Blueprint Available for a Successful Diabetes Self-Management Education Program
A program study of the successful diabetes program at the Bay Clinic, Inc., in now available. The Development of a Diabetes Self-Management Education Program at the Bay Clinic, Inc.: a Program Study was funded by the Charitable Mentor Fund of Boston that intends to use the document as a blueprint to assist other community health centers to start similar programs in other multi-cultural communities.
HIThe Bay Clinic, Inc., is a nonprofit, federally qualified community health center on Hawai‘i Island. It is part of the national health safety net for low income, uninsured and medically under-served populations. Community health centers are among the most cost-effective federal programs. They effectively keep medical costs low while delivering excellent evidence-based health care and meeting top national standards. Bay Clinic’s groups are among the hardest hit by diabetes.
HIIn 2009, the federal government ranked the Bay Clinic first among 44 rural facilities nationwide for its service to people with diabetes. During fiscal year 2009, the rural clinics joined a health care quality improvement initiative run by the Health Resources and Services Administration’s Division of Rural Policy. The Bay Clinic ranked first because its patients had the most improvement in A1C blood glucose percentage from 8.1% to 7.8% across all patients for the year. The normal range of the A1C is 4 to 6%. The A1C blood test gives a picture of the glucose level in a person’s blood stream for the past few months.

A series of classes, then long-term support groups
The focus of the Bay Clinic program has been the series of eleven weekly classes it has offered people diagnosed with diabetes since 2004. The classes follow guidelines developed by the American Diabetes Association. The classes are followed by long-term support groups that meet weekly.HI HI HI HI HI HI HI HI HI HI I HI HI HI HII HIA recent survey compared 13 people in the long-term support group from their start at the Bay Clinic to their outcomes in October 2009. When the participants entered the program their A1Cs averaged 8.11%; in 2009 the average was 6.42%. All 13 attended the Diabetes Self-Management Education classes and continued as members of the Warriors Against Diabetes long-term support group. Average time attending group sessions is 30 months.
HIParticipants can interact with providers after each session if they wish, about any health problem. The program is now available at all four of the Bay Clinic’s Family Health Centers.

Charlotte Grimm, an Advanced Practice Registered Nurse (APRN), and co-author of the Program Study, is responding to questions posed by members of a diabetes class. Grimm is the Director of Clinical Operations of the nonprofit Bay Clinic, Inc. and helped create the diabetes program. In front of her on the table are many healthy diabetes-friendly foods created by class members that were brought for a potluck. Participants in the classes have access to many different health care professionals on a regular basis and after class may consult with them privately if they care to. Stacy Haumea is shown on the right. She is also a co-author of the report, is a Registered Dietitian, a Nutritionist, a Certified Diabetes Educator and is the Director of Diabetes Education at the Bay Clinic.

On the First Wednesday of each month all the Bay Clinic's diabetes classes meet at Wailoa River State Park in Hilo from 9:30 to 11:30 a.m. The public is invited. There is a speaker of general interest, a lesson from the series of diabetes classes offered by the Clinic, an exercise routine led by community volunteer Hannah Hedrick (in red) who is in the photograph leading the group in what she calls jigga, jigga, a routine to get people to vigorously rub each other's backs and shoulders. Hannah is inspiring because, besides her charming personality, she is 70 years old, has had two hips and a femur replaced and suffers from arthritis. Hedrick and the Bay Clinic Warriors group are working to create an exercise video. Hedrick and Tom Whitney are advocates of self-help groups to deal with diabetes. Following the exercise routines is a huge potluck in which usually about forty people bring diabetes-friendly foods to share.

HIBay Clinic supplements very brief acute-care, one-on-one doctor patient interactions with a team of health care providers focused on empowering patients to self-manage their treatment of their own diabetes. This is a big shift in health care for chronic illness. The term within the health care profession for this is the Chronic Care Model. It requires a re-thinking of roles by everyone in the health care professions to now place the patient on an equal level with the health care professionals as an expert in managing their own care.
HIOne of the support groups calls itself the Warriors Against Diabetes which includes participant advocates who reach out to involve the public in monthly meetings in a beautiful local park with the theme: Living the Sweet Life Healthy – and having fun doing it!

This is a poster placed on the walls of the five Bay Clinic waiting rooms. It gets across the idea that food choices are a very important part of the solution to problems with diabetes and an important part of the program.

HIThe program has been successful in engaging hard-to-reach Pacific Islander populations. Classes are also offered for people who speak the language of the Marshall Islands and for those from the Island of Truk in the South Pacific.
HIThe Bay Clinic is operating the program effectively with non-physician health care providers: Advance Practice Registered Nurses, Physician Assistants, Registered Dietitians and Behavioral Health staff. A physician is available for consulting.

Getting a program started
To establish a self-supporting diabetes education program like the Bay Clinic’s, (where staff time for the education will be paid for by health insurance companies and Medicare) an entity must become certified by the American Diabetes Association (ADA). When this is achieved, all health insurers are likely to allow billing for diabetes education services. In Hawaii it was finally discovered that providers do not have to be Certified Diabetes Educators (CDE). The Hawaii Medical Service Organization position was that that staff did not have to be CDEs, but they had to be eligible to be CDEs. This new arrangement from HMSA gave the Bay Clinic’s diabetes program the ability to bill for education by a Registered Nurse, a Registered Dietitian, a Medical Doctor and an Advanced Practice Registered Nurse, all professions that are eligible to become CDEs. Years later, at the time this report was written, Stacy Haumea, who is the Director of Diabetes Education at the Bay Clinic and is a Registered Dietitian, has become a Certified Diabetic Educator. While the ADA application process is underway, health providers are able to bill for medical consultation services that are provided after the diabetes classes.
HIOne of the program’s goals was financial sustainability through revenue collected for diabetes education services rendered. The Clinic achieved this in 2009. Grant funding helped sustain program costs until certification was received. This involved obtaining grants and assistance from local health insurers, pharmaceutical companies, foundations and food stores. Each step in the process is described in the Program Study.

To to To understand their daily patterns of food, water and exercise, many people find it helpful to keep a detailed diary for a few weeks or longer as Pearl Kadota shows us. As part of learning to take care of themselves and their diabetes, in the middle photograph Kenton Aichele is taking Jim Foxworthy's blood pressure before the start of a support group meeting.

The Complete Program Study is available only on Bay Clinic Diabetes DVDs To obtain the two Program Study DVDs as described in this text, send $15 for the Diabetes Program DVDs to the Bay Clinic, 224 Haili Street, Suite B, Hilo, HI 96720, attention Monica Adams. This will cover disc duplication, labeling, and postage. mi mi miAvailable here and on the DVDs from the Bay Clinic are the Procedures and Forms the Bay Clinic has created to implement the program. This section is a detailed guide to create a program, along with the Program Study. Other items available here are a Basic Diabetes Library list, and Internet Resources for Diabetes. Included on the DVDs are a copy of the original Quality Improvement Plan with a 2009 update showing how the Clinic has implemented the Chronic Care Model, copies of a diabetes program proposal and final report to the funder, a Bay Clinic Brochure, sections that include news and magazine articles about the program, and all Bay Clinic PowerPoint presentations about the program.
HIIn addition, a section on graphics is available on the DVDs. One of the patients created a vegetable alphabet that Bay Clinic is using to create posters for the monthly meetings in the local park. It was also used to create the Warriors Against Diabetes logo. Since food is an important part of the solution to diabetes, other diabetes programs may want to use the alphabet. The group has t shirts available with the Warriors logo.
HIAlso available on Diabetes DVD 2 from the Clinic is a session showing the visit with the Warriors in 2008 by Dr. Richard Jackson of the Joslin Diabetes Center in Boston and an interview by Charlotte Grimm of Dr. Dijon Lim, a Hilo cardiologist talking about the relationship of heart disease and diabetes. Diabetes DVD 1 contains the Program Study and the items described above, for those who cannot download the information over the Internet.
HICo-authors of the study include Tom Whitney, a writer and diabetes patient at the Bay Clinic; Charlotte Grimm, an Advanced Practice Registered Nurse who helped start the program and is Director of Clinical Operations at the Bay Clinic; Stacy Haumea, Nutritionist, Registered Dietitian and Certified Diabetes Educator who is the Director of Diabetes Education at the Clinic; and Monica Adams, a mental health counselor who is also the Development Director at the Bay Clinic.
HIThose with more questions about the study can contact Monica Adams at (808) 961-4080 or by email at madams@bayclinic.org.

Short Summary of Bay Clinic's Diabetes Self-Management Education Program Highlights
1. The Program Summary and the Bay Clinic Diabetes DVD offer a blueprint of the diabetes program developed at Bay Clinic, Inc., that could be applied in other multi-cultural communities.

2. Bay Clinic, Inc., is a nonprofit, Federally Qualified Community Health Center on Hawaii‘i Island. Bay Clinic is part of the national health safety net for low income, uninsured and medically under-served populations.

3. In 2009, the federal government ranked the Bay Clinic first among 44 rural facilities nationwide, including one run by the Mayo Clinic, for its service to people with diabetes. During Fiscal Year 2009, the rural clinics joined a health care quality improvement initiative run by the Health Resources and Services Administration’s Division of Rural Policy. The Bay Clinic ranked first because its patients had the most improvement in HbA1C blood glucose percentage from 8.1 to 7.8 across all patients for the year.

4. Community health centers are among the most cost-effective federal programs. They are good at keeping medical costs low while delivering excellent evidence-based health care while meeting top national standards.

5. Bay Clinic supplements brief acute-care, one-on-one doctor patient interactions with a team of health care providers focused on empowering patients to take control of managing disease, especially chronic disease. This is a big shift in health care for chronic illness.

6. For diabetes, the Bay Clinic approach is to offer 11 weeks of classes followed by long-term weekly support groups. Participants can interact with providers after each session if they wish, about any health problem.

7. One of the support groups is the Warriors Against Diabetes that includes participant advocates who reach out to involve the public in monthly meetings in a beautiful local park with the theme: Living the Sweet Life Healthy – and having fun doing it! The program has been successful in engaging hard-to-reach Pacific Islander populations. The Warriors web page is here: http://www.tomwhitney.net/DiabetesAdvocacy.html

8. The Bay Clinic is operating the program effectively with non-physician health care providers: Advance Practice Registered Nurses, Physician Assistants, Registered Dietitians and Behavioral Health staff. A physician is available for consulting.

9. One of the program’s goals is financial sustainability through revenue collected for education services rendered. To achieve this, programs must become certified by the American Diabetes Association. Grant funding helps sustain program costs until certification is received.

Brief Outline of Initial Steps to Implement a Program
Similar to the Bay Clinic Diabetes Program
To establish a self-supporting diabetes education program like the Bay Clinic’s, an entity must become certified by the American Diabetes Association (ADA). When this is achieved, all health insurers are likely to allow billing for diabetes education services. While the ADA application process is underway, health providers will be able to bill for medical consultation services that are provided after the diabetes classes. Becoming certified requires applying to the ADA and beginning to deliver a diabetes self-management program consistent with the ADA policies. Local funding will be needed to support the education program, a dietitian and the food purchases until it can exist entirely by billing for services. This will involve obtaining grants and assistance from local health insurers, pharmaceutical companies, foundations and food stores.

1. Apply to the ADA. The website for complete information for organizations seeking recognition by the American Diabetes Association to operate Diabetes Self-Management Education programs is:
http://professional.diabetes.org/Recognition.aspx?typ=15&cid=57996

2. Item 2 on the Bay Clinic Diabetes DVD and available above contains the Procedures and Forms the Bay Clinic has developed to implement the program. This is a detailed guide to create a program, along with the narrative tin the Program Study document.

3. This new approach to chronic disease management is different than typically brief acute-care sessions. It requires adjustment by all health care providers to include the patient as the most important part of the health care team. An excellent introduction to this is provided in the book The Art of Empowerment, by Bob Anderson, EdD, and Martha Funnell, MS, RN, CDE. Equally important is becoming familiar with the Chronic Care Model. Try here: http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/HowToImprove/

4. Use grant-writing resources for fund development. There are many useful papers published by the Grantsmanship Center in Los Angeles, important for both fund raising and obtaining grants from foundations and the federal government. The Center also offers highly regarded training in cities around the country. Many funding sources have adopted and approve of the Center’s methods. Visit the Center’s website: http://www.tgci.com/about.shtml. For their publications go here: https://www.tgci.com/publications.php.

This poster was created using graphics available in the public domain at WikiMedia Commons. In Google, search using these words: Human Body Diagrams - Wikimedia Commons Anyone is welcome to use our words here and insert a photograph of someone who is member of their community. We heartily give credit to Norwegian medical student Mikael Haggstrom for creating the project. At Haggstrom Diagrams you can see more examples of medical diagrams freely available for use by anyone.
Ali‘i Kimo Pihana is the person in this photograph by Tom Whitney. Mr. Pihana made this statement included on the photograph: "If my posing here at age 67 in my malo can help more people think about getting checked for diabetes, I am all for it. Our people are fighting against it. My own family has the problem. It affects my children. We need to be willing to talk openly about our health problems. We all need to be warriors so we can overxcome our fear of shame and protect our families. Count me in as a Warrior Against Diabetes."