Patients with a limited understanding of health issues and poor command of English often fail to receive appropriate medical care. Studies have shown that these patients have problems accessing care and receive lower-quality care. Such problems arise in part due to inadequate clinician-patient communication and insufficient patient support. In response to the needs of this population, the Improving Diabetes Efforts Across Language and Literacy Project (IDEALL) was developed at the Community Health Network of San Francisco, with support from The Commonwealth Fund, The California Endowment, and the Agency for Healthcare Quality and Research. Two forms of support, automated telephone diabetes management and group medical visits, were implemented for a group of patients with poor control of Type 2 diabetes. The results of the intervention have been quite promising.
Organization: University of California, San Francisco
Date of Implementation: June 2003
Target Population: Patients with low health literacy and/or limited English
The issue: Patients who have a limited understanding of health issues and struggle to comprehend English often fail to receive appropriate medical care. Studies have shown that these patients have problems accessing care and receive lower-quality care across a range of clinical settings and conditions. It also has been demonstrated that such problems arise in part due to inadequate clinician–patient communication and insufficient patient support.
The intervention: In response to the needs of this population, the Improving Diabetes Efforts Across Language and Literacy Project (IDEALL) was developed at the Community Health Network of San Francisco. Two forms of support, automated telephone diabetes management and group medical visits, were implemented for a group of patients with poor control of Type 2 diabetes. Patients receiving the automated telephone diabetes management intervention are called each week at their preferred time for a period of nine months. At this time, they complete a survey in English, Spanish, or Cantonese that includes a rotating set of about 15 items on many aspects of diabetes self-care.
The first question on week one, for example, asks "In the last seven days, how many days did you test your blood sugar by pricking your finger?" If a patient enters "0," they will receive a call back from a care manager or health educator within 24 to 48 hours after the patient's daily report is obtained. Those entering "0 to 2" are told that, "Testing your blood sugar lets you know if your blood sugar is too high or too low. You should write these numbers down and talk to your doctor about them. A good time to test your blood sugar is before meals. At least check your blood sugar every morning. It's never too late to start!" Those entering "3 to 6" are told "Keep up the good work! Testing your blood sugar helps you control your diabetes. A good time to test your sugar is before meals. At least, check your blood sugar every morning. If you can, write down your numbers and show them to your doctor at your next visit." An entry of "7" or more results in a simple "Great."
Most health education messages are provided in the form of patient narratives, not instructions. There also are detailed guidelines for these calls. Care managers and health educators are reminded that education is essential. Patients need to understand why clinical guidelines exist, why they should care about reaching those goals, and how they can bring about change. It is also important to establish clinical and non-clinical goals for each patient, breaking them into steps that are obtainable in the short and long term. These goals should be set by the patient and could range from eating three tortillas less a week to checking blood sugar levels two times a week. If possible, patients' families as well as the patients themselves should be encouraged to become engaged in the process.
The other intervention, group medical visits, involves a series of nine monthly, two-hour meetings. These sessions, unlike traditional, didactic diabetes education, evolve from patient experiences, guided discussions, and patient-identified goals. As with the telephone intervention, the ultimate goal is to improve self-management skills. Visits are led by two health providers, a bilingual nurse or physician and a bilingual health educator, and attended by 12 to 15 patients. A bilingual pharmacist also is available at the end of the group visit to review adherence to medications and any necessary regimen changes.
The group visits begin with a 30-minute check-in, where patients discuss their symptoms, needs, and progress towards their goals, followed by a 45-minute group learning session, 30-minute break-outs with providers for patients who need more care, and a 15-minute wrap-up. Typical group topics include glucose monitoring and initiating exercise, exercise and relaxation, nutrition and diet basics, nutrition and cooking or shopping demonstration, monitoring medications, foot care, and risk reduction and access to care. Initially, patients should be encouraged to develop action plans, followed later on in the process by more formal goal setting.
Preliminary results from the first phase of the IDEALL project suggest that these interventions generate significant patient engagement in care and clinical activity, including education, counseling, medication changes, and action plans. Thus, it's thought that it might be feasible to add these interventions to the primary care of diabetes patients who are receiving care in a safety net setting. The second phase of IDEALL is currently underway. It aims to expand the project and measure and compare the impacts of the telephone and group visit interventions. In particular, this phase of IDEALL will evaluate patient enrollment, patient engagement, diabetes outcomes, and resource use. It is expected that the project will increase awareness of the health care barriers faced by minorities and improve practices, clinical care, and outcomes for this population. The links on the right allow you to download the training guide for group medical visits and sample protocol for automated telephone calls. For more information, please contact Dean Schillinger, M.D., University of California at San Francisco, associate professor of clinical medicine, San Francisco General Hospital.
