Growing concern over low “health literacy” & age-related cognitive decline with PWDs, but -Diabetes education materials vary widely; content, but not complexity, matched to PWD’s learning needs. - PWDs are given pre-determined meters and supplies, regardless of their abilities.

1Data for 2003-2004. Source: “Changes in Instructional Hours in Four Subjects by Public School Teachers of Grades 1 Through 4,“ May 2007, NCES report 2007-305 http://www.eric.ed.gov/PDFS/ED497041.pdf/2http://www.cdc.gov/diabetes/statistics/preventive/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf

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Little differentiation

Limited time

Materials too complex

Example of required task for all PWDs:

Glucose metersand

lancet devices

Demonstration !!

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Our efforts

1. Describe job of self-care from patient’s perspective.

– Collaboration with CDS: AUCD Conference

– AADE Conference: “Cognitive Demands of DSME”

– NACDD Teleconference: “Cognitive Demands of DSME”

– AADE Conference 2013: “Psychometrics of DSME in the Elderly”

2. Identify the job’s most critical tasks

3. Trace (and limit) cognitive complexity of learning tasks

4. Differentiate instruction by ability (“literacy”) level

5. Provide scripts for providers that minimize complexity

6. Provide patient handout that reinforces learning

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AADE’s description of DSM*Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:

• Requires making and acting on choices, on a regular and recurring basis, that affect one’s health

• Includes learning the body of knowledge relevant to the disease state, defining personal goals, weighing the benefits and risks of various treatment options, making informed choices about treatment, developing skills (both physical and behavioral) to support those choices, evaluating the efficacy of the plan toward reaching self-defined goals.

*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf

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AADE’s description of DSM*Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:

• Requires making and acting on choices, on a regular and recurring basis, that affect one’s health

• Includes learning the body of knowledge relevant to the disease state, defining personal goals, weighing the benefits and risks of various treatment options, making informed choices about treatment, developing skills (both physical and behavioral) to support those choices, evaluating the efficacy of the plan toward reaching self-defined goals.

*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf

What Bloom level would you assign to each?• Remember• Understand• Apply• Analyze• Evaluate• Create 27

AADE7TM curriculum content

1. Healthy eating2. Being active3. Monitoring4. Taking medication5. Problem solving6. Reducing risks7. Healthy coping

Objective: Maintain blood glucose within healthy limits to avoid complications• Learn about diabetes in general (At “entry’)

– Physiological process– Interdependence of diet, exercise, meds– Symptoms & corrective action– Consequences of poor control

• Apply knowledge to own case (Daily, Hourly)– Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner– Adjust food, exercise, meds in timely and appropriate manner

• Coordinate with relevant parties (Frequently)– Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support– Communicate status and needs to practitioners

• Update knowledge & adjust regimen (Occasionally)– When other chronic conditions or disabilities develop– When new treatments are ordered– When life circumstances change

• Conditions of work—24/7, no days off, no retirement

Our more patient-centered job description

Self-

management

Training

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Objective: Maintain blood glucose within healthy limits to avoid complications• Learn about diabetes in general (At “entry’)

– Physiological process– Interdependence of diet, exercise, meds– Symptoms & corrective action– Consequences of poor control

• Apply knowledge to own case (Daily, Hourly)– Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner– Adjust food, exercise, meds in timely and appropriate manner

• Coordinate with relevant parties (Frequently)– Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support– Communicate status and needs to practitioners

• Update knowledge & adjust regimen (Occasionally)– When other chronic conditions or disabilities develop– When new treatments are ordered– When life circumstances change

• Conditions of work—24/7, no days off, no retirement

Our more patient-centered job description

Self-

management

Training

29

It is NOT just following a plan.

It is also thinking and acting to minimize problems.

Our efforts

1. Describe job of self-care from patients’ perspective

2. Identify the job’s most critical tasks

3. Trace (and limit) cognitive complexity of learning tasks

4. Differentiate instruction by ability (“literacy”) level

5. Provide scripts for providers that minimize complexity

6. Provide patient handout that reinforces learning

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UD survey: Criticality

rankings

31

Our efforts

1. Describe job of self-care from patients’ perspective

2. Identify the job’s most critical tasks

3. Trace (and limit) cognitive complexity of learning tasks

4. Differentiate instruction by ability (“literacy”) level

5. Provide scripts for providers that minimize complexity

6. Provide patient handout that reinforces learning

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Bloom’s Taxonomy of Learning ObjectivesLatest (2001) revision

Bloom levels = continuum of cognitive complexityNot just readability!!

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*Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching,

and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.

To be or not to be, that is the question.

To be or not to be, that is the question.

To be or not to be, that is the question.

To be or not to be, that is the question.

To be or not to be, that is the question.

To be or not to be, that is the question.

“To be or not to be”Bloom’s taxonomy of educational objectives (cognitive domain)*

Simplest tasks1. Remember

recognize, recall,Identify, retrieve

2. Understand paraphrase, summarize,

compare, predict, infer

3. Apply execute familiar task,,

apply procedure to unfamiliar task

4. Analyze distinguish, focus, select,

integrate, coordinate

5. Evaluate check, monitor, detect

inconsistencies, judge effectiveness

6. Create hypothesize, plan, invent,

devise, design

Most complex tasks34

*Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching,

and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.

Anticipate effect of exercise & foods on blood glucose.

Coordinate meds, diet, and exercise.

Manage sick days.

Determine when & why blood glucose is out of

control

Monitor symptoms; assess whether action needed;

evaluate effectiveness of actions

Create daily and contingency plans that control blood

glucose

Recall effects of exercise on glucose.

Remember to take BGs & Rx.

Bloom’s taxonomy of educational objectives (cognitive domain)*

Simplest tasks1. Remember

recognize, recall,Identify, retrieve

2. Understand paraphrase, summarize,

compare, predict, infer

3. Apply execute familiar task,,

apply procedure to unfamiliar task

4. Analyze distinguish, focus, select,

integrate, coordinate

5. Evaluate check, monitor, detect

inconsistencies, judge effectiveness

6. Create hypothesize, plan, invent,

devise, design

Most complex tasks

Remember to measure foods, drinks & read labels.

35

What about reading nutrition labels?

• How important?

• How complex?

Essential

Extremely

36

37

Information is better because it’s inchart form

Amount per serving

But, it contains aconfusing technical symbol.

Can you spot it?

“Amount/serving”

38

What’s the problem here?

39

And here?

Organic

HealthyNo sugar

added40

Pros: • Fewer items• Single vertical

list • Major headings

stand out

Cons: • Lots of irrelevant

info

• Seemingly inconsistent info

Better, but…

41

Food Label revision…counting carbohydrates

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Bloom’s taxonomy of educational objectives (cognitive domain)

Simplest tasks1. Remember

recognize, recall,Identify, retrieve

2. Understand paraphrase, summarize,

compare, predict, infer,

3. Apply execute familiar task,,

apply procedure to unfamiliar task

4. Analyze distinguish, focus, select,

integrate, coordinate

5. Evaluate check, monitor, detect

inconsistencies, judge effectiveness

6. Create hypothesize, plan, invent,

devise, design

Most complex tasks

Distractors:CHOs vs Fiber vs Fat

Carb vs non-carb ??Sequence of labelTotal CHOs important, “Sugars” notGrams as volume vs wt

Part of meal vs snack OK?CHOs in intended serving? CHOs vs Fat/Chol vs Na

Location of relevant CHO (carb) gms

How many CHO gms in 1 serving?Subtract fiber gms from CHO gms

Plan a meal or snack

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Our efforts

1. Describe job of self-care from patients’ perspective

2. Identify the job’s most critical tasks

3. Trace (and limit) cognitive complexity of learning tasks

4. Differentiate instruction by ability (“literacy”) level

5. Provide scripts for providers that minimize complexity

6. Provide patient handout that reinforces learning

How different in ability can adults be?

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Typical literacy items, by difficulty levelNational Adult Literacy Survey (NALS), 1993

NALS difficulty level (& scores)

% US adults (age 65+) peaking at this level

Simulated everyday tasks

5(375-500)

3% ~0%

Use calculator to determine cost of carpet for a room Use table of information to compare 2 credit cards

4(325-375)

15%4%

Use eligibility pamphlet to calculate SSI benefits Explain difference between 2 types of employee benefits

3(275-325)

31%16%

Calculate miles per gallon from mileage record chart Write brief letter explaining error on credit card bill

2(225-275)

28%33%

Determine difference in price between 2 show tickets Locate intersection on street map

1(0-225)

23%47%

Total bank deposit entry Locate expiration date on driver’s license

Daily self-maintenance in modern literate societies

45

NALS difficulty level (& scores)

% US adults (age 65+) peaking at this level

Simulated everyday tasksNational Adult Literacy Survey (NALS), 1993)

5(375-500)

3% ~0%

Use calculator to determine cost of carpet for a room Use table of information to compare 2 credit cards

4(325-375)

15%4%

Use eligibility pamphlet to calculate SSI benefits Explain difference between 2 types of employee benefits

3(275-325)

31%16%

Calculate miles per gallon from mileage record chart Write brief letter explaining error on credit card bill

2(225-275)

28%33%

Determine difference in price between 2 show tickets Locate intersection on street map

1(0-225)

23%47%

Total bank deposit entry Locate expiration date on driver’s license

level of inference (“connecting the dots”) abstractness of info

distracting information

number of features to match

Not reading per se, but “problem solving”

Typical literacy items, by difficulty levelNational Adult Literacy Survey (NALS), 1993

46

Complexity & aging

47

g - Basic information processing(GF)

Basiccultural Knowledge(GC)

Age-related cognitive decline

Learning & reasoning abilityAge 8

48

Age 80

Our efforts

1. Describe job of self-care from patients’ perspective

2. Identify the job’s most critical tasks

3. Trace (and limit) cognitive complexity of learning tasks

4. Differentiate instruction by ability (“literacy”) level

5. Provide scripts for providers that minimize complexity

6. Provide patient handout that reinforces learning

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“Rx for Physical Activity” for a Rural Community Health Center

Linda S. Gottfredson, PhDSchool of EducationUniversity of Delaware

Kathy Stroh, MS, RD, CDEDiabetes Prevention & Control ProgramDelaware Division of Public Health

Presented at the 2009 Diabetes Translation Conference of the Centers for Disease Control & Prevention (CDC). Long Beach, CA, April 24, 2009

50

51

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Basic pedometer—just counts steps

53

Graduated RxBasic Rx

increases

speed

http://www.udel.edu/educ/gottfredson/Rx54

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Teaching the teacher: Script for CDE when prescribing “Rx for Walking”

Provides the CDE with:

Educationally sound teaching strategy

• Key ideas • Content, sequence, and pace of

instruction, etc.

Implicit training • Be concrete, personalize,

use meaningful metaphors, etc.

56

57

58

59

Lesson plan: Don’t assume they know what’s obvious to you

Can’t assume:

That patient will know: • What a pedometer is• How to wear it • The exact regimen of the Rx

• i.e., extra steps

That the educator will know specific learning steps for:

• Aim of script (e.g., extra steps)• How to adjust regimen

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Our efforts

1. Describe job of self-care from patients’ perspective

2. Identify the job’s most critical tasks

3. Trace (and limit) cognitive complexity of learning tasks

4. Differentiate instruction by ability (“literacy”) level

5. Provide scripts for providers that minimize complexity

6. Provide patient handout that reinforces learning

61

62

Thank you.

Questions?Advice?

63

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5 levels of diabetes educators*o Level 1, non-healthcare professional,o Level 2, healthcare professional non-diabetes educator,o Level 3, non-credentialed diabetes educator,

Level 4, credentialed diabetes educator, and Level 5, advanced level diabetes educator/clinical manager.

*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf

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