Socioeconomic Challenges in Diabetes - Ningapi.ning.com/files/-*rf1dO92wwRu08SxlOsZ7Cx6X... ·...

All Rights Reserved©2015 International Diabetes Center

Socioeconomic Challengesin Diabetes

Janet Lima, MPH, RN, CDEDiabetes Nurse Specialist, IDC

The Early 80sA different healthcare climate

• Two medical specialties seeing same patient may have ordered same lab test

• To start insulin: Patient admitted to hospital for 2‐4 days for education

• Costly “Primary Nursing” model dominated hospital care

• “Total knee replacement”: Admitted 2 days early for pre‐op teaching!


Today…

• We are all health care consumers‐‐more cost passed on to us

• Co‐pays and deductibles—the norm

• Persons with diabetes have additional health care expenses (Total cost of diagnosed diabetes in the U.S. in 2012 was $245 billion¹ ‐‐‐ up from $174 in 2007)

• Diabetes supplies, education, and medications essential to managing diabetes optimally and preventing costly complications.

. As educators, we are often asked to assist patients in finding what they need

¹American Diabetes Association: Economic costs of diabetes in the U.S. in 2012. Diabetes Care April 2013 36: 1033‐1046

Objectives

Discuss how socioeconomic issues impact diabetes care:

Define and discuss socioeconomic barriers to diabetes education and self‐management

Identify strategies & resources to address these barriers

Identify insurance options for uninsured and underinsured persons with diabetes


Socioeconomic Barriers to

Diabetes Self‐Management

Transportation

Employment/

Financial Status

Familial/social

support

Language proficiency

Health Literacy

Numeracy

Psychological Status/

Hx PTSD

Culture

Organizational Skills

Immigration Status

Level of Formal

Education

Family/Work Responsibilities

Insurance status

Copay/Deductible

Poverty

Homelessness

Barriers to Diabetes Education

• Culture & language proficiency

• Health literacy and numeracy

• Psychological status/history of PTSD

• Socioeconomic, insurance & transportation issues

• Time constraints due to family/work responsibilities


Health Literacy

Is the ability to: read health information understand health information use it effectively

Can be assessed with standardized tests Literacy skills can be 3‐4 grades below educational level Patients may hide their literacy problems

Average American reads at 8th‐9th grade level*

*Dianne Davis RD, LDN, CDE, Vanderbilt University Diabetes Center

Health Literacy: A widespread issue

• Most people with limited health literacy skills are white, native‐born Americans

• Higher‐risk groups:• Over age 65

• Less education

• Ethnic & racial groups

• Limited English proficiency

• Poor or near poverty

8


Health Literacy Facts

• Greater than 1/3 of English‐speaking patients have low health literacy

• Patients with the greatest healthcare needs may have the least ability to read & understand information needed for optimal self care

• Inadequate health literacy may negatively influence health outcomes

Williams et al.1998, Gazmararian et al. 2003

American Medical Association 1999

Williams et al. 1998

Numeracy

Is the ability to: Use math skills

Recognize numbers

Understand number sequences

Needed for DSMT: Blood glucose goal ranges Record keeping, carb counting Insulin dosing

According to the US Department of Education*, 55% of US adults have numeracy literacy skills that

are at a basic level or below

* 2003 National Assessment of Adult Literacy (NAAL), US Dept of Education


Case Example: Struggling with Numeracy

• “Ruth”: 64 y/o African American woman

• 19 diabetes education visits since 2005

• A1c range of 7.4%‐10.5% since 2008

• Current regimen: 20 units background BID; 12 units mealtime breakfast & dinner plus correction factor

• Very talkative, gets off track

• May forget insulin doses, difficulty with carb counting

• Unable to accurately add correction factor to mealtime doses

• “My eyes are tired & dry. I can’t see the numbers very well.”

Case Example:Ruth’s Current Regimen

Background insulin: 20 units BID

Mealtime insulin: 12 units breakfast & dinner (doesn’t eat lunch)

Correction Factor (Sliding Scale)

Blood Sugar Mealtime Insulin Dose

151‐200 Add 2 units





Suggestions for Ruth?


Case Example: Struggling with NumeracyPossible Solutions for Ruth

Blood Sugar Insulin

Less than 150 12 (Your base dose)

151‐200 14

201‐250 16

251‐300 18

301‐350 20

351‐400 22

OR Consider a regimen change

What dose of mealtime insulin should she take if pre‐meal glucose is 221?(Base mealtime dose: 12 units)

A. 12

B. 14

C. 16

D. 18

E. 20

Correction FactorBlood Sugar Insulin

151‐200 Add 2201‐250 Add 4251‐300 Add 6301‐350 Add 8351‐400 Add 10


Education Suggestions

• Focus on critical behaviors • Decrease complexity of information

e.g. Hand or plate method for portion control.

• Avoid the use of technical termse.g. “hypoglycemia” or “monitor”

• Use the “teach back” method. e.g. “Show me how much rice you will eat at supper tonight”

Beach, et al, Journal of General Internal Medicine, 2007;

LEARN, www.DiversityRx.org

Utilize the Right Visuals

• Tailor materials to the individual

• Use materials in patient’s first language when possible

• People of higher literacy may prefer lower literacy materials (pictures, less text)


Psychological StatusPost Traumatic Stress Disorder (PTSD)

• An anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.

• Can result from any history of abuse or traumaImmigrantsMilitary Verbal or physical abuse (domestic, workplace, community)A catastrophic event

National Institute of Mental Health (electronic reference)

PTSD

• Medical, psychiatric & social consequences

• A significant barrier to seeking and receiving care

• Can impact diabetes self care (testing, injecting)

• Smoking, alcohol use and overeating may be coping strategies for stress management

• Know when to refer (The Center for Victims of Torture)


Audience Participation

• Find 3‐4 people sitting near you

• Identify 7 events starting with letter “D” that could significantly change your lifestyle in a short period of time

Many Faces of Community Health Conference, October, 2007

Terie Dreussi Smith, M.A. Ed. aha! Process, Inc.

Possible Answers

• Death

• Divorce

• Disease

• Deployment

• Domestic abuse

• Disability

• Dismissal

• Desertion

• Depression

• Debt

• Delinquent Mortgage

• Disaster

• Dismemberment

• Deportation

• Dementia

• DUI


Generational Poverty

• Poverty for at least 2 generations

• Survival orientation

• Future orientation less common (may not be thinking about complications)

• Lifestyle more chaotic

• Distrust of authority and institutions

Many Faces of Community Health Conference, October, 2007Terie Dreussi Smith, M.A. Ed. aha! Process, Inc.

Situational Poverty

• Lack of resources due to a particular event

• May be reluctant to accept help, charity

• May not be as familiar with social service resources

• Usually bring more social/educational resources

Education

Social support

Decision‐making ability




Persons With Socioeconomic Challenges

• May not feel part of the culture. “I’m dodging bullets and you want me to eat a pear?”

• May be thinking, “What benefit will I get right now?” “If it ain’t broke right now, why fix it?”

• Limited resources may be a barrier to achieving optimal health & fitness.

• May be working >1 job; Challenged to find exercise and food preparation time.



Physical Activity

• Previously active in homeland

• Now less active in US.– Weather

– Availability of transportation

– Neighborhood safety

• Work with patients to facilitate low‐cost activity strategies. Think outside the box!Ex: Some YMCAs offer scholarships (Transportation not provided)


Meal PlanningFinding/Preparing Healthy Food on a Budget

• Barriers

Cost, preparation time, availability of nutritious foods

Messages about healthy eating: confusing

Lack of information regarding healthy eating

Poor role modeling

Limited access to nutritional information

Low literacy, language barriers

Meal PlanningFinding/Preparing Healthy Food on a Budget

• Possible solutions

Coupons, comparison shopping, food shelves

Aldi—Very low prices, including fruits/vegetables

For produce: Shop in season, shop specials

“Fare for All”: Twin Cities, MN, some WI cities

Everyone welcome

EBT* (Electronic Benefit Transfer), debit & credit cards accepted, 40% < grocery store prices

Hungersolutions.org*EBT cards allow state welfare depts to issue benefits via an encoded

payment card.


Diabetes Supplies and Insurance

Key Facts Regarding the Uninsured Population

• Prior to Affordable Care Act (ACA) > 41 million uninsured (2013 data)• ACA expands coverage for currently uninsured people through:

Expanded Medicaid eligibilityEstablishment of Health Insurance Marketplaces

• Evidence suggests the ACA has reduced # of uninsured• High cost of insurance & job loss: Major reasons people go without coverage• Most uninsured: In low‐income working families • People without insurance: Worse access to care than those insured • In 2013, almost 30% of uninsured adults went without needed medical care due to

cost• Uninsured often face unaffordable medical bills—can lead to medical debt

Kaiser Family Foundation. (2014, October). Kaiser Commission on Medicaid and the Uninsured. Retrieved from www.kff.org


Affordable Care ActHHS.gov/Healthcare

Signed into law by President Obama 3/23/2010

A website for each state

For people without any insurance

If a person qualifies for Medical Assistance through county or state, can sign up anytime

As of 2014, individuals not covered by employer insurance can buy it directly through the Health Insurance Marketplace

Health Insurance

• Private insurance

www.einsurance.com on‐line tool

State high risk pools• Medicaid programs

State Department of Human Services websitesUnited Way 2‐1‐1

• Organizational assistance programs

Ex. St. Mary’s Health Clinics http://www.stmaryshealthclinics.org/

• Community Clinics/Sliding‐scale Clinics


Health Insurance

• Medicare www.Medicare.govMedicare savings program

Refer to Department of Human ServicesMay pay for the following:

Part B premium Part A premium, if any Copays and other health care costs that Medicare does not cover

Part DRefer to Social Security Administration

“Extra Help” with prescription drug plan

Case Example: Georgia

• 45 y/o native of Liberia

• Inconsistent employment as a nursing assistant

• Cycles of insurance

• Doesn’t fill prescriptions or visit provider during times of unemployment/no insurance

• Supports family in US and sends money to Africa

• Taking care of self becomes low priority

• Presents with A1c of 12%, no insurance, needs insulin


Solutions for Georgia

• Refer to social worker

• Have patient apply for charity care & state health insurance programs

• Consider generic glucose monitor & generic insulin

• Refer to care coordinator/health support nurse for follow up (can see patient ongoing at no charge)

Medications: Generic Programs

Oral diabetes medications currently included in the generic programs (subject to change)*

Insulin: $25 per vial

Glimepiride Metformin

Glipizide Metformin XR

Glyburide

ReliOn generic insulin

Novolin R, Novolin N, Novolin 70/30

Only at Wal‐Mart or Sam’s Club

*National Conference of State Legislatures. Generic Drug Pricing and States $4 and free drug promotions by large chains affected by state laws. January 2009, www.ncsl.org.


Medications: What the provider can do

Prescribe a generic if possibleRefer to pharmacies with $4 generics lists

Costco & Sam’s Club: Don’t need membership to use

Complete a prior authorization if appropriate

Apply for patient assistance programsNeedyMeds (www.needymeds.org)

Encourage patients to shop around

Medications—Generics*pricing subject to change

Pharmacy Price Yearly Fee Note

Walgreens $5‐$15 30 day$10‐$30 90 day

$20/person$35/family

Costco Varies by location $50Free for members

Membership not required

CVS $11.99—90 day $15/person

Kmart $5—30 day$10—90 day

$10/person

Target $4—30 day$10—90 day

Free

Walmart $4—30 day$10—90 day

Free

Sam’s Club $4—30 day$10—90 day

Free Membership notrequired


Insulin Assistance Programs

Company Website Medications Offered

Eli Lilly www.lillytruassist.com Humalog, Humalog 75/25,

Humalog 50/50, Humulin R,

Humulin N, Humulin 70/30

Novo‐Nordisk

www.cornerstones4care.com NovoLog, NovoLog Mix 70/30,

Novolin R, Novolin N,

Novolin 70/30, Levemir

Sanofi‐Aventis

www.sanofi.us/l/us/en/layout.jsp?scat=FA582E76‐C4AF‐453B‐BE47‐228829600888

Apidra, Lantus

Diabetes Supplies

• Patient assistance programs

– NeedyMeds (www.needymeds.org)

• Generic glucose monitor and test strips

• Comparison shop

• Utilize coupons/special offers

• Consider 90‐day mail order


Diabetes Supplies: Utilize DME Benefit

Offered by many payers

Patient can often use any meter

Can help patients avoid “donut hole”

Some vendors are a DME supplier & a pharmacy

“My car broke down a week ago. I don’t have the money to fix my car, and as a result can’t make it to my clinic for an appointment.”


Transportation

Public transportation system

• http://metrotransit.org/ (MN)

• Your state transit system

Community transportation

• City, non‐profit organizations

Social support network

• Family, friends, religious

organizations

United Way 2‐1‐1

• www.211.org

Metro Mobility (MN)

•Or your state transit program

TransitLink• http://www.metrocouncil.org/trans

portation/TransitLink/index.htm

Senior Linkage Line:

1‐800‐333‐2433

Transportation Resources

Medical transportation coverage available through Medical Assistance

Public Transportation System

Medical rides for low cost

Social support network

United Way 2‐1‐1

Some home care agencies

Staff member travels with patient, takes notes

A fee is charged


Transportation Services for Disabled and/or Elderly Individuals

• Metro Mobility or your state program

• Low cost community transportation

• Social support network

• TransitLink

• United Way 2‐1‐1

• Senior Linkage Line: 1‐800‐333‐2433

When In Doubt: Call United Way 2‐1‐1

What is 2‐1‐1?The number that connects people to community services and volunteer opportunities…

It’s free, confidential information 24 hours a day.

How do I find my local 2‐1‐1 number?Go to this website: www.211.org


Services of Religious & Community Organizations

Food shelves, social services, transportation

Shelter and meals for the homeless

Salvation Army

Care ministries, parish nursing programs

Health demonstration projects, support groups, counseling

Catholic Charities

Encourage patients, if capable, tostay organized and do their research……

• If possible, shop around

• Understand coverage

• Ask questions

• Request generics whenever possible

• Use mail order pharmacy service

Organize health care information

Write questions down

Review all bills & statements for accuracy

Stay current with provision of necessary documents/income info


Going Beyond the Healthcare Setting

Bring community members and health professionals together

Collaborate, integrate services, team up

Consider government grants and private sources for funding pilot projects

Let’s Not Forget Our Mission……

Ensuring that every individual with diabetes or

at risk for diabetes receives the best possible care


Additional Resources

• North Dakota Department of Human Services– http://www.nd.gov/dhs/

• Wisconsin Department of Human Services – http://www.dhs.wisconsin.gov/health/diabetes/consumer.htm#medication ‐

• Iowa Department of Human Services– http://www.dhs.iowa.gov/

• South Dakota Department of Human Services– http://dhs.sd.gov/ ‐

• Minnesota Department of Human Services– http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_

CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=Health_Care


• North Dakota Community Action Partnership

– http://www.capnd.org/programsservices/health.htm

• Iowa Diabetes Resource Guide

– http://www.idph.state.ia.us/hpcdp/common/pdf/diabetes/dir.pdf

Portico Health Net (MN)

• http://www.porticohealthnet.org/index.php

• United way 2‐1‐1

– http://www.211.org/



• https://www.idph.state.ia.us/hpcdp/diabetes_resource_directory.asp (Iowa)

• http://www.dhs.Wisconsin.gov/diabetes/consumer.htm (Wisconsin)

• http://www.diabetesnd.org (North Dakota)

• http://www.sddiabetescoalition.org/Resources/Diabetes‐Education.aspx (South Dakota)

• http://www.tudiabetes.org/notes/Diabetes_Patient_Assistance_Resources

For Refugees:

US Committee for Refugees & Immigrants: www.refugees.org

Office of Multicultural Services‐Hennepin County (MN)

www.hennepin.us

References

• “Eat Well on a Budget: 15 Money‐Saving Tips.” Today’s Diet & Nutrition Sept. & Oct. 08:66. Print

• http://www.extension.iastate.edu/foodsavings/prepare

• Web MD. Kathleen M. Zelman. Web.27 Mar. 2010.

• www.healthlit.themlc.org

• www.mn‐dc.org

• http://aspiruslibrary.org/literacy/SAM.pdf (can be helpful when developing your own materials)

• http://www.fda.gov/opacom/lowlit/englow.html

• http://www.nlm.nih.gov/medlineplus/healthtopics.html (click on easy to read)

• http://diabetes.niddk.nih.gov/dm/a‐z.asp

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