Type 2 diabetes is a common health problem in older adults, affecting nearly 20% of the United States population between ages 65 and 74 (Reid, Sox, Comi, & Atkins, 1996). It accounts for 28% of annual Medicare expenditure for older Americans (Ratner, 1998). Evidence from recent trials demonstrates that intensive glycémie control of Type 2 diabetes reduces microvascular disease (Nathan, 1999; Ohkuba et al., 1995; United Kingdom Prospective Diabetes Study Group [UKPDS], 1998a, 1998b). Based on these findings, the National Institute of Health and Centers for Disease Control and Prevention are co-sponsoring a major national initiative to increase awareness and to improve treatment and outcomes for diabetic patients (Clark, 1999). The Balanced Budget Act of 1997 supported patient diabetes education by providing Medicare reimbursement for diabetes self-management training services, including self-glucose monitoring, diet, and exercise. (Health Care Financing Administration [HCFA], 1998).
Despite evidence supporting tighter glycemic control, physicians treating diabetic patients older than 65 may remain cautious about implementing these recommendations. First, the United Kingdom Prospective Diabetes Study included few patients older than 65 (UKPDS, 1998a, 1998b). Second, older patients are a more heterogeneous group with more co-morbidity than their younger cohorts, possibly increasing the risks of intensive therapy. Third, older patients often have greater difficulty implementing complex pharmacological and behavioral regimens than their younger counterparts. Elderly individuals are, on average, less well educated and have less social support, diminished mobility, greater co-morbidity, and are more likely to have an increased incidence of cognitive disability than their younger counterparts (Tu, McDaniel, & Gay, 1993).
A continuing care retirement community (CCRC), however, may be an ideal setting to study the management of Type 2 diabetes in older patients. These communities, which are increasingly popular residential sites for seniors, may house 18% of United States adults 75 and older by 2020 (Netting & Wilson, 1991). The CCRCs provide a broad continuum of services that can potentially address many of the challenges older adults face, such as limited transportation, social isolation, requirements for increased assistance with activities of daily living, and reduced access to health care.
Services, such as on-site medical care, combined with nursing care, dining, social work, exercise groups, and transportation, could create an environment where safe implementation of an intensive control program for diabetes could be performed. A group care model may be an effective method to combine the services of the interdisciplinary team, and introduce the concept of secondary prevention education to diabetic patients residing in a CCRC.
Care involving small groups of patients and emphasizing an interdisciplinary approach can be effective in improving health care outcomes (Beck et al., 1997; Campbell, Redman, Moffitt, & Sanson -Fisher, 1996; D'Eramo-Melkus, WylieRosett, & Hagan, 1992; Raz, Soskolne, & Stein, 1988). One recent study comparing group outpatient visits to traditional physician-patient visits in older patients (mean age of intervention group 72) found participants attended a mean of 6.6 of 12 group sessions. Significantly greater satisfaction with quality of care and meeting health care needs, provider satisfaction, and more immunizations and completed advanced directives were reported in the intervention group. Emergency department visits and repeat hospitalizations decreased significantly in the intervention group, possibly decreasing hospitalization costs through a group education model (Beck et al., 1997).
Patient education plays a central role in effective diabetes management and care (American Diabetes Association, 2000; Baker et al., 1993; D'Eramo-Melkus et al., 1992; Garcia & Suarez, 1996; Tu et al., 1993). Studies of populations with diabetes have demonstrated need for more patient education and better access to care. There are a number of studies in the literature evaluating diabetic education interventions, including group sessions, home care, and telephone interventions in a variety of settings, but none in a CCRC.
Many of these studies demonstrate that diabetic educational interventions can have a positive effect on glycémie control (D'Eramo-Melkus et al., 1992; Garcia & Suarez, 19%; Hanefeld et al., 1991; Weinberger et al., 1995). Wilson and Pratt (1987) demonstrated that a peer support intervention improved weight and glycémie control with a group of elderly individuals with Type 2 diabetes mellitus. Rettig, Shrauger, Recker, Gallagher, & Wiltse (1986) evaluated individual instruction by home health nurses, and found significant improvement in knowledge in the intervention group compared to the control group, but no reduction in diabetes related hospitalizations.
The purpose of this pilot study was to develop, implement, and evaluate an interdisciplinary group diabetes education course in a CCRC. The study was designed to determine if a small group diabetes education program conducted at a CCRC would affect the participants' glycémie control, knowledge of diabetes, satisfaction, and sense of well-being. An additional purpose of the study was to ascertain individuals' suggestions for future studies of group education and group care in a longitudinal study in this and similar CCRCs.
The pilot study was conducted on the campus of a large, fee-for-service, nonprofit, nonsectarian CCRC located in suburban Baltimore, which opened in March 1995. At the time participants were selected for this study, 1,362 residents lived in independent apartments, and 179 residents lived in the assisted living and nursing care facilities. Six hundred seventy-four of the residents living independendy used the health center operated by faculty of The Johns Hopkins School of Medicine's Division of Geriatric Medicine and Gerontology. On-site medical, dental, ophthalmology, podiatry, and physical therapy offices were available.
Other on-campus services included social work, pastoral care, home nursing, and geriatric nursing assistants. Free transportation on the campus was provided by shuttle, and transportation off campus was available for a fee. The resident population was 98% White, and 85% had a high school education or above and were in the upper quartile of income.
DIABETIC COURSE OUTLINE
The CCRC had three dining halls and one café in which the residents could eat meals. Most residents ate supper communally and prepared other meals in their apartments. The monthly fee included one meal per day.
The CCRC had two exercise rooms and a supervised health club and indoor swimming pool. Enclosed walkways connected all buildings on an 85-acre campus allowing safe, all-season walking. Secure outdoor space was available for walking and jogging, as well.
The study was designed to accommodate between 15 and 20 participants. A group this size would allow for peer and instructor interaction. Charts from 674 residents using the on-site health center for primary care were reviewed, and 65 patients with a diagnosis of Type 2 diabetes recorded on their medical center problem list were identified. Residents with a Folstein MiniMental Status Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) score less than 25, or those with cognitive, functional, visual, or auditory disabilities precluding effective understanding and communication were excluded.
Thirty residents on this list had the cognitive and sensory ability to participate in a small group educational program. Of these 30 residents, 4 could not be reached by phone, 1 was hospitalized, and 7 were indecisive or declined to participate. Eighteen independent residents living in the CCRC who received primary care at the on-site health center and had a diagnosis of Type 2 diabetes agreed to participate in the study. Sixteen of those residents attended the initial class and completed the pre- and post-study questionnaires. All participants continued to receive their usual health care, including routine visits, urgent and preventive care, and medication changes as needed.
Twelve 1 -hour sessions were conducted biweekly by members of an interdisciplinary team consisting of a registered nurse certified diabetic educator (CDE), a nurse practitioner, a physician, a dietitian, and an exercise trainer. The course session titles and health care team participants are outlined in Table 1. Content was taught using a lecture format with handouts and blackboard illustrations.
The CCRC dietitian and the CDE nurse taught participants to read and interpret nutrition labels during a trip to a grocery store designed to educate participants on how to make healthy choices when shopping for food. In addition, participants were supplied with a guidebook on reading nutrition labels. During one session, the dietitian and CDE had dinner with the group in one of the CCRCs dining rooms to discuss the CCRC menu and meal choices. One class was held in a local restaurant with the interdisciplinary team to help participants learn to make healthy choices when dining out.
COMPARISON OF OUTCOMES BEFORE AND AFTER GROUP DIABETES COURSE (N = 16)
The exercise trainer of the CCRC discussed the effect of exercise on diabetes in older adults. The exercise trainer encouraged the participants to use the exercise and activity programs available within the CCRC as a method to improve glycémie control.
Fasting serum glucose and glycosylated hemoglobin levels were measured during the 2-week period before and after the course was conducted. The normal value for the glycosylated hemoglobin was 4.4% to 6.4% for the laboratory performing the assays. A 25-item Diabetes Knowledge Test (Fitz-Patrick, 1996), the Short Form 36 (SF-36) Health Survey (McHorney, Ware, Lu, & Sherbourne, 1994), and three questions about satisfaction related to diabetes care and knowledge were administered during the first and last classes.
The Diabetes Knowledge Test, developed and used by David FitzPatrick, MD (1996) of the Diabetes and Hormone Center of the Pacific, consisted of multiple-choice and true/false questions. Content included diet, exercise, and medical management of diabetes. The score was based on the percentage of correct answers. The SF-36 Health Survey, which is a measure of sense of well-being, consists of 36 Likert-type items representing eight health concepts:
* Physical functioning.
* Social functioning.
* Emotional role functioning.
* Physical role functioning.
* Mental health.
* Energy and fatigue.
* General health perceptions.
The scores are standardized and reported on a scale of 0 to 100 with 0 being the poorest sense of well-being and 100 the highest (McHorney, 1996; McHorney, et al., 1994; Tilly, Belton, & McLachlan, 1995; Weinberger et aL, 1995). Reliability coefficients for internal consistency ranged from .65 to .94, depending on the subscale (McHorney et al, 1994). Satisfaction with knowledge, time spent with checkups, and current treatment of diabetes was measured using a fiveitem, Likert-type scale. These questions were obtained from the Diabetes Quality of Life Scale, which was developed for use with younger, Type 1 diabetic patients (Diabetes Control and Complications Trial [DCCT], 1988). The questions were:
* "How satisfied are you with your knowledge about your diabetes?"
* "How satisfied are you with the amount of time you spend getting checkups?"
* "How satisfied are you with your current treatment?"
Participant attendance was recorded at each session. Participants' comments related to the course were recorded throughout the program as well. During the last class, a questionnaire with open-ended questions was distributed to elicit participants' comments related to course content and structure.
The Johns Hopkins Bayview Institutional Review Board reviewed and approved the study. All participants gave informed consent.
SF-36 HEALTH SURVEY "(RESULTS OF SUBSCALES) (N = 16)†
Pre- and post-intervention measures were compared using paired t tests. The JMP version 3.1 statistical software (SAS Institute, Cary, NC) was used for these analyses.
Characteristics of Participants
The mean age of the 16 participants was 79 (SD = 5.65). Sixty-nine percent of the sample were women, and all participants had a high school education or above. All participants had Type 2 diabetes; 19% were managed with insulin, 75% with oral agents, and 6% with diet alone. The median MMSE score for participants was 28 (range 25 to 30).
The baseline and post-intervention glycosylated hemoglobin and fasting serum glucose are displayed in Table 2. Glycosylated hemoglobin and fasting serum glucose values increased slightly. Mean difference in glycosylated hemoglobin level from baseline to post-intervention was .61% (SD = .81) (p = .014). Mean difference in serum glucose level from baseline to post-intervention was 24.33 mg/dL (SD = 20.75) (p = .260).
The diabetes knowledge test scores are found in Table 2. Post-course scores on the diabetes knowledge test changed significantly (p = .046) from a baseline mean of 75.75% (SD = 11.73) to 82.67% (SD = 5.99).
Satisfaction and Sense of Well-Being
The satisfaction scores are displayed in Table 2. Satisfaction scores increased for diabetes knowledge (p = .055). Although not statistically significant, satisfaction with time of checkups and current treatment also increased slightly.
The SF-36 Health Survey results are reported in Table 3. No statistically significant changes in any of the eight subscales of the SF-36 Health Survey occurred. Although increases in the post-intervention mean value for general health, emotional role function, social function, and energy occurred, the differences were not statistically significant.
On average, participants attended 6.94 (SD = 3.32) of a total of 12 sessions. Individual participants attended 1 to 11 classes. Class attendance for each session is displayed in Table 1.
Comments made throughout the course and recorded on the postcourse survey revealed that participants reported a high degree of satisfaction with the group interaction - most indicating they would like the group to continue. They reported that restaurant and grocery store outings were highly effective teaching methods. Most of the members indicated they felt more confident about their diabetes management, and enjoyed the social aspects of meeting with peers, and the ability to meet health care professionals in a less formal setting than the physician's office.
Almost all participants recommended more extensive and specific information about diet. Most preferred using large print handouts rather than chalkboard or overhead projections to supplement lecture information. Many participants indicated a preference for longer sessions held more frequently, they preferred weekly classes held for 1.5 hours.
The purpose of this study was to develop, implement, and evaluate a group diabetes education course in a CCRC. Diabetic education is an important component of long-term diabetic care. A large CCRC provides many of the services needed for long-term diabetes management, such as on-site medical and nursing care, dietary services, and exercise facilities. Coordination of these services by a nurse-directed interdisciplinary team is a feasible method of providing a group health education program on diabetes in a CCRC. The CDE was the only service not usually provided on-site in this CCRC. Using the on-site clinicians, including a CDE, to provide instruction to a group of diabetic patients may be more cost-effective and time efficient than individual counseling.
The CCRCs with a managed care plan or an all-inclusive monthly fee covering all health care services may find group education cost-effective. Medicare would provide some reimbursement for individual and group diabetes training programs meeting the Center for Medicare and Medicaid Services (formerly HCFA) guidelines.
Diabetic patients residing in a CCRC were easily recruited and expressed satisfaction with this model of diabetic education. Many of the residents were well-educated about their disease and motivated to maintain their health. Participants valued the social aspects and interactions with peers and health care providers.
The study was also designed to evaluate the effectiveness of the group diabetes education course on glycemic control, knowledge, satisfaction, and sense of well-being. Measurable outcomes and benefits of the course would be important if this type of group education program is implemented as a part of diabetic care in a CCRC. The sample size in this pilot study may not be sufficient to adequately evaluate the effect of this type of program on these outcome variables. Results suggest this type of group education program may affect these outcome measures.
The participants, as a group, had good baseline glycemic control, demonstrated by a baseline mean glycosylated hemoglobin of 7.05% (1.19). It is possible that individuals volunteering to participate in a diabetes management study may be more motivated to engage in health promoting behaviors. There was a small, but statistically significant, increase in glycosylated hemoglobin from baseline. Eating habits, weight, physical activity level, and medication use and changes were not measured. Therefore, the authors were unable to determine if participants altered some or all of these behaviors as a result of becoming more knowledgeable about diabetes. For example, participants may have increased snacks to reduce the risk of hypoglycemia, but the study design did not allow the authors to determine an explanation for this increase in glycosylated hemoglobin. Future studies are needed to explore the relationship between behavior changes and outcomes.
This well-educated group had high diabetic knowledge test scores at baseline. Therefore, it is noteworthy that diabetes knowledge test scores and satisfaction with diabetic knowledge increased at the end of the course. Although improvement in diabetic knowledge test scores does not necessarily result in improved glycemic control, it has been shown to result in improved self-care (Tu et al., 1993). Although the SF-36 subscale scores did not change, participants reported improved confidence in managing their diabetes and improved satisfaction in diabetic knowledge.
Attendance of 57% with a range of 1 to 11 sessions attended was lower than expected, despite the course being located on site and residents having access to free campuswide shuttle service. Attendance was similar to other studies of community-based group education (Beck et al., 1997; Funneil, Arnold, Folger, Merritt, & Anderson, 1998). Funnel et al. (1998) reported that community dwelling individuals with a mean (5D) age of 69 (4.3) attended from 2 to 12 monthly sessions during 18 months, or 72% of the first 6 sessions and 68% of the last 12 sessions. Beck et al. (1997) reported 55% attendance at 12 group sessions.
The primary reasons for missing the sessions cited in the Funnell et al. (1998) study were out-of-town travel, transportation problems, illness or hospitalization, and demands or crises of family (Funnell et al., 1998). The participants in this study reported similar experiences, and some experienced poor mobility and impaired access even to the on-campus shuttle service. It is clear that many factors impede attendance. Living in close physical proximity to the course location did not obviate many of the barriers to regular attendance. Some participants suggested a more central location on campus or holding classes in their individual apartment buildings.
A 1-hour, biweekly session was chosen to avoid fatigue. Yet, many of the participants in this study suggested weekly classes held for 1.5 hours would be more desirable. Participants reported more frequent classes improved their retention of class material and enhanced the social aspects of the group. More frequent classes also may enhance attendance. However, Beck et al. (1997) found that 2-hour sessions, divided into 15- or 30-minute breaks for refreshment, discussion, and presentations resulted in similar attendance rates.
Other recommendations from participants were to use large print materials and provide more diet information. Some participants reported that hand-held materials were easier to see and aided in their retention of the information. Participants requested more extensive and specific information related to diet, reporting that the grocery store and restaurant outing were educationally and socially beneficial.
The Sidebar lists recommendations for implementing group education for older adults based on this pilot study of group diabetes education in the CCRC.
Results from this pilot study demonstrate that implementing a group health education program using a nurse-coordinated interdisciplinary team in the CCRC is feasible. The results indicate further development and evaluation of group education and group care models for diabetes and other chronic illnesses are needed. Specifically, studies assessing the effect of these educational programs on other outcomes, such as complications, hospitalizations, and health care costs are needed.
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DIABETIC COURSE OUTLINE
COMPARISON OF OUTCOMES BEFORE AND AFTER GROUP DIABETES COURSE (N = 16)
SF-36 HEALTH SURVEY "(RESULTS OF SUBSCALES) (N = 16)†