Introduction
Type 2 diabetes Mellitus (T2DM) inflicts over 6% of the population in the United States with another 5% having pre-diabetes (Maez, Erickson, & Naimuk, 2014). In rural areas, the prevalence of T2DM increases to 17% over central cities (Maez, et al. 2014). There is widespread consensus that the quality of diabetes care needs to be improved. Quality indicators for diabetes care illustrates the sub-optimal care that rural residents and patients with lower socio-economic status experience (Maez, et al. 2014). With this in mind, there is an increasing interesting in using telehealth technology to improve the quality of care in individuals with diabetes living in rural areas. Individuals with diabetes living in rural areas face barriers in accessing care, lack of educational resources and cultural barriers. One way to help address these barriers is through an innovative nursing care delivery model that focuses on educating diabetic patients living in rural areas on managing their disease through lifestyle changes, nutritional education, and through motivational interviewing via telehealth technology. The population for this model is individuals diagnosed with Type 2 Diabetes Mellitus (T2DM) living in rural southcentral Missouri. The care specialty is nursing education. The name of the model is DiaCon – short for Diabetes Self-Management Conferencing.
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Description of DiaCon
Telemedicine is a promising technology in improving the health care delivery to populations in underserved rural areas (Shea et al 2009). Although the results of its use in a variety of clinical settings have been documented, the effectiveness of telemedicine in improving the health care delivery in individuals with T2DM has yet to be fully examined (Shea et al. 2009). Further, the ways in which it assists in overcoming such barriers as weather, socio-economic status, and geographic location are not fully understood. Applying a telemedicine or telehealth intervention in the context of diabetes is justified due the high prevalence of T2DM, its significant morbidity and mortality rates and the huge costs associated with the disease. Diabetes is especially prevalent in rural areas (Maez, et al. 2014).
The DiaCon Model was developed with the goal of educating individuals with T2DM on self-managing their disease. DiaCon is delivered as a telemedicine intervention. The intervention consists of a web camera enabled computer which allows video-conferencing with nurse case managers and individuals with T2DM. It also requires access to an educational web page that was created by the American Diabetes Association, which is available in both English and Spanish and in low-literacy versions and regular versions in both languages. The videoconferencing sessions would provide education on lifestyle medication, motivational counseling and nutritional education. This model requires nurse managed care, collaboration, continuity of care and teleconferencing technology.
Nurse Led/Managed
This intervention is led by nurses and nurse case managers. Nurse case managers require training in the diabetes management program and how to use the videoconferencing tool in order to communicate with patients. Nurses are also trained on collecting patient outcome data in order to assess any improvements with the intervention. Nurse leaders are responsible for communicating the telehealth technology training initiative procedures and goals.
Partnerships and Collaboration
The DiaCon model also requires partnership and collaboration with local hospitals; community organizations and community members, and nurses. Local hospitals in rural Missouri will provide the data on patients with a diagnosis of T2DM in their service area to the case management nurses who will be responsible for educating this underserved population. Community members and other community agencies will be contacted to determine if there are available community resources for those individuals who do not have internet access.
Continuity of Care
The DiaCon Model promotes continuity of care even if the patient moves because the conferencing can be done from any location with an internet connection. Patient and family members will be provided with surveys to assess their satisfaction with the teleconferencing educational program. This survey will allow for the patient and their family to provide feedback so that their needs can be consistently met. This can be done across settings because of the nature of the delivery method.
Technology
An internet connection to a computer with teleconferencing technology is required for the DiaCon Model. This delivery method allows nurses from large hospitals in metropolitan areas or virtually any location to communicate with diabetic patients in rural areas. The aim is to educate these patients on lifestyle modification, self-management of their diabetes, and nutritional education via telehealth technology.
Development/Implementation Team
To implement the DiaCon Model requires a team of registered nurses, nurse practitioners, community workers, nurse assistants, licensed practical nurses, nutritionists, and community leaders. Nurse leaders will be responsible for training nurses on how to use the telehealth educational program and how outcomes will be measured. Charge nurses will be responsible for evaluating the effectiveness of the program and in addressing any concerns or issues with the educational intervention. Nutritionists will be consulted to gain knowledge on the best lifestyle and nutritional choices for diabetics. Community leaders will also be involved in order to gain an understanding of the available resources available within the community for those patients who do not have access to an internet connection.
Evaluation of DiaCon
The DiaCon Model is a diabetes self-management intervention that includes a total of 13 sessions. Of these sessions, 3 are individual sessions and 10 are group sessions. During the first month of the intervention, one individual and one group session will be held as a “springboard” for the intervention. Three sessions will be conducted via videoconferencing technology by a nurse and dietician. Make up sessions will be conducted via telephone calls. Due to the rural location of the clinical sites, an LPN will coordinate at the site and take the role of assistant for the team.
The Health Belief Model (Hurly, 1990) and the Transtheoretical Model (Zimmerman, Olsen, & Bosworth, 2000) frame this initiative which emphasizes goal setting during each session. The program requires participants to set behavior goals. Meeting these behavior goals is one outcome measure that will evaluate the effectiveness of the model. Participants will document their individual self-monitored blood glucose, daily food consumption, and physical activity. The content of the intervention is composed of three existing, evidence-based practice initiatives and guidelines: The Diabetes Prevention Program Lifestyle Change materials; clinical practice guidelines as outlined by the American Diabetes Association (ADA, 2008), and Pounds off With Empowerment tools (Mayer-Davis ,D’Antonio, Smith, Kirkner, Levin, Parra-Medina, & Schulz, 2004).Modifications will be made to these sources to accommodate low-literacy for this rural area.
Outcome Measure
Evaluating the effectiveness of the DiaCon Model will require the measurements of specific outcome measures. The primary outcome for this intervention is reduction in glycated hemoglobin (GHb). Secondary outcome measures include LCL cholesterol levels and blood pressure rates, body mass index (BMI) measures, as well as data from the patient self-report logs. Data will be collected on the patients’ demographics, medical history, knowledge and beliefs towards diabetes behavior, typical diet and physical activity levels, and health care utilization. Outcome data will be collected on all participants at baseline and at six month intervals. The anticipated outcomes are improvements in GhB, reduced BMI, increase in physical activity, and awareness and knowledge of self-managing diabetes. At the end of the Dia-Con, questionnaires will be mailed to each participant to assess their satisfaction with the program.
Assessing the patient’s HbA1C levels at baseline and periodically over the course of the teleconferencing program is another outcome measure that will help gauge the effectiveness of the model. Glycemic control is another outcome measure as well as family and patient satisfaction with the educational program.
Conclusion
Quality indicators for diabetes care illustrate the sub-optimal care that rural residents and patients with lower socio-economic status experience (Maez, et al. 2014). With this in mind, there is an increasing interest in using telehealth technology to improve the quality of care in individuals with diabetes living in rural areas. Telemedicine is a promising technology in improving the health care delivery to populations in underserved rural areas (Shea et al 2009). Although the results of its use in a variety of clinical settings have been documented, the effectiveness of telemedicine in improving the health care delivery in individuals with T2DM has yet to be fully examined (Shea et al. 2009). To address this gap, The DiaCon Model was developed with the goal of educating individuals with T2DM on self-managing their disease. DiaCon is delivered as a telemedicine intervention. The intervention consists of a web camera enabled computer which allows video-conferencing with nurse case managers and individuals with T2DM. It also requires access to an educational web page that was created by the American Diabetes Association, which is available in both English and Spanish and in low-literacy versions and regular versions in both languages. The goals of this program are to improve GhB levels, reduced BMI, increase physical activity, and promote awareness and knowledge of self-managing diabetes among rural diabetics in southern Missouri.
- American Diabetes Association. Clinical practice recommendations (2008). Diabetes Care, 31(Suppl. 1):S3
- The Diabetes Prevention Program Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care 25: 2165–2171)
- Hawkins, S.Y. (2012). Improving glycemic control in older adults using a videophone motivational diabetes self-management intervention. Research & Theory for Nursing Practice 24(4): 217-232.
- Hurley, A.C . (1990). The Health Belief Model: evaluation of a diabetes scale. Diabetes Education 16:44–48
- Maez, L., Erickson, L., & Naumuk, L. (2014). Diabetic education in rural areas. Rural and Remote Health, 2742. Retrieved from: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=2742
