Diabetes Education and Case Management (DECM)

Denton County Public Health (DCPH) has a longstanding history of providing preventative and clinical services to residents of Denton County, Texas. Denton County is the eighth largest county in Texas with an estimated population of 906,422 and 3.11% growth rate, according to the U.S. census data. Denton County is a community with diverse resources and engaged community partners, aiming to meet the community's needs with the vision of leading our communities to a healthier future. Currently, DCPH is one of eight local health departments in Texas to receive a national accreditation from Public Health Accreditation Board (PHAB), and one of four local health departments statewide with dual accreditation from PHAB and Project Public Health Ready (PPHR).  

Despite DCPH promoting and preserving sustainable community health through exceptional education, compassionate care, and quality of service, chronic diseases continues to be an area of concern. In Texas, diabetes is an epidemic being the 7th leading cause of death. According to the American Diabetes Association (ADA), approximately, 2,333,000 individuals in Texas have a diagnosis of diabetes, and 621,000 individuals have undiagnosed diabetes. Annually, there are about 162,000 newly diagnosed individuals with diabetes in Texas. The estimated cost of diagnosed diabetes in Texas is about $26 billion each year. Diabetes is a complex, chronic illness affecting most of the organ systems, leading to severe complications if not properly managed.  

As part of the Texas Medicaid transformation 115 waiver, the Delivery System Reform Incentive Payment (DSRIP) program has allowed DCPH to secure funding and develop a Diabetes Education and Case Management Program (DECM). DSRIP incentivizes DCPH to improve access and delivery of care targeting low income, uninsured individuals in Denton County. Diabetes is a chronic illness requiring continuous medical care, support, education, and self-management. The ultimate goal of DECM is to assist individuals with diabetes to acquire the knowledge, skills, and behaviors needed to maintain glycemic control and prevent health related complications. Patients enrolled in DECM are 100% low income; uninsured and about 94% are Hispanic/Latino, non-English speakers.  To heighten quality of life for patients living with diabetes and reduce healthcare costs associated with unmanaged diabetes, DECM established measurable program goals and objectives. 

1.       Reduce the proportion of adults with diabetes 18-75 years of age, who have a HbA1c value above 9% 

·         Provide culturally and linguistically diabetes education through Si Yo Puedo” Wisdom Control” in a group or individual setting  

·         Provide glucose meter, supplies and education 

·         Provide diabetes medication  

2.       Reduce patient 18-75 years of age biometric health indicators, blood pressure control <140/90mm Hg 

·         Provide blood pressure medication  

·         Provide blood pressure monitor for home testing  

3.       Reduce multiple patient visits by increasing in-house Point-of-care (POC) testing.  

·         Available POC testing: Retina Scan, Lipid Panel, Microalbumin, HbA1c 

Through DSRIP funding, DCPH and DECM have been able to provide access to care to underserved communities in Denton County. This funding has reduced out-of-pocket financial barriers for diabetes patients. Point-of-Care allows patients to receive the recommended test by the ADA in one visit, retina scan, lipid panel, microalbumin, HbA1c, and monofilament foot exam. Patients also receive their diabetes, blood pressure, cholesterol medications during the same visit at no cost to the patient.   

With continuous health care through primary care, diabetes health educators, community health workers, diabetes case managers, and community partners, DECM, has successfully accomplished every milestone, metric and goal. DECM focuses in providing patients with the tools needed to take control and increase self-confidence in maintaining a healthy blood pressure and blood glucose levels.  

The specific factors leading to the success of this practice were due to improving cultural competency, health literacy and community support. As about 94% of patients experience a language barrier, DCPH provides language accessibility for accurate communication with their medical provider. Furthermore, diabetes education being an important tool for successful glucose management, DECM utilizes Si, Yo Puedo” an exemplary community health program curriculum, recognized by the National Institute of Food and Agriculture (NIFA); targeting low-literacy Hispanic/Latinos with diabetes. In addition, community support, peer supporters, and community health workers is a vital strategy to improve health outcomes in diabetes management.  

Today, 78% of DECM patients have an HbA1c value below 9%, 44% have an HbA1c value below 7.0% as recommended by the American Diabetes Association, and 60% have reduced their blood pressure under 140/90mmHg.  

The website for Denton County Public Health is https://www.dentoncounty.gov/643/Public-Health. The website for Diabetes Education and Case Management is https://www.dentoncounty.gov/656/Diabetes-Education-Case-Management.   

Diabetes is a complex chronic illness, according to the CDC, about 34.2 million adults in the US and about 2.6 million adults in Texas have diabetes. Diabetes is associated with severe medical complications due poorly managed blood glucose levels, including, diabetic retinopathy that may lead complete vision loss. Other serious life threating complications include heart disease, stroke, end-stage kidney disease and amputations. While Denton County Diabetes rates are lower than the state and national average, diabetes remains the 7th leading cause of death. According to County Health Rankins and Roadmaps, 7% of Denton County residents identified diabetes as their major health condition.

For this practice, the target population are uninsured residents of Denton County between the ages of 18-75, low income, below the 200% federal poverty line (FPL), with a diagnosis of type 1 or type 2 diabetes. As 94% of DECM patients identify as Hispanic/Latino, non-English speakers, it is important to provide a systematic approach supporting patients' behavior change efforts. Empowering, supporting, coaching patients through culturally and linguistically self-management education. Providing access to care to underserved patients of DECM program has made an impact in improving their health outcomes.  

Furthermore, Point-of-Care testing has made it feasible for patients to obtain medical testing advised by the Standards of Medical Care in Diabetes, in clinic visit. Reducing multiple clinic/lab appointments, transportation, loss wages and compliance barriers. To increase overall quality of health, DECM provides diabetes medication/insulin, cholesterol and hypertension medications.  For patients unable to meet medication adherence, they are enrolled in a direct video observation program through eMocha, supervised by a diabetes case manager. In addition, patients are provided with a glucose meter and testing supplies to continue daily diabetes self-management.

Denton County does not have a County Hospital, leaving Denton County Public Health as the safety net provider for residents of Denton County. With the utilization of Wagner's Chronic Care Model, health care providers, case managers, health educators, community health workers and community health partners, Diabetes Education and Case Management program was established in 2013. The Chronic Care Model by Wagner was designed to improve and provide high quality chronic disease care. Elements include:

• Health System: Create a culture, organization and mechanisms to promote safe, high quality care.
• Delivery System Design: Assure the delivery of effective, efficient clinical care and self-management support.
• Decision Support: Promote clinical care that is consistent with scientific evidence and patient preferences.
• Clinical Information Systems: Organize patient and population data to facilitate efficient and effective care.
• Community: Mobilize community resources to meet the needs of patients
• Self-Management Support: Empower and prepare patients to manage their health and healthcare

Equally important, culturally appropriate diabetes prevention and self-management education is a vital tool for DECM. Si, yo puedo controlar mi diabetes!” is the cultural adaptation education curriculum of Do Well, Be Well with Diabetes”. Through this curriculum, DECM is able to provide culturally adapted diabetes self-management education by bilingual health educators.  Areas of focus include:

• Self-efficacy
• Social support
• Role Modeling
• Goal Setting
• Self-monitoring

Six session modules include:

• What is Diabetes?
• Checking your blood glucose levels
• Eating healthy with diabetes
• Be active with diabetes
• Medicines with diabetes
• Preventing diabetes problems

Denton County Public Health and Diabetes Education Case Management Program, provide a multifaceted approach to diagnose, treat and provide continuous diabetes management. The goals and objectives of the practice are the following:

1.       Reduce the proportion of adults with diabetes 18-75 years of age, who have a HbA1c value above 9% 

o    Provide culturally and linguistically diabetes education through Si Yo Puedo” Wisdom Control” in a group or individual setting  

o    Provide glucose meter, supplies and education 

o    Provide diabetes medication  

2.       Reduce patient 18-75 years of age biometric health indicators, blood pressure control <140/90mm Hg 

o    Provide blood pressure medication  

o    Provide blood pressure monitor for home testing  

3.       Reduce multiple patient visits by increasing in-house Point-of-care (POC) testing.  

 o    Available POC testing: Retina Scan, Lipid Panel, Microalbumin, HbA1c 

With ongoing health care through primary care, diabetes health educators, community health workers, diabetes case managers, and community partners, DECM focuses in providing support to patients' behavior change efforts. By providing culturally and linguistically diabetes education DECM patients have shown to improve self-management and improved glucose outcomes. Supplying the basic tools needed for glucose management, blood glucometer, testing strips and lancets, patients are ready to continue diabetes self-management at home. Through primary care and the assistance of case managers, health educators, community health workers, reducing patient biometric health indicators, blood pressure and increasing Point-of-Care testing is significant to diabetes management. Increasing retina scans, sensory foot exams with monofilaments yearly is part of Standards of Medical Care in Diabetes. Based on the results performed, data suggests the multifaceted case management model implemented is effective in reduction of HbA1c, resulting in cost aversion for common complications of uncontrolled diabetes. Furthermore, DCPH aims to continue furthering impact through synchronized video notification and compliance monitoring system for individuals having a difficulty following medication adherence, as it encourages accountability for medication management to overall improve quality of life and reduce markers of uncontrolled diabetes.

DECM follows standard procedures from Denton County Treasurer's office and Purchasing Department for the program's budget. Below is the summary of budget year 2021.

DENTON COUNTY DEPARTMENT BUDGET INQUIRY

Budget Year: 2021 Department: 37.70.12 (DIABETES CASE MNGMT PRGM DSRIP)

Fund: MEDICAID DSRIP PROGRAM FUND    Report Date: 12/23/2021 

Account                               Amended Amount             Actual Amount             Budget Balance        Percent Expended 

4020 Salary Assistants                   475,000.00                    465,282.56                           9,717.44                            98%

4060 Longevity Pay                            5,500.00                        5,065.00                             435.00                             92%

4085 Bilingual incentive Pay              4,500.00                         3,800.00                            700.00                           84.4%

4120 FICA                                        35,000.00                       33,766.15                         1,233.85                          96.5%

4130 Retirement                               65,000.00                      65,390.84                           -390.84                         100.6%

4140 Workers Comp                              800.00                          731.34                              68.66                           91.4%  

4150 Unemployment Insurance             500.00                          410.19                              89.81                           82.0%

4160 Health Insurance                    110,000.00                   110,000.00                                0.00                            100%  

4204 Administrative Supplies            45,228.00                       2,090.33                       43,137.67                            4.6%

4210 Mileage Reimbursement            1,000.00                          206.43                            793.57                           20.6%

4230 Postage                                         100.00                         175.31                             -75.31                         175.3%

4241 Administrative Equipment          3,500.00                         779.94                          2,720.06                          22.3%

4256 Technology Equipment              5,000.00                      2,085.00                          2,915.00                          41.7%

4320 Medical Supplies                   291,094.00                    79,561.19                       211,532.81                          27.3%

4350 Dues & Subscriptions               5,000.00                      1,325.00                           3,675.00                          26.5%

5010 Training and Education            5,000.00                             0.00                           5,000.00                            0.0%

6260 Wireless Services                    3,500.00                             0.00                           3,500.00                            0.0%

6661 Tech/Software Serv.              14,568.00                       9,110.08                          5,457.92                           62.5%

6865 Contractual Serv.              1,541,521.00                   703,258.18                      838,262.82                           45.6%

8005 Capital Equipment                     980.00                           980.38                                  -.38                         100.0%

TOTAL                                      2,612,791.00                  1,484,017.92                   1,128,773.08                          56.8%

Without DSRIP funding DECM would have not been possible. Successfully achieving goals and objectives through collaboration of DCPH, was an important asset to the success of the practice. Overall, the importance of case managers, health educators, community health workers who are able to understand each patient and make a connection while respecting their cultural beliefs was also vital to the success of the practice. Over the past 5 years, we have seen a series of changes to DECM. The practice began in only focusing in high risk diabetics with a HbgA1c above 9%, we evaluated and recognized, to make a difference in the population and prevent further complications, focusing on treatment at an early stage would be beneficial for patient health outcomes.

Through eClinicalWorks an Electronic Medical Records (EMR), patient data was recorded by medical staff. Electronic medical records provide accurate, up-to-date patient information, following HbA1c, blood pressure trends/improvements. A diabetes registry is maintained with information obtained through EMR, in order to track practice objectives and utilize this information to report to DSRIP.

Furthermore, DCPH developed a Health Equity Council to assess, develop, and implement health equity best practices as a core commitment to our staff and community. DCPH-HEC provides an opportunity for strategic community partnership between Public Health, service providers and the residents of Denton County. This collaboration allows for better health services to improve diabetes health outcomes as it relates to our program.

Understanding the community we serve is vital for the success of the DECM program. DCPH is the safety net for the low income uninsured residents of Denton County and patients are not refused services due to financial hardships. Over the past years, we have seen a series of changes in our program. Majority of patients at DCPH and DECM are non-English speakers. To address the language barrier and maintain healthcare accuracy a Case Manager and/or access to a language line is provided during patient's clinic visits and services.  This provides the patient with trust and confidence to take part in their health to receive treatment and recommendations in their native language. Additionally, understanding their health may not be a priority, as the majority of the population we serve are low income, missing work is not ideal. To eliminate multiple clinic appointments, a series of POC is offered to provide patients with access to care during the same clinic visit. In collaboration with Texas AgriLife Extension Office, patients were able to receive a wide range of education classes. Though these classes were successful in empowering patients, a lesson learned was there is still a need for bilingual partners in order to address the language barrier. Through the DECM program, we were able to provide translation services for the education classes. In collaboration with The Lions Club, we were able to provide patients with assistance for prescribed eyeglasses. This was a highly needed service as there are not many programs in the area that are able to provide this assistance. However due to The Lions Club funding during the pandemic, this service is currently on hold.

Current sustainability plans for DECM program include approval for an additional year of DSRIP funding. Throughout the years, a percent of the funding has been set aside in order to sustain the program for the next five years as is. For future sustainability, additional funding sources will be reviewed upon availability.