Viji Sundaram
New America Media

Luis de Jesus says he enjoys a better quality of life now than when he was first diagnosed with diabetes 10 years ago, thanks to having better control over the disease.

De Jesus, a Spanish-speaking factory worker, enrolled in a program at San Francisco General Hospital’s (SFGH) Center for Vulnerable Population. The program is specifically tailored for “vulnerable” people like him with poor control of their diabetes and with low incomes. Although DeJesus works two jobs to support himself and his family, he has no health insurance.

“I had zero knowledge about how to control or manage diabetes prior to my participation in the project,” the 54-year-old Jesus said through an interpreter. “[The program] was so practical.”

An estimated 23.6 million people, or nearly 8 percent, of the US population, live with diabetes. Nationally, the number of people diagnosed with type-2 diabetes has doubled over the past two decades, qualifying it as an epidemic, according to the federal Centers for Disease Control and Prevention. In California, one out of nine adults has the disease.

Diabetes is more prevalent among those without a high school education, and disproportionately affects underserved and ethnically diverse populations, including Latinos, African Americans, Native Americans and Asian and Pacific Islanders.

The correlation between the disease and educational level is in part because of the patient’s ability to read food labels, track blood sugar levels, assess insulin amounts, record meal schedules and communicate with clinicians when complications arise.

IDEALL Program
Called Improving Diabetes Efforts Across Language and Literacy (IDEALL), the hospital's approach uses simple communication technology to help people manage their diabetes without having to make frequent hospital visits.

The IDEALL project team developed an automated telephone support system (ATSM) for diabetes management.

The system provides weekly calls in the patient’s native language--English, Spanish or Cantonese--regarding issues ranging from symptoms and taking prescribed medications, to diet, physical activity and self-monitoring of blood sugar.

The calls also offer advice about psychological issues and referrals for preventive services.

Depending on their automated responses during the call, the patient then receives automated health education messages and a “live” telephone call back from a bilingual nurse care manager. The IDEALL team found that the program could reduce diabetes-related health disparities in vulnerable populations.

“We were really impressed that diabetes patients with limited literacy and limited English proficiency, who many health care workers consider to be ‘hard to reach,’ were the most likely to use this communication tool,” said Dr. Dean Schillinger, director of the SFGH’s Center. He is also chief of the California Diabetes Program in the California Department of Public Health and head of the IDEALL team. “We found that better communication between a public health care system and the vulnerable populations they serve yielded concrete benefits,” Schillinger said.

But Schillinger warned that the program should be seen as “an adjunct” to primary care offered by physicians, not a replacement.

“Diabetes requires daily home management by the patient and occasional visits to the clinic,” noted Susan Lopez-Payan, coordinator of the California Diabetes Program. “The IDEALL project reaches out to patients in their homes.”

Standard of Care
Schillinger said he hopes that the IDEALL project becomes a “standard of care” across California, given how “scaleable and cost-effective it is.”

The Center for Vulnerable Populations has received additional federal funding to scale up and adapt the ATSM system with a local Medi-Cal health plan partner, the San Francisco Health Plan.

De Jesus has nothing but praise for the program. “Had I not had this opportunity, I would have had to look for alternative programs to help me," he said. "Because of the program, I now know how to live better.”

Meanwhile, the California Medical Association Foundation, too, is trying to reduce the disparities in diabetes care in ethnic minorities.

The foundation just released the outcome of a Qualitative Collaborative it launched in 2006 to help improve the quality of diabetes care provided by solo and small group practices.

Called the “Advancing Practice Excellence in Diabetes,” the project was initiated to improve diabetes care provided by individuals or groups of primary care physicians fewer than five, said Elissa K. Maas, the foundation’s vice president for programs.

“It was also done to find how the disparities in diabetes care in ethnic minorities could be reduced,” Maas said, noting that ethnic physicians are the most likely to be seeing patients in underserved communities.

In California, small group health care providers represent approximately 60 percent of all primary care physicians who, in 2007, provided care to over 800,000 patients with type-2 diabetes, she said. In the United States, most diabetes care is provided by primary care physicians.

Twenty-four solo/small group primary care practices started in the collaborative, all of them working in the largely agricultural communities of Butte, Glen, San Joaquin, Riverside and San Bernadino.

“We wanted to work with physicians serving a large number of South East Asian communities,” Maas said.

Small Steps
The collaborative found that regardless of the size of the practice, improvements in patient care could be made by taking “small steps,” she said.

For instance, only two primary care groups had patient information stored in electronic devices, something necessary to efficiently track the care patients with diabetes were receiving.

By the end of the Qualitative Collaborative, in December 2008, Maas said, “we helped [participants] build a system that fit the size of their practice.

“We were stunned by the changes that had occurred. We saw improvement not only in the staff’s performance, but also noticed such changes in patients as a drop in blood sugar and cholesterol levels,” as well as an increase in the number of foot exams. (Blisters and red spots on the foot, as well as numbness, are telltale signs of high blood sugar.)

Maas said that by making basic changes in their practice, primary care physicians could help in reducing the number of hospital admissions of their patients with diabetes.

In the long run, “it can save money and improve patients’ health and well-being,” she said.

Reprinted with permission of New America Media  Copyright 2009