The Greater Detroit Area Health council (GDAHC), which leads the AF4Q initiative in Detroit, wanted to make it more convenient for people in southeast Michigan with diabetes to learn how to manage their care better. Inspired by an earlier effort funded by the Agency for Healthcare Research and Quality (AHRQ) to identify interventions with the most impact, in 2008 GDAHC started developing a pilot program to provide diabetes self-management education (DSME) sessions to local employees where they work.
“Most DSME programs in our region are offered in hospital settings, but our goal was to make the classes much more accessible—we thought it would help if participants could take a free class during their lunch break and didn’t have to leave their worksite,” said Lisa Mason, vice president of cost quality for GDAHC.
Initially, GDAHC reached out to Detroit-area employers and unions directly and asked them to consider offering an onsite DSME program. They used a diabetes cost calculator AHRQ developed to demonstrate to the employers and unions that they could potentially save money in the long term on employee medical costs and improve productivity by implementing a DSME program. Although the employers agreed with the projected savings in medical costs, they were not willing to make the up-front investment required to cover the cost of the DSME sessions because they were concerned about the effects of the economic recession on their businesses.
GDAHC and its partner, Medical Network One, decided to approach Blue Cross Blue Shield of Michigan (BCBSM), a nonprofit corporation that is the state’s largest provider of health insurance. BCBSM agreed to cover the cost of a DSME pilot program and help identify employer and union groups who would be willing to offer the DSME at their worksites and union halls. Ultimately, the DSME pilot program included five employer sites and two union halls. Medical Network One provided the American Diabetes Association-certified education sessions. At each site, an average of 20 participants were recruited to participate in eight one-hour DSME sessions with professional staff, including registered nurses and dietitians, certified diabetes educators, and behavioral health and exercise specialists. The first class started in the fall of 2009. In most cases, the class sessions took place during lunch, but at the unions, they were offered in the evening and Saturday morning.
“We grappled with whether the classes should just be for people with diabetes, but the employers we worked with didn’t want them to feel singled out, and we decided to make the classes available to anyone who was interested,” said Mason. She noted that about half of the people who signed up for the pilot had been diagnosed with diabetes, and half were either at risk for diabetes or caring for a family member with diabetes.
Classes were free for participants and covered topics such as how to better manage or even prevent diabetes with diet and exercise, how to monitor blood sugar levels, and how to prevent complications from diabetes. Shanda Reardon signed up for the DSME sessions that were offered starting in 2010 through OakFit, a wellness program for Oakland County employees. An office leader in Oakland County Circuit Court’s Family Division, she lives in Waterford, MI, with her husband and two children. Although she does not have diabetes, she wanted to attend the lunchtime classes to learn how to eat healthier and prevent diabetes because of her family history. Her father has diabetes, and her aunt and grandfather died from diabetes-related complications.
Reardon said the classes helped her lose weight and change her family’s eating habits. “I learned about portion control, healthier snacking, and how to read food labels,” she said. “I’m much more cautious and aware of what we’re eating now. We avoid snacking after 7 p.m., and when we do snack, we reach for fruit or granola bars rather than chips.” Reardon also has shared some of the information and handouts from the class with her father.
She said she appreciated that the teachers made her feel comfortable about asking questions at any time. “They were very forthcoming and encouraging,” she said. “It made me realize that you should never be afraid to ask your health care provider any questions you have.”
Before the educational sessions began at each site, Medical Network One collected baseline data on the participants’ weight, blood pressure, body mass index, cholesterol, and blood sugar levels. The participants also completed a survey about their health behavior—containing questions about medication adherence, exercise, nutrition, and blood glucose monitoring—and a questionnaire developed by Tufts University about their productivity levels at work. They were asked to return for follow-up evaluations so these data could be collected again at three, six, and 12 months after the initial educational sessions ended. At the three- month and six-month follow-up evaluations, participants also filled out a program satisfaction survey.
Mason noted it was challenging to get participants to return for the six- and 12-month follow-up evaluations. GDAHC eventually began offering $50 gift cards for participating in these sessions. This improved attendance, but low attendance continued to be a problem that hampered data collection efforts.
The last of the 12-month follow-up evaluations was completed in the summer of 2012, and the University of Michigan is helping to analyze the data.
Results show that the participants’ at-work productivity increased by 20 percent at six months and more than 11 percent after 12 months, as measured by their reduced burden of illness in that setting. At some sites, participants also showed significant improvement in clinical measures—for example, weight, BMI, and systolic and diastolic blood pressure decreased significantly for employees at General Dynamics Land Systems at their six-month follow up evaluation. GDAHC is collecting data from the employers and health plans to see if there was an impact on medical and pharmaceutical claims costs for the participants and their family members.
During the pilot, Blue Cross Blue Shield of Michigan changed its reimbursement policy to cover DSME in locations other than outpatient facilities and physician offices. GDAHC and its partners are working to encourage other southeast Michigan health plans to do the same. “We’re trying to remove the barriers so that we can make this important education more widely available in the community,” said Mason.
• Health care plans view the employers as customers and often know which ones are more forward thinking and progressive about things like health and wellness education. Ask the health care plans which employers in the community would be most receptive to offering a diabetes self- management education program. At the same time, work with the plans to see if they can cover the cost of the program both for people with diabetes and for those at risk for the disease.
• Employers vary widely in their readiness to take on a health education activity. Some already have health and wellness promotion programs, and others are not as accustomed to thinking about investing in employees in this way. But you can show them the value—for example, by demonstrating the potential long-term savings in medical costs—and tailor the program to meet their needs.
• More health care organizations need to be encouraged to deliver DSME in workplaces and other community settings and not just hospital settings. GDAHC found that Medical Network One was the only health care organization in its region that had the clinical expertise and experience to offer DSME in community settings. Convincing health plans to cover the cost of the program can provide an incentive for vendors to become involved. To find potential organizations to provide the training, ask the American Association of Diabetes Educators and the American Diabetes Association for recommendations.
• Partnership and collaboration are the keys to success. Our pilot depended on an innovative health care organization willing to take the DSME sessions into the community, a health plan willing to try something new, and employers and unions who viewed their members’ health as a priority.