By Stephanie Spernak, contributor
Vernon “Shorty” Whetzel hadn’t been feeling well for a couple of days, but when he suddenly began to slur words and couldn’t walk, his wife, Lois, called 911. They both feared Vernon had a stroke because his sister died of a stroke at the young age of 30.
In the ambulance on their way to Sentara RMH’s Emergency Department, the EMTs tested Vernon, who is 65, for high blood glucose, called hyperglycemia. His reading was far above normal. Vernon was admitted and treated until his blood sugar lowered and stabilized.
Lois said Vernon’s hospitalization and subsequent diagnosis of Type 2 diabetes was frightening and overwhelming. She said no one in either of their families had ever had diabetes, and the couple knew nothing about the disease and its symptoms.
While Vernon was in the hospital, Sentara connected the Whetzels, who live in Mt. Crawford, with an inpatient diabetes educator who explained the diagnosis, gave them a “diabetes kit” with basic equipment and supplies necessary for him to test his blood at home and showed them how to inject insulin. The diabetes educator also emphasized the importance of daily management of diet, exercise, blood testing, and medications.
This is part of Sentara RMH’s Diabetes Self-Management Education and Support program, which last year won an innovation award from a Richmond-based health consulting firm. The award, the 2021 Health Quality Innovators of the Year Award, cited the diabetes education program for improving outcomes in patients.
Alyssa Pacheco, spokesperson for Sentara RMH, said in a December press release announcing the award that the hospital bolstered the program “when data revealed a significant increase in uncontrolled diabetes and hypertension in their community.” The program increased its outreach to patients in different settings and tracked the results, which showed “improved the quality of life, reduced the mortality rate and decreased hospital admissions,” Pacheco said.
Building a routine
While Lois and Vernon Whetzel were first learning about diabetes and how to manage it, Lois worried that she would never remember everything.
“It was just mind-boggling,” she said.
Sentara RMH connected them with the diabetes self-management program after Vernon was discharged and the couple began meeting with Julie Pierantoni, Sentara RMH’s diabetes quality care coordinator, at Sentara’s South Main Health Center. Pierantoni, who has nursing degrees from Eastern Mennonite University and James Madison University, had worked in several nursing units at the hospital before becoming the diabetes quality care coordinator more than two decades ago.
Lois said with the support of education program she became confident that management of diabetes at home was really “doable.”
“It became a routine,” she said.
In addition to building her confidence, Lois said the program provided practical advice such as focusing on portion control rather than on the “foods you can’t eat.” Pierantoni also reviewed all Vernon’s blood sugar levels and medications at each visit.
She recommended Vernon use a continuous glucose monitor which provides glucose readings in real time via a tiny transmitter in a skin patch applied to the patient’s upper arm or abdomen. Instead of requiring a blood sample, a continuous monitor measures glucose levels in the fluid circulating around cells just under the skin. The device can store a record of the readings and sounds an alarm if a reading is out of range.
But a continuous monitor is more expensive than the old-style monitors and is not available over the counter. Continuous monitors require a prescription, which can sometimes lead to insurance hassles. Pierantoni took care of it all and explained how each component worked.
Pierantoni also told Lois to call her if she had questions or concerns — an offer Lois said she did take her up on. That personalized support via a phone call was so important for staying on track, Lois said.
“The diabetes educators sincerely want you to get well,” she said. “I can’t imagine not taking advantage of the excellent support you can get from this program.”
Role of self-management
Pierantoni said the diabetes patient “provides 97% of their [own] health care” because of the intensive self-management necessary to control blood sugar and prevent disease progression, complications, and repeated hospitalizations.
One study of diabetes self-management education found that before beginning the program, patients said their physician was responsible for controlling their diabetes. But after completing the program, patients said they were responsible.
Many of the patients in the diabetes program have poor vision, poor hearing and other physical and behavioral issues that constrain their mobility and negatively affect their other self-care skills, Pierantoni added.
Some research has shown that group self-management sessions lead to greater improvement in glucose control than individual sessions, and the RMH program is planning to offer them soon.
The Sentara RMH East Rockingham Health Center located in Elkton “would most likely be our first office for groups. They have a nice, dedicated group room,” Pierantoni said.
Key innovations in the Sentara RMH program
Pierantoni said an important innovation was shifting part of the diabetes self-management program out of the hospital and into the community. Diabetes patient participation tripled after that change, she said.
“Our program is unique in that we are in the community at the Sentara physicians’ practices,” she said. “We are located where the patients are, where the patients are comfortable — at their primary care office. The patients don’t have to travel into Harrisonburg and try to find their way around the hospital.”
Pierantoni said another major innovation in the SRMH self-management program is the “conversation map” tool developed for specifically for use in self-management programs by Healthy Interactions of Chicago, in collaboration with the International Diabetes Foundation.
These maps depict common scenes of daily living that patients recognize. This prompts them to share their experiences in these situations, to raise questions, and present problems they might be having with the activities shown.
Pierantoni said that with the Conversation Map method there are “no lectures, no power point slide shows.”
The main purpose of the session, she said, is to talk with the patient, get to know them and their circumstances and challenges, and not present a one-way flow of information.
A typical session will begin with the question: “So tell me about your diabetes?” Pierantoni said.
This technique, she said, lets the patient know right away that the session is about “their experience and understanding of their disease and how it affects their life.”
And some of the unseen effects can be deadly. Chronic diseases, including diabetes, are the leading causes of death and disability in America and the leading drivers of health care costs, according to the Centers for Disease Control and Prevention.
The population health approach to improved diabetes outcomes
The population health approach seeks to improve outcomes for all patients. To accomplish this goal, outcomes among a specified group of patients are compared. In this way, factors associated with those patients with worse outcomes can be identified and their care pathway improved.
Population health proponents advocate for a much broader perspective on understanding disparities in health outcomes, such as the role of non-medical factors, called social determinants, in evaluating health outcomes.
The U.S. Department of Health and Human Services in its Healthy People 2030 report defines social determinants of health as “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
‘Educate, empower and encourage’
To provide incentives for health care providers to develop a population health focus, both public and private insurers are moving away from a fee-for-service reimbursement system to a value-based care payment system where the quality of health care provided is evaluated. Providers are rewarded by increased payments or penalized by reduced payments depending upon patient outcomes.
The value-based care model of provider payment shifts part of the accountability for patient outcome to the provider. This payment approach, however, has drawn some criticism because many socioeconomic factors that affect patient outcomes are not within the control of the health care provider.
In and around Harrisonburg, Pierantoni said physicians with diabetes patients who have participated in Sentara’s self-management program have reported noticeable results.
In a statement provided by Pierantoni, Dr. Jessica Yoder, a family medicine practitioner, said general practitioners don’t always have the time needed to help diabetes patients with disease management questions and strategies.
“Patients that participate in diabetes education are more engaged and empowered to improve their blood sugars and I consistently see better diabetes control and patient satisfaction when they are involved in diabetes education along with their office visits,” Yoder said.
And Dr. Jeff Taylor, an endocrinologist called the program’s educators “invaluable.”
“They educate, empower, and encourage active patient participation in diabetes care,” he said.
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