PA cAARds!
An integrated intervention for diabetes and tobacco control
professionals and paraprofessionals
Marlin L. Williams, MBA
Diabetes Symposium
November, 17 2010
Training Objectives
• Improve understanding of statewide and local resources for
diabetes education and management and tobacco cessation
services
• Improve understanding of integrated strategies and identify
where organizations fit into the organizational integration
continuum
• Encourage you to attend PA cAARds! Training
• Increase the use of the Ask Advise Refer brief intervention in
diabetes and tobacco programs
• Increase the use of PA cAARds among community based
health care organizations
PA cAARds!
• PA cAARds! is the first integrated initiative of its kind
in Pennsylvania and a unique collaborative effort
between the Pennsylvania Department of Health’s
Diabetes and Tobacco Prevention and Control
Programs
PA cAARds! Is funded by the Pennsylvania Department of Health
Problem
133 million people, or almost half of all Americans live
with a chronic condition. That number is projected
to increase by more than one percent per year by
2030, resulting in an estimated chronically ill
population of 171 million
Tobacco Use is one of the single most modifiable risk
factors of ALL chronic diseases
Data from www.improvingchroniccare.org. 2008
Problem
• In 2007, it was estimated that 26.3 million individuals or 7.8%
of the US population were diabetic. Of those, 5.7 million were
undiagnosed. (CDC, 2008)
• A study published in the December issue of Diabetes Care
suggests that the number of Americans with diabetes is
expected to nearly double by 2034 (Diabetes Care, 2009)
• Smoking represents the leading cause of preventable death in
the Unites States; Responsible for 1 in 5 deaths (CDC, 2009)
• In Pennsylvania, there are more than 764,000 adults
diagnosed with diabetes and approximately 17% of them
smoke. (CDC 2005, BRFSS 2006)
Smoking & Diabetes
A dangerous combination
• Smoking increases the harmful effects of diabetes by
making diabetes more difficult to control (JRSPH, 1998)
• Smoking increases diabetes-related complications
that include blindness, kidney disease, heart disease,
and neuropathy (JRSPH, 1998)
Tobacco Use & Diabetes
Tobacco use…..
• narrows blood vessels contributing to high blood pressure, heart
disease and poor circulation in those with diabetes(CDC, 2004).
• increases insulin resistance and deteriorating diabetes control
(Diabetes Care, 1999)
• increases the risk for Peripheral Arterial Disease, multiplying the
likelihood of amputations by 5. (of people with diabetes who need
amputations, 95% are smokers)(Diabetes Care, 2001)
• is suggested in studies to be an independent risk factor for type 2
diabetes (JAMA, 2007)
• doubles the risk of heart disease in people with diabetes
(approximately 65% of people with diabetes die from heart disease
and stroke (CDC, 2005)
For nonsmokers…
• Approximately 60% of non-smokers have biological
evidence of TSP exposure
• The combination of diabetes and secondhand smoke.
• raises the risk of developing glucose intolerance
• decreases the ability of the pancreas to make insulin
• reduces the insulin sensitivity in people with type -2
diabetes
Smokeless tobacco products
• Spit, oral, chew, snuff and dip are not safe
alternatives to smoking.
• People who dip or chew get comparable amounts of
nicotine to regular cigarettes.
• Chew tobacco is high in sugar.
Economic Toll
• In 2004, cost for diabetes hospitalization in PA reached
$673 million and accounted for more than 131,000
hospital days. (PADOH, 2007)
• Over the past five years, total costs in PA reached $2.6
billion and accounted for more than 649,000 hospital
days. (PADOH, 2007)
• Direct health care and lost productivity costs due to
smoking related illness are estimated for PA to be over
$8.5 billion annually. (PADOH, 2008)
Due to the complex and overwhelming
relationship between diabetes and tobacco
use/exposure, addressing the harmful impact
requires an integrated approach that
emphasizes communication across disciplines.
Solution
• The goal of PA cAARds! is to proactively address the
dual risks of unmanaged diabetes and tobacco use by
maximizing utilization of regional and statewide
resources.
– educate health care and other CBOs providing diabetes
and/or tobacco cessation in an integrated brief
intervention and referral process
– work with these organizations to sustain integrated
tobacco, diabetes, and other chronic disease efforts.
PA cAARds!
• Integrated brief intervention and referral process
where diabetes and tobacco professionals are
trained to use the Ask, Advise, Refer intervention
with their patients/clients
• The Ask, Advise, Refer model integrates the “5 A’s”
(Ask, Advise, Assess, Assist, Arrange)
• Ask/Advise/Refer based on ADHA’s/SCLC’s
adaptation of 5A’s
PA cAARds!
• Adapted from California’s Do you cAARd?
Program
• Adapted to Pennsylvania
• Bidirectional between diabetes and tobacco
Development Process
 Literature review and environmental scan
 Recruited diabetes and tobacco control key
stakeholders
 Facilitated a planning summit
 Solicited regional review and feedback
 Solicited DOH Feedback
 Pilot the initiative
Implementation
Intervention
• Primary tool in addressing the dual risks of
unmanaged diabetes and tobacco use/exposure
• Facilitate cross referral
• Do not need to be cross-disciplinary experts
• “Brief” Intervention
• Group & Individual Settings
Intervention
Motivational Interviewing
• a directive, client-centered counseling style for
eliciting behavior change by helping clients to
explore and resolve ambivalence.
The art of getting people to do what you want them to
do because they want to do it.
(Dwight Eisenhower)
Referral
Goal: Facilitate cross referral to get patients/clients
into appropriate services.
• Option of choosing between local or statewide
services
• Provide referral tool (available on website and in
your packets)
• Complete referral tracking form
Referral
• Local Resources
Referral Lists and Regional Prescription
– Community diabetes management/education programs
– Community tobacco cessation programs
• Statewide Resources ( Take Charge Card ordered thru the website)
– PA Free Quitline
• Community based health care organizations use Fax referral form
along with the Take Charge Card)
– American Diabetes Association
Quitline (Diabetes Providers) (1-800-Quit Now)
• Free evidence-based, individualized phone cessation
counseling
• Multiple counseling sessions to callers committed to
quit
–
–
–
–
–
Work with clients to set a quit date
Offer information about medications
Recommend tactics for dealing with urges
Provide suggestions for reducing triggers to smoke
Provide referrals to local cessation providers
National Diabetes Help Line (1-800-Diabetes)
(1-888-Diabetes regional office)
• Center for Information & Community Support
• Provides information on managing diabetes and
nutrition
• Local educations classes
• Support groups
Referral Tools
• Take Charge Card (statewide diabetes
management/education and tobacco cessation)
– Fax Referral provided in tandem with the Take Charge Card
(Diabetes professionals/paraprofessionals)
• Regional Prescription Pad (local referrals)
Fax Referral
• PA DOH tobacco prevention and control program is
partnering with PA cAARds! to pilot the fax referral
process with community based health care providers
• Fax referral will serve as a tool to facilitate referral to
the PA Quitline which is the statewide resource for
PA cAARds!
Fax Referral
• Links the services of the Quitline directly to your
patients with your help.
• Tobacco users no longer have to take the first step in
calling the quitline.
• Quit coach pro-actively contacts your patients to
provide an intervention after receiving a fax referral
from you.
Technical Assistance
• Provide technical assistance related to integration
readiness and implementation outreach and
strategies to build organizational capacity
– Providing training to utilize an evidence-based curriculum
alone does not guarantee that a program will be
successfully adopted within an organization
– HPC will also provide ongoing comprehensive technical
assistance (TA) for organizations participating in the
training workshops to implement and sustain PA cAARds
Technical Assistance
Programmatic T/A
– help address and resolve any issues or questions regarding
curriculum, tools , state and/or local resources and
referrals (website)
Intensive T/A
– Increase organizational capacity to sustain integrated
diabetes, tobacco and other chronic disease efforts
(Leadership buy-in, Policy Development, Systems Change)
Integration Continuum
Not Linked
Communication
Cooperation
Coordination
Collaboration
Partnership
Fully Linked or
INTEGRATED
Not Linked -We don’t work together at all and have separate program goals.
Communication –We share information only when it is advantageous
Cooperation –We share information and work together when any opportunity arises
Coordination - We work side-by-side (independently) to achieve common program goals
Collaboration – We work side-by-side and actively pursue opportunities to work together
Partnership – We work together with specified responsibilities to achieve common program
goals
Fully Linked or Integrated – We mutually plan, share staff and/or
evaluate activities to accomplish our common goals.
funding resources and
Integration Model adapted from NACDD Tobacco Program Integration Report 2004
Website
• PA cAARds web portal is a trainee-specific tool
that allows you to:
– Download curriculum, tools and materials
– Receive technical assistance
– Communicate with the project staff and other
trainees (message board and blog)
– Report referrals and success stories
– Access national and local resources (i.e. articles,
toolkits, data reports etc.)
Continuing Education Credits
• UPMC
• Dietician, Social Work, Nursing, General Health Care
Professional
• 5.5 credit hours
• Credit Designation
• Course Evaluation
North East Training
December 1, 2010 10am – 4pm
Monroe County Public Safety Center
100 Gypsum Road, Suite 2
Stroudsburg, Pa 18360
To register please visit www.pacaards.org
THANK YOU
on behalf of……..
Pennsylvania Department of Health
Diabetes Prevention & Control
Tobacco Prevention & Control
Health Promotion Council
Acknowledgements
BE A BRIDGE Partnership
California Diabetes Program
California Smoker’s Helpline
Regional Advisory Council Members and Other Key
Stakeholders
Marlin Williams
215-731-6109
marlin@phmc.org