Bringing health care home

Diabetes is the seventh leading cause of death in America, with more than 30 million adults diagnosed with the disease. Although people with type 1 diabetes often require daily insulin injections, type 2 diabetes can be managed with diet, physical activity, and medications that control blood sugar levels. Texas A&M University Health Science Center, through the Brazos Valley Care Coordination Program, is going to the heart of the issue—by going to patients’ homes and educating them about the best diabetes management techniques.

The majority of these patients have high hemoglobin A1c (HbA1c) levels, which is a measure of blood sugar. Due to lack of transportation or their work schedules, they are unable to attend diabetes education classes offered by Texas A&M, so the community health workers come to them, either at their homes or wherever else is convenient for them.

This program is a part of A&M Rural and Community Health Institute, a health extension center that offers programs to promote safe, effective health care practices. The Brazos Valley Care Coordination Program ensures appropriate follow-up care for patients discharged from the hospital, thereby decreasing the volume of frequent emergency department users.

“We have partnered with the Brazos Valley Food Bank, which provides diabetic-friendly food boxes,” said Debbie Muesse, BSN, RN, program manager of the Brazos Valley Care Coordination Program. “We take boxes to the patients, going through all of the food items, and we teach them about healthy eating, helping them learn about foods high in sugar versus foods that make a balanced diet.”

The home visit service is part of their arrangement with Texas A&M Physicians, a medical practice consisting of faculty, resident physicians and staff from Texas A&M College of Medicine. Patients referred from this practice receive visits from certified community health workers who teach them how to manage their diabetes through diet.

“Our community health workers provide diabetic education,” Muesse said. “This includes teaching patients about the Plate Method—which helps with portion control of food, healthy cooking tips, properly reading nutrition labels and the importance of physical activities. Patients are also provided educational booklets on diabetes management.”

These health professionals spend approximately two hours with each patient, asking them to describe an everyday pattern of eating and suggesting healthier alternatives.

Diabetic monitoring engages patients in preventative behaviors to prevent further health deterioration.

“Teaching proper diet can improve patients’ HbA1c levels, if they apply the diabetes management plan that we recommend,” Muesse said. “This test looks at the last three months of a patient’s blood sugar level, like a marker on a cell. We want this number to stay below nine, which indicates a more controlled blood sugar. We started this program in June, and already I can tell you that one patient dropped her HbA1c by 2.5 points in a month after our visit. We do follow-up visits, and if a patient like the one I mentioned is determined to be doing well, then they have completed this program.”

Muesse is interested in getting more data on patients’ HbA1c test results. In particular, she wants to compare patients’ data one to three months after the intervention. As the home visits reach more patients, test results can be quantified to see how this program is impacting diabetic patients who would not have access to educational materials otherwise.

“Some patients have HbA1c  levels above 14, which is way out of control” Muesse said. “We would like to see all patients get within a normal level. Keep in mind, diabetes contributes to other health conditions, such as heart disease, stroke, kidney disease and even vision loss. By addressing diabetes, we can possibly limit these serious health risks as well.”