Monday, June 22, 2009

Overcoming Barriers to Care

During diabetes self-management education sessions, patients learn to manage their disease

Three years ago, 41 percent of Latino patients at Massachusetts General Hospital’s Chelsea HealthCare Center had out-of-control diabetes, compared to just 23 percent of white patients. “When you see the numbers, you realize how significant the gap is,” says Alexander Green, MD, MPH, associate director of the Disparities Solutions Center at Mass General. “Our immediate goal was to reduce disparities in our own patient population, but we also wanted to develop a model program that could serve as a blueprint for reducing health care disparities in other parts of the country and for other diseases.”

Together, the Disparities Solutions Center, the Chelsea HealthCare Center, the Massachusetts General Physicians Organization and the Center for Community Health Improvement developed an award-winning model of care to help diabetics take control of their health. In just two years, Latino patients had a 13 percent reduction in their hemoglobin, a measure of diabetes control. Approximately 437 patients have participated in the program since its inception.

Working to Close the Gap

Minority populations are more likely to be in poor control of their diabetes and have higher rates of complications. They are also less likely to have been tested for blood sugar levels that would diagnose the disease.

Diabetes nurse educator Eli Sanchez, RN, BSN, leads a group diabetes self-management education session

Physical therapist Sofia Devine, PT, DPT, works with patients in the diabetes program to incorporate exercise into their lifestyle

The diabetes model uses a multidisciplinary team approach to overcome these and other barriers to care, targeting what Green says is missing in health care – culturally competent chronic disease management. “Patients are usually just treated medically, which doesn’t always address the cultural barriers a patient might experience,” says Green. “Scheduling an appointment can be a barrier for patients who don’t understand the system or have language difficulties.”

The model employs a bilingual nurse educator and a bilingual diabetes coach as well as a dedicated team of nurse practitioners, a registered dietitian, a physical therapist and two mental health professionals, all of whom work closely with the patient’s primary care physician or nurse practitioner and one-on-one with patients to help get their diabetes under control. “This combination of culture and medicine,” says Green, “is really the future of patient care.”

“We try to connect with patients from all walks of life and understand their individual obstacles,” says Eli Sanchez, RN, BSN, the program’s diabetes nurse educator. “Patients appreciate our ability to accommodate their schedules and that we speak the same language. This encourages patients to keep appointments and stay in touch, which contributes to good diabetes control.”

Staying in Control

The diabetes model has worked well for Robert, a patient at the center. When he first entered the program, his A1C number was 17 – normal is typically below 7. This put him at high risk for developing complications, including kidney failure and blindness.

Robert’s physician referred him to Eddie Horta, MA, MHC, for one-on-one diabetes coaching. “I come from the same community as my patients and speak several languages, including Spanish. This creates a cultural bond,” Horta explains. “Patients know they can trust me to understand them, which makes them more likely to sustain the behavioral changes needed to control their diabetes.”

Together, Horta and Robert identified the reasons for his uncontrolled diabetes and developed a care plan to address them, which was approved by Robert’s primary care physician. Robert began exercising, cut back his alcohol consumption and started snacking on fruit. A year later, Robert’s A1C is 8.5 – half his previous number. It’s a goal he credits Horta with helping him achieve. “Eddie calls to check on me and make sure I keep our appointments,” he says. “It’s been really good.”

Based on their success in Chelsea, Green and his colleagues are developing a similar program targeting Cambodians with poorly controlled diabetes at Mass General’s Revere HealthCare Center. The have also applied for a grant to extend the model to diabetes prevention in Latino patients with multiple risk factors for developing the disease.

Applying Lessons in Diabetes to Cancer Prevention

Could the diabetes model be adapted to develop a similarly successful program to encourage colorectal cancer screening among lower income Latinos in Chelsea?

“I was frustrated because I was having a hard time getting my patients screened,” says Sanja Percac-Lima, MD, a physician at the Chelsea HealthCare Center.

Many of Percac-Lima’s patients don’t speak English, which limits their ability to understand scheduling calls and colonoscopy preparation instructions. In addition, they are less apt to practice preventive care, including screenings. “Similar to the diabetes model, our program’s patient navigator guides patients through the entire process, from scheduling their appointment to accompanying them home following the screening, which requires sedation,” says Percac-Lima.

The results have been impressive. In a study of 1,223 patients published in the February 2009 issue of theJournal of General Internal Medicine, Percac-Lima and colleagues found that 27 percent of patients assigned to a navigator underwent colorectal cancer screening in the first 9 months, compared to 12 percent who received no coaching. More precancerous polyps were discovered in the intervention group, a sign that the program might reduce risk of death. The patient navigator is currently approaching participants in the study’s control group who may be at risk for not getting screened.

“We’ve shown the program works and we have the numbers to prove it,” says Percac-Lima. Eventually, she plans to apply the same approach to breast and cervical cancer screenings throughout the Mass General community. “We just need the resources to do it,” she adds. “That’s our ultimate goal.”

In addition to the Chelsea HealthCare Center, Mass General offers world-class care at seven other convenient locations in Greater Boston.

Back to Top