Linda S Gottfredson PhD School of Education University of Delaware Kathy Stroh MS RD CDE Diabetes Prevention and Control Program Delaware Division of Public Health 1 CEHD Colloquium University of Delaware February 28 2013 ID: 387522
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Slide1
Teaching Diabetes Self-Management—in 4 Hours (or Less)
Linda S Gottfredson, PhDSchool of EducationUniversity of Delaware
Kathy Stroh, MS, RD, CDE
Diabetes Prevention and Control Program Delaware Division of Public Health
1
CEHD Colloquium, University of Delaware, February 28, 2013Slide2
Juvenile Diabetes Maturity-onset Diabetes
Insulin dependent Non-insulin dependent
Diabetes (IDD) Diabetes (NIDD) Type I Diabetes Type II DiabetesType 1 Diabetes Type 2 Diabetes
Types of Diabetes
2Slide3
Types of Diabetes (DM)
Type 1
-cell destruction;
autoimmune disease; complete lack of insulin 5-10% of total patientsType 2 -cell dysfunction and insulin resistanceGestational -cell dysfunction and insulin resistance during pregnancy 3Slide4
There is no such thing as Borderline Diabetes
or a “Touch of Diabetes.”
Pre-diabetes
is a diagnosis.4Slide5
There is no such thing as
Borderline
Diabetes or a “Touch of Diabetes.”
5Pre-diabetesSlide6
DM defects
6Slide7
Diabetes is a cardiovascular disease.
The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program
People with diabetes are
twice as likely
to suffer a heart attack or stroke
compared to people without diabetes.
7Slide8
Natural
history of Type 2 diabetes
Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.
ObesityDiabetesUncontrolled Hyperglycemia
50
100
150
200
250
300
350
50
100
150
200
250
Glucose
(mg/dL)
Relative
Function (%)
-10
-5
0
diagnosis
5
10
15
20
25
30
Years of Diabetes
Post-meal Glucose
Fasting Glucose
Insulin Resistance
Insulin Level
-cell Failure
Insulin Resistance
Family
History
PrediabetesSlide9
Why teach self-management?Patients
must control their blood glucose (BG) levels to avoid complicationsControlling BG is a complex, 24/7, life-long taskRx’s change, increase; may not insure optimal BG controlChanges in dietary intake & physical activity necessaryAnd more…So much to learn and do (or stop doing)9Slide10
PWD’s* everyday reality
* “Diabetic” is not a noun10Slide11
11Slide12
12Slide13
13Slide14
As teacher educators,
how would you recommend teaching diabetes self-management?Here’s the challenge14Slide15
Private schools
0.4 mil teachers 5.4 mil pupils$673 billion15
Federal
State
District
Federal
State
District
Regulations
P
ublic schools
3 million
50 million
Diabetes education??Slide16
$673 billion
16
Federal
State
District
Federal
State
District
Regulations
P
ublic schools
3 million
50 million
Instruction
Learning tasks
Private schools
0.4 mil teachers
5.4 mil pupils
Diabetes education??Slide17
Context: Exploding numbers
12012 Condition of Education, Table A-3-1. http://nces.ed.gov/pubs2012/2012045_5.pdf2 For 1970, All A
ges is interpolated from 1968 and 1973. http://www.cdc.gov/diabetes/statistics/diabetes_slides.htm.
3For 1990 and 2010, All ages and 65+ derived from http://www.cdc.gov/diabetes/statistics/prev/national/tnumage.htm, and 18+ from http://www.cdc.gov/diabetes/statistics/prev/national/figadults.htm4 Boyle et al (2010), Projection of the year 2050 burden of diabetes in the US adult population. Population Health Metrics, 8(29).I averaged the results from their 4 models. Huang et al. (2009) estimated 34.2M for Type 2 alone: Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. 5CDC’s Diabetes Data & Trends.
http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx,
Just 5 years!
Public schools
Diabetes cases
Number needing instruction
Millions enrolled
1
Millions
diagnosed
with diabetes Type 1 or 2
(non-institutionalized civilians)
Fall of
Total
Elementary (
preK
-8)
HS (9-12)
1970
45.5
32.5
13.0
1990
41.2
29.9
11.3
2010
49.5
34.6
14.9
2020
52.7
37.3
15.4
All ages
Adults (18+)
Older (65+)
1970
2
3.6
1990
3
6.6
6.6
2.8
2010
3
20.9
20.7
7.8
2020
4
33.5
2004 % diagnosed adults
>
20 years 5 200917Slide18
Average $/person
2
4,3107,925
10,694 (2008)11,0936,7451,834466Context: Exploding costs12011 Digest of Education Statistics, Table 28, http://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp. Table reports costs in current dollars, so inflation calculator used to bring up to 2010 values.
22011 Digest of Education Statistics, Table 194
,
http
://
nces.ed.gov/programs/digest/d11/tables/dt11_194.asp
3
Dall
et al.(2010). The economic burden of diabetes.
Health Affairs, 29
(2), exhibit 4. Used inflation calculator to translate dollars from 2007 to 2010.
http://
www.usinflationcalculator.com
4
Huang
et al. (2009) Using clinical information to project federal health care spending.
Health Affairs, 28
(5), w978-990. Includes Type 2
only.
Type 1 would be <5
% of cases but higher per capita cost. Inflation calculator used to change costs from 2007 to 2010 dollars.
5
No 2020-2030 projections available for school expenditures, so just repeated % GDP from the prior 2 decades. Used Huang et al.’s total diabetes medical costs for 2007, together with 2007 GDP, to calculate costs as % GDP in that year (1.1%). Then used their Exhibit 3 (projected real growth as multiple of GDP) to estimate % GDP in 2010, 2020, and 2030. No data prior to 2007, so just took line toward
asymtope
.
Students in public schools , K-12
Diabetes cases, diagnosed and undiagnosed
Total expenditures
(2010 dollars)
Medical costs only
(2010 dollars)
1970
1990
2010
2007
3
2020
4
Total $ (billions)
1
270
415
673
Type 1
11
Type 2
111
Undiag
12
Pre-
diab
27
Total
160
Type 2
237
Diabetes
Schools
18Slide19
Total
medical costs, by age & diabetes type, 2007$ (billions)25.3
105.7
11.0 10.5Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.19%(prevalence)Slide20
35,365
Average cost ($)
Average
medical costs per person by age & diabetes type, 2007Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.20Slide21
Context: Institutional resources
Public schoolsDiabetes self-management education
Dedicated spacePermanent buildingsVaries; hospitals, medical offices, community sites
Guaranteed funding100% tax-supported1 (local, state, federal)Varies by health plan; free community classes provided by DPH/DPCP. Mandatory attendance10-14 yearsNone, all voluntary. ~ 24% of Medicare patients attended DSMT class.Teaching force:Trained in content areaCertified to teach Classroom teachersAll (N=3.1 million) 199%1Many staff do DSME: medical (e.g., MD, RN, RD, NP, PA, RPh); non-medical (e.g., CHW, CHES, peer educators).
DSMP classes given by lay trainers.Trained in disease management: MD, RN, RPh, RD, NP, CDE.
Trained to educate: Only CDEs (N=8710), national credential; possible state licensure too.
Curriculum content
&
Teacher lesson plans
State national standards (CCSS
2
)
Always. Vary by teacher
common planning
Curriculum content:
ADA and AADE certify Recognized Programs. DSMP has evidence-based curriculum.
Lesson plans:
vary with ADA & AADE programs. Fidelity agreement for DSMP.
1
2012
Condition of Education
, Tables A-19-1 (2008-2009), A-17-1 & A-17-2 (2007-2008)
2
http://www.corestandards.org/
=
trend towards
21
M
ore variable for DSMESlide22
5 levels of diabetes educators*Level 1, non-healthcare professional,
Level 2, healthcare professional non-diabetes educator,Level 3, non-credentialed diabetes educator,Level 4, credentialed diabetes educator, andLevel 5, advanced level diabetes educator/clinical manager.*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf
22Slide23
Context: Instructional resources
op0Public schoolsDiabetes self-management education
Hours of instruction in content area
(average per year)State/district-mandated minimum hours:1G1-4: 418 read/write 194 math 292 scienceVaries greatly by health plan & site - Classes: 10-15 hrs - Individual DSME: variesInstructional strategiesSystematic use of pedagogical principlesFor individual patients: CDE’s assessment of patient’s needs.
For groups: scripts for some non-medical educators (e.g., DSMP)
Pace, sequencing, Bloom level not always considered.
Special needs students
Established protocols?
Yes, legal obligation (IDEA)
Currently, no
DSME materials or curricula specifically for elderly or persons with disabilities.
Age- and ability-differentiated instruction & materials
Age grouping, preK-12
Elem:
reading/math groups within or between
classrooms, all
with different lessons
HS:
Tracks
None.
Growing concern over low “health literacy” & age-related cognitive decline with PWDs, but
-Diabetes education materials vary widely; content, but not
complexity, matched to PWD’s learning needs.
- PWDs are given pre-determined meters and supplies,
regardless of their abilities.
1
Data
for 2003-2004. Source: “
Changes in Instructional Hours in Four Subjects by Public School Teachers of Grades 1 Through 4,“ May 2007, NCES report 2007-305
http://www.eric.ed.gov/PDFS/ED497041.pdf
/
2
http
://www.cdc.gov/diabetes/statistics/preventive/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf
23
Little differentiation
Limited time
Materials too complexSlide24
Example of required task for all PWDs:
Glucose metersand lancet devicesDemonstration !! 24Slide25
Our efforts
Describe job of self-care from patient’s perspective. Collaboration with CDS: AUCD ConferenceAADE Conference: “Cognitive Demands of DSME”NACDD Teleconference: “Cognitive Demands of DSME”
AADE Conference 2013: “Psychometrics of DSME in the Elderly” Identify the job’s most critical tasksTrace (and limit) cognitive complexity of learning tasks
Differentiate instruction by ability (“literacy”) levelProvide scripts for providers that minimize complexityProvide patient handout that reinforces learning25Slide26
AADE’s description of DSM*Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:
Requires making and acting on choices, on a regular and recurring basis, that affect one’s healthIncludeslearning the body of knowledge relevant to the disease state, defining personal goals, weighing the benefits and risks of various treatment options, making informed choices about treatment, developing skills (both physical and behavioral) to support those choices, evaluating the efficacy of the plan toward reaching self-defined goals. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes
Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf26Slide27
AADE’s description of DSM*Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:
Requires making and acting on choices, on a regular and recurring basis, that affect one’s healthIncludeslearning the body of knowledge relevant to the disease state, defining personal goals, weighing the benefits and risks of various treatment options, making informed choices about treatment, developing skills (both physical and behavioral) to support those choices, evaluating the efficacy of the plan toward reaching self-defined goals. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes
Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdfWhat Bloom level would you assign to each?
RememberUnderstandApplyAnalyzeEvaluateCreate27
AADE7TM
curriculum content
Healthy eating
Being active
Monitoring
Taking medication
Problem solving
Reducing risks
Healthy copingSlide28
Objective: Maintain blood glucose within healthy limits to avoid complications
Learn about diabetes in general (At “entry’)Physiological processInterdependence of diet, exercise, medsSymptoms & corrective actionConsequences of poor control
Apply knowledge to own case (Daily, Hourly)Implement appropriate regimen Continuously
monitor physical signs Diagnose problems in timely mannerAdjust food, exercise, meds in timely and appropriate manner Coordinate with relevant parties (Frequently)Negotiate changes in activities with family, friends, job Enlist/capitalize on social supportCommunicate status and needs to practitionersUpdate knowledge & adjust regimen (Occasionally)When other chronic conditions or disabilities developWhen new treatments are orderedWhen life circumstances changeConditions of work—24/7, no days off, no retirement
Our more patient-centered job description
Self-
management
Training
28Slide29
Objective: Maintain blood glucose within healthy limits to avoid complications
Learn about diabetes in general (At “entry’)Physiological processInterdependence of diet, exercise, medsSymptoms & corrective actionConsequences of poor control
Apply knowledge to own case (Daily, Hourly)Implement appropriate regimen Continuously
monitor physical signs Diagnose problems in timely mannerAdjust food, exercise, meds in timely and appropriate manner Coordinate with relevant parties (Frequently)Negotiate changes in activities with family, friends, job Enlist/capitalize on social supportCommunicate status and needs to practitionersUpdate knowledge & adjust regimen (Occasionally)When other chronic conditions or disabilities developWhen new treatments are orderedWhen life circumstances changeConditions of work—24/7, no days off, no retirement
Our more patient-centered job description
Self-
management
Training
29
It is NOT just following a plan.
It is also thinking and acting to minimize problems. Slide30
Our efforts
Describe job of self-care from patients’ perspectiveIdentify the job’s most critical tasksTrace (and limit) cognitive complexity of learning tasksDifferentiate instruction by ability (“literacy”) levelProvide scripts for providers that minimize complexityProvide patient handout that reinforces learning
30Slide31
UD survey:
Criticality rankings
31Slide32
Our efforts
Describe job of self-care from patients’ perspectiveIdentify the job’s most critical tasksTrace (and limit) cognitive complexity of learning tasksDifferentiate instruction by ability (“literacy”) level Provide scripts for providers that minimize complexity
Provide patient handout that reinforces learning32Slide33
Bloom’s Taxonomy of Learning Objectives
Latest (2001) revisionBloom levels = continuum of cognitive complexity
Not just readability!!
33Slide34
*
Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.
To be or not to be,
that is the question.
To be or not to be,
that is the question.
To be or not to be,
that is the question.
To be or not to be,
that is the question.
To be or not to be,
that is the question.
To be or not to be,
that is the question.
“To be or not to be”
Bloom’s taxonomy of educational objectives (cognitive domain)*
Simplest tasks
1.
Remember
recognize, recall,
Identify, retrieve
2. Understand
paraphrase, summarize, compare, predict, infer
3.
Apply
execute familiar task,, apply procedure to unfamiliar task
4.
Analyze
distinguish, focus, select, integrate, coordinate
5.
Evaluate
check, monitor, detect inconsistencies, judge effectiveness
6.
Create
hypothesize, plan, invent,
devise, design
Most complex tasks
34Slide35
*
Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.
Anticipate effect of
exercise & foods
on blood glucose.
Coordinate meds, diet, and
exercise.
Manage sick days.
Determine when & why blood glucose is out of control
Monitor symptoms; assess whether action needed; evaluate effectiveness of actions
Create daily and contingency plans that control blood glucose
Recall effects of exercise on
glucose.
Remember to take
BGs & Rx.
Bloom’s taxonomy of educational objectives (cognitive domain)*
Simplest tasks
1.
Remember
recognize, recall,
Identify, retrieve
2. Understand
paraphrase, summarize, compare, predict, infer
3.
Apply
execute familiar task,, apply procedure to unfamiliar task
4.
Analyze
distinguish, focus, select, integrate, coordinate
5.
Evaluate
check, monitor, detect inconsistencies, judge effectiveness
6.
Create
hypothesize, plan, invent,
devise, design
Most complex tasks
Remember to measure
foods, drinks & read labels.
35Slide36
What about reading nutrition labels?How important?
How complex?EssentialExtremely36Slide37
37Slide38
Information is better
because it’s inchart form
Amount per serving
But, it contains aconfusing technical symbol.Can you spot it?“Amount/serving”38Slide39
What’s the problem here?
39Slide40
And here?
Organic
Healthy
No sugar added40Slide41
Pros:
Fewer items
Single vertical list Major headings stand out
Cons: Lots of irrelevant infoSeemingly inconsistent info
Better, but…
41Slide42
Food Label revision…
counting carbohydrates
42Slide43
Bloom’s taxonomy of educational objectives (cognitive domain)
Simplest tasks1. Rememberrecognize, recall,Identify, retrieve
Understand paraphrase, summarize, compare, predict, infer,3. Apply
execute familiar task,, apply procedure to unfamiliar task4. Analyze distinguish, focus, select, integrate, coordinate5. Evaluate check, monitor, detect inconsistencies, judge effectiveness6. Create hypothesize, plan, invent, devise, designMost complex tasks
Distractors:
CHOs
vs
Fiber
vs
Fat
Carb
vs
non-carb ??
Sequence of label
Total CHOs
important,
“Sugars”
not
Grams as volume
vs
wt
Part of meal
vs
snack OK?
CHOs in intended
serving?
CHOs
vs
Fat/
Chol
vs
Na
Location of relevant
CHO
(carb)
gms
How many CHO
gms
in
1 serving?
Subtract fiber
gms
from CHO
gms
Plan a meal or snack
43Slide44
Our efforts
Describe job of self-care from patients’ perspectiveIdentify the job’s most critical tasksTrace (and limit) cognitive complexity of learning tasksDifferentiate instruction by ability (“literacy”) levelProvide scripts for providers that minimize complexity
Provide patient handout that reinforces learningHow different
in ability can adults be?44Slide45
Typical literacy items, by difficulty levelNational Adult Literacy Survey (NALS), 1993
NALS difficulty level (& scores)
% US adults
(age 65+) peaking at this levelSimulated everyday tasks 5(375-500)
3%
~
0%
Use calculator to determine cost of carpet for a room
Use table of information to compare 2 credit cards
4
(325-375)
15%
4%
Use eligibility pamphlet to calculate SSI benefits
Explain difference between 2 types of employee benefits
3
(275-325)
31%
16%
Calculate miles per gallon from mileage record chart
Write brief letter explaining error on credit card bill
2
(225-275)
28%
33%
Determine difference in price between 2 show tickets
Locate intersection on street map
1
(0-225)
23%
47%
Total bank deposit entry
Locate expiration date on driver’s license
Daily self-maintenance in modern literate societies
45Slide46
NALS
difficulty level (& scores)
% US adults (age 65+)
peaking at this levelSimulated everyday tasksNational Adult Literacy Survey (NALS), 1993) 5(375-500)
3%
~
0%
Use calculator to determine cost of carpet for a room
Use table of information to compare 2 credit cards
4
(325-375)
15%
4%
Use eligibility pamphlet to calculate SSI benefits
Explain difference between 2 types of employee benefits
3
(275-325)
31%
16%
Calculate miles per gallon from mileage record chart
Write brief letter explaining error on credit card bill
2
(225-275)
28%
33%
Determine difference in price between 2 show tickets
Locate intersection on street map
1
(0-225)
23%
47%
Total bank deposit entry
Locate expiration date on driver’s license
level of inference (“connecting the dots”)
abstractness of info
distracting information
number of features to match
Not
reading per se, but “problem solving”
T
ypical literacy items, by difficulty level
National Adult Literacy Survey (NALS),
1993
46Slide47
Complexity & aging
47Slide48
g -
Basic
information processing(GF)Basiccultural Knowledge(GC)Age-related cognitive declineLearning & reasoning ability
Age 8
48
Age 80Slide49
Our efforts
Describe job of self-care from patients’ perspectiveIdentify the job’s most critical tasksTrace (and limit) cognitive complexity of learning tasksDifferentiate instruction by ability (“literacy”) levelProvide scripts for providers that minimize complexityProvide patient handout that reinforces learning
49Slide50
“Rx for Physical Activity”
for a Rural Community Health Center
Linda S.
Gottfredson, PhDSchool of EducationUniversity of DelawareKathy Stroh, MS, RD, CDEDiabetes Prevention & Control Program
Delaware Division of Public Health
Presented at the 2009 Diabetes Translation
Conference of the Centers for Disease Control & Prevention (CDC).
Long Beach, CA, April 24, 2009
50Slide51
51Slide52
52Slide53
Basic pedometer—just counts steps53Slide54
Graduated Rx
Basic
Rxincreases
speedhttp://www.udel.edu/educ/gottfredson/Rx
54Slide55
55Slide56
Teaching the teacher: Script for CDE when prescribing “Rx for Walking”
Provides the CDE with:
Educationally sound teaching strategyKey ideas Content, sequence, and pace of instruction, etc.Implicit training Be concrete, personalize, use meaningful metaphors, etc.
56Slide57
57Slide58
58Slide59
59Slide60
Lesson plan: Don’t assume they know what’s obvious to you
Can’t assume:
That patient will know:
What a pedometer is How to wear it The exact regimen of the Rx i.e., extra stepsThat the educator will know specific learning steps for: Aim of script (e.g., extra steps) How to adjust regimen60Slide61
Our efforts
Describe job of self-care from patients’ perspectiveIdentify the job’s most critical tasksTrace (and limit) cognitive complexity of learning tasks Differentiate instruction by ability (“literacy”) levelProvide scripts for providers that minimize complexity
Provide patient handout that reinforces learning61Slide62
62Slide63
Thank you.
Questions?Advice?63Slide64
64Slide65
5 levels of diabetes educators*Level 1, non-healthcare professional,
Level 2, healthcare professional non-diabetes educator,Level 3, non-credentialed diabetes educator,Level 4, credentialed diabetes educator, andLevel 5, advanced level diabetes educator/clinical manager.*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf
65