The Providence St. Peter Hospital
Boldt Diabetes Center & Family Medicine
Medical Assistant Curriculum
For
Diabetes Self-Management Care
The Providence St. Peter Hospital Boldt Diabetes and Family Medicine Teams
Author:
Janet F. Wolfram R.N., M.N., C.D.E.
Boldt Diabetes Center
Providence St. Peter Hospital
Olympia, WA 98506
Family Medicine and Boldt Diabetes Center Team Members:
Devin Sawyer M.D.
Linda Gooding R.D., CDE
Shari Gioimo C.M.A.
Michelle Edmonston M.A.
Acknowledgments:
The Medical Assistants at Providence St. Peter Hospital Family Medicine
Joe Wall, Executive Administrator at Providence St. Peter Hospital Family Medicine
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Heidi Vasilauskas RN, Manager at Providence St. Peter Hospital Family Medicine
Cassandra Beard, Data Specialist at Providence St. Peter Hospital Family Medicine
Staff and Patients at Providence St. Peter Hospital Family Medicine and Boldt Diabetes Center
Special thanks to:
Carol Brownson, Robert Wood Johnson Foundation Diabetes Initiative at Washington University
in St. Louis.
Sharon Fought RN, PhD at University of Washington School of Nursing.
Stephen Luippold, RN, MSN, Boston University.
Janet Primomo RN, PhD, Univeristy of Washington School of Nursing.
Melissa Rickert, MPH, Saint Louis University School of Public Health.
Judith Schaefer M.P.H., MacColl Institute for Healthcare Innovation.
Loren Williamson, Photographer.
Medical Assistant Curriculum for Diabetes Self-Management Care
Table of Contents
I.
Introduction………………………………………………………………….4
II.
User Guidelines……………………………………………………………..13
III.
Curriculum Outline…………………………………………………………14
IV.
The Medical Assistant Curriculum- “Daytime Hollywood”
Day One:
1.
Welcome and Icebreaker……………………………………………….25
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2. “Survivor”-- Essential Diabetes Self Management Skills……………….27
3. “Another World”-- Expanded Role of the MA in the CCM………….....38
4. “The Young and the Restless”-- Exercise and Diabetes ……..………....28
5. “Concentration”-- Didactic Diabetes Information……………………….33
Day Two:
6. “Days of Our Lives”-- MA Self-Management Log Review……………..48
7. “Wheel of Fortune”-- Practice with the SMGC…….…..………………..57
8. “Edge of Night”-- Diabetes Complications…………………….……..…60
V.
References……………………………………………………………...........64
VI
Appendices…………………………………………………………….....….66
I.
Introduction:
Purpose
The Medical Assistant Curriculum for Diabetes Self-Management Care is intended to be
used as a guide by certified diabetes educators (CDEs) who are assisting community family
medicine teams adopt a comprehensive planned care model for diabetes patients. This curriculum
is designed to augment the skill and knowledge level of Medical Assistants (MAs) in the area of
diabetes care, within their scope of practice. It incorporates a combination of information from
professional CDE course material and patient oriented diabetes self-management education
(DSME) courses.
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CDE Mandate
In January of 2006, the American Association of Diabetes Educators (AADE) announced
their full support for the adoption of the Chronic Care Model (CCM). CDEs were encouraged to
support the relationship between patients and the providers using the CCM in caring for people
with diabetes (Peeples, 2006). Using this curriculum as a tool to train MAs is one way that CDEs
can extend their expertise into the family medicine community.
Program Background
The Medical Assistant Curriculum for Diabetes Self-Management Care began as a
coordinated effort between two Providence St. Peter Hospital (PSPH) outpatient departments,
Family Medicine (FM) and the Boldt Diabetes Center (BDC). In 2003, PSPH was funded through
the Robert Wood Johnson Foundation (RWJF) Diabetes Initiative’s Advancing Diabetes SelfManagement national program. One of the objectives of this program was to demonstrate that
self-management support, one of the six components of the CCM, can be successfully
demonstrated in primary care settings.
The components of the CCM (self-management support, decision support, delivery system
design, clinical information systems, health systems, and community support) were first presented
by Group Health Cooperative of Puget Sound, Seattle (Wagner, Austin, Van Korff, 1996). These
components provided a workable structure to deliver and maintain planned care within an
ambulatory care setting.
Bodenheimer, 2003, described the activities required of team members providing planned
care in family medicine. These activities include the support for patient self-management and goal
setting, maintaining patient population registries, organizing group visits, performing planned care
visits with standing orders, and conducting telephone inquiries. These concepts are reflected in the
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Self-Management Goal Cycle (SMGC), the framework created by PSPH to depict their approach
to advancing diabetes self-management through support of patient goal setting (Sawyer, 2006). In
developing the SMGC, the PSPH team recognized the central role of the MA for the successful
FM redesign for chronic illness care.
Figure 1: The Self-Management Goal Cycle
Implementing the Self-Management Goal Cycle
As shown in Figure 1, the steps of the cycle are depicted in a wheel starting with the
identification of patients with diabetes and their entry into the Chronic Disease Electronic
Management System (CDEMS), an outcomes tracking computer program used in the State of
Washington through the support of the Washington State Diabetes Collaborative. The next step
is to invite patients to participate in a planned visit with a MA to acquire standard diabetes
laboratory testing, foot checks, immunizations, referrals, and behavioral goal setting. The
preliminary visit with the MA is designed to prepare the patient for a more in-depth visit with the
provider during which the patient-provider team can review and discuss the previous work-up,
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including laboratory results. Having the basic standards of diabetes care completed and entered
into the patient medical record saves on time which the provider can use to discuss the patient’s
self-management goals. The SMGC continues when the MA calls the patient two weeks after the
provider visit to checks-in and follow-up on the patient’s self-management goal. At this time the
patient is invited to join a small group visit to continue their diabetes care and education.
Designing the Medical Assistant Curriculum
The training of the MAs, in an expanded role in diabetes care and self-management, was
contracted to the BDC certified diabetes educators when the RWJF grant was awarded to PSPH in
2003. Literature searches for MA education and preparation related to planned care or the CCM
yielded little, so FM and the BDC devised their own training program.
The development of the MA curriculum began with a MA focus group to obtain feedback
and hear their concerns regarding their new responsibilities in implementing the SMGC. The MAs
expressed a heartfelt desire to help their patients manage diabetes and prevent complications.
They wanted to feel comfortable discussing diabetes with their patients (Barry & Barlow, 2003)
and felt that it was necessary for them to be as knowledgeable about diabetes as their patients.
The MAs expressed excitement about learning more about diabetes, and they were also
forthcoming in expressing what little they knew about the disease. During the focus group
sessions, the MAs indicated that the diabetes curriculum needed to be comprehensive and directly
applicable to their jobs. Further, they wanted the training to be conducted in an off-site setting so
that they were not pulled into the clinic or distracted by clinical demands. Finally, they wanted the
training to be fun!
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Three methods were used to ascertain the MA current knowledge and understanding about
diabetes. First, the curriculum outline from one local accredited MA training course was reviewed
regarding its diabetes instruction and content. The technical college’s course outline on diabetes
was brief, limited to the description of Type 1 and Type 2 diabetes, some common diabetes
medications, and then some common complications such as diabetes ketoacidosis.
Secondly, the MAs were given a knowledge survey adapted from the American Academy
of Clinical Endocrinology (AACE) patient survey (2002). Though multiple diabetes patient
knowledge surveys were reviewed, the AACE survey was the most difficult and comprehensive.
Thirdly, the MAs responded to surveys and interviews about their educational needs. They
wanted to know about:
Medications commonly used with diabetes.
Laboratory tests that they frequently requested from standing orders.
The digestion of food, how food turned into glucose, and how glucose entered the
blood.
And desired glucose ranges.
After an examination of the MA current preparation in diabetes care, two MAs from FM
attended the ADA certified patient diabetes self-management classes. These two MA
“champions” gave feedback to the CDEs regarding what was pertinent information to include into
the MA curriculum. These MAs reviewed and provided feedback on the PowerPoint slides used in
the class. Their insights and opinions were incorporated into the design of the MA curriculum.
Implementing the MA Training
Eighteen MAs, in groups of four to six, were initially rotated through the
curriculum program. The training incorporated cognitive, behavioral, and affective domains of
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educational activities. Teaching methods included lectures, PowerPoint, discussion, games, role
modeling, testing, and motor skill building. Every chapter used multiple methods to build on the
MA’s previous experience and knowledge.
To enliven the curriculum, a “Hollywood” theme was later designed. Titles given to the
didactic material were represented as recognizable television programs, e.g., “Wheel of Fortune”,
“Survivor”, etc. Celebrities with known diabetes were later incorporated to illicit discussion on
lifestyle and diagnosis.
Our experience suggests that the optimal number of MA participants during the training is
five, with an instructor ratio of 1:5. This size group is large enough for a variety of opinions and
lively discussion, yet small enough for detailed instruction and attention to individual needs.
During the skill building sections of motivational interviewing and goal setting, we found that the
material is best taught or co-taught with a MA peer leader and a ratio of 1:3. Skill building
stations for instruction on computer registry entry, telephone coaching, goal setting, and foot
checks promote a hands-on approach to education. These smaller, intimate, settings enhance the
MA learning of new skills, invite discussion, and build confidence.
Quality Improvement
The Plan-Do-Study-Act (PDSA) rapid cycle improvement process was used with each
training cycle. Improvements were made to the curriculum based on MA evaluations of the
program. The trainings were further evaluated in the FM team meetings where the MAs were
encouraged to give additional feedback on the curriculum. As a result, more information kept
being added to the curriculum.
The MAs discussed their concerns regarding their expanded role in the Self-Management
Goal Cycle. As they became more comfortable with the material in the curriculum and with
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information they learned through participation in RWJF trainings and conferences, the MA
champions became leaders and instructors themselves. For example, they developed their own
peer-led classes on skill building techniques for telephone follow-ups, foot checks, and goal
setting.
Curriculum Overview
The following curriculum matrix illustrates the relationship between components of the
MA curriculum and the MA roles within the Self-Management Goals Cycle. The columns reflect
the duties the MAs perform within the SMGC beginning with registry data entry, telephone
follow-up, planned visits, provider visits, and group visits. The rows itemize the didactic
components of the diabetes curriculum. The intersection of the rows and columns depicts the
applied knowledge for the job function.
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Curriculum Content and its Relationship to the Expanded Role of MAs in
Implementing the Self-Management Goal Cycle
Curriculum
MA Job Functions within the Self-Management Goal
Content
Cycle
Data
Registry
Entry
MA
Planned
Visits
Provider
Visits
Group
Visits
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Long-Term
Complications
X
X
X
X
Goal Setting
X
X
X
X
X
X
X
Age, Race,
Gender, Diversity
Awareness
Diabetes
Pathophysiology
Diabetes
Telephone
Interaction
SMGC
Tracking
X
Treatments
Acute
Complications
Reporting
Scope of Practice
Other considerations for the building of the MA curriculum included a review of the MA
scope of practice to ensure that the content of the curriculum followed the standards set by the
American Association of Medical Assistants and the Western Washington Area Health Education
Center. Documents were reviewed from the Washington State Society of Medical Assistants
including the Health Care Assistant Law 18.135 RCW, 1984 (2002).
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MAs at PSPH practice under the license of a physician. The MA role is delineated in a job
description, and performance is monitored by a nurse manager at PSPH using a competency based
skills checklist. As the MA role expanded to incorporate patient self-management functions, new
performance expectations were developed and integrated into the MA job description and skills
checklist.
Results
After the implementation of the MA training program, Sawyer (2006) reported the results
of patient satisfaction surveys on the SMGC program. Patient responses indicated that the patients
valued and trusted their interactions with MAs. Patient saw the MAs as “critical members of the
health care team.”
Two hundred and seventy-two patients participated in the SMGC program. Approximately
41% of all the patients within PSPH Family Medicine had HbA1c’s less than 7.0 and the patients
who did participate in the planned or group medical visits had even lower HbA1c’s than the
clinic’s average.
The BDC experienced a greater number of referrals from the FM providers. The MAs
automatically incorporated into their planned visit a referral to the BDC. Therefore the business at
the BDC benefited from sharing its expertise with the FM team. The CDEs became unofficial
team members of FM, and the MAs became very comfortable calling the CDEs about patient
concerns. The MAs and the CDEs became colleagues in the support of patient self-management.
Commentary
The course of health care delivery is rapidly changing from an acute care delivery system
to a chronic care delivery system. The MA participation in the delivery of chronic illness care has
economic and practical potential. However the MAs have been under-prepared and underutilized
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member of the patient care team. We hope this curriculum will be successful in helping diabetes
educators prepare MAs to fully participate in chronic illness care.
The strength of this curriculum comes from the engagement with the PSPH Medical
Assistants who were full participants in the curriculum design. I hope you enjoy this curriculum
as much as I enjoyed the cooperative journey in developing this program.
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II.
User Guidelines:
The Medical Assistant Curriculum for Diabetes Self-Management Care prepares the MA
for an expanded role in outpatient family medicine. The curriculum describes MA roles within the
framework of the Chronic Care Model, and supports the activities needed to implement the SelfManagement Goal Cycle. The curriculum is based on Mezirow’s Theory of Transformative
Learning and Critical Reflection, as well as Knowles’ Adult Learning Theory. The sessions are
interactive and they build on the MAs’ prior experiences in diabetes care and management.
We recommend that the trainers be Certified Diabetes Educators from local American
Diabetes Association Recognized Diabetes Self-Management Education programs. MAs with
prior experience in the Self-Management Goal Cycle may serve as assistant trainers. Peer to peer
instruction is especially powerful because the modeling of the necessary skills described in the
curriculum helps to enhance the MAs’ self-confidence in adopting the expanded role.
The intended audience for the training is MAs from area family medicine clinics and
offices. Attendees may also be other professional office staff members such as Registered Nurses
and Staff Assistants.
The class size may be variable. An ideal size is 5-10 participants with an
instructor/participant ratio of 1:5. During the skill building sessions, which include role-play and
return demonstration, the ratio is best at 1:3 with MA instructors present.
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III.
Curriculum Outline
Objectives
Content Outline
Time
Frame
Welcoming
MA will state reason for being at
the session.
MA will identify a favorite
personality who has/had
diabetes.
Materials
Teaching Methods
15 Minutes
Review the course outline.
Review the Notebook
Material
Collect MA completed
Surveys
Icebreaker and introduction
of people in the class.
List of famous people with
diabetes.
5 minutes
Laptop
LCD Projector
Notebook
Material
Lecture
PPT
10
minutes
Pictures of
Personalities
with Diabetes
PPT
Discussion
“Survivor” 3 Essential Self-Management Skills for Diabetes
90 Minutes
MA will demonstrate self-blood
glucose monitoring.
MA will demonstrate the proper
filling of an insulin syringe using
hospital aseptic technique with
100% accuracy
MA will name the carbohydrate
food groups with 100% accuracy
on a quiz
MA will properly match the
digestion process of
carbohydrates with the digestive
organ sites on a quiz.
MA will notate the serving size
and total gram of one food label
with 100% accuracy on a quiz.
MA will count the carbohydrate
content of common breakfast
foods with 80% accuracy on a
quiz using a carbohydrate guide.
Purpose of blood glucose
testing.
Normal blood glucose
ranges.
Techniques for glucose
testing.
Proper insulin
administration.
25
minutes
New glucose
test kits for each
seat.
Sharps
Container
PPT
Demonstration
Return Demonstration
Discussion
20
minutes
Demonstration
Return Demonstration
Discussion
Introduction of the food
components: carbohydrates,
fat, and protein.
Introduction of carbohydrate
containing foods.
The digestive process.
The absorption of glucose
into the blood.
5 minutes
Insulin start kit
for each seat.
Vial of normal
saline for each
seat.
Sharps
Container
USDA Food
Pyramid or
Chart
Carbohydrate identification
on food labels
5 minutes
Food label
Examples such
as Yogurt
Container
Carbohydrate counting
30
minutes
Breakfast Foods
5 minutes
PPT
Lecture
PPT
Lecture
Carbohydrate
Cards
PPT
Lecture
Demonstration
Return Demonstration
Discussion
Demonstration
Return Demonstration
Discussion
Quiz
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“Another World” Chronic Care Model, Self-Management Goal
Cycle, and the MA Scope of Practice
60 Minutes
List the six components of the
Chronic Care Model with 80%
accuracy on a quiz.
List the elements of the SelfManagement Goal Cycle with 80%
accuracy on a quiz.
The MA will demonstrate
understanding of his/her
understanding of the MA expanded
role and scope of practice by
answering Yes/No to questions with
100% accuracy on a test.
Quiz
The Chronic Care Model
(CCM).
The MA job responsibilities
within the CCM.
The Self-Management Goal
Cycle (SMGC).
The MA job responsibilities
within the SMGC.
The MA scope of practice
within any respective state.
20
minutes
LCD Projector
Laptop
20
minutes
Laptop
LCD Projector
15
minutes
Laptop
LCD Projector
Quiz
5 minutes
Quiz
PPT
Slides
Lecture
Discussion
PPT
Slides
Lecture
Discussion
PPT
Slides
Lecture
Discussion
Quiz
“ The Young and the Restless” Exercise and Diabetes
30 Minutes
Describe the physiological effects of
physical activity on blood glucose levels
with 100% accuracy on a quiz.
Physiological effects of
muscular activity on insulin
resistance.
5 minutes
LCD Projector
Laptop
Glucometer
List three barriers to physical activity on
a quiz.
Barriers to physical activity.
Solutions to these barriers.
10
minutes
Laptop
LCD Projector
List three safety behaviors for people
with diabetes participating in physical
activity on a quiz.
Mishaps which can occur with
physical activity and diabetes.
Safety measures to take to
prevent mishaps.
The Diabetes Prevention
Program (DPP).
Recommendations from the
DPP to prevent diabetes.
Quiz
5 minutes
Laptop
LCD Projector
5 minutes
Laptop
LCD Projector
5 minutes
Quiz
List two components shown to reduce
the incidence of Type 2 diabetes.
Quiz
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PPT
Slides
Lecture
Discussion
PPT
Slides
Lecture
Discussion
PPT
Slides
Lecture
Discussion
PPT
Slides
Lecture
Discussion
Quiz
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References
American Association of Clincial Endocrinologists, American College of Endocrinology (2002).
American Academy of Clinical Endocrinology Diabetes Guidelines, AACE Knowledge
Evaluation Forms. Endocrine Practice, 8 (Supplement 1) 71-77.
AACE Diabetes Mellitus Clinical Practice Guidelines Task Force (2007). American Association
of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Management of
Diabetes Mellitus. Endocrine Practice, 13 (Supplement 1), May/June.
Funnell, M.M., Arnold, M.S., Barr, P.A. (1997). Life with diabetes. Alexandria. American
Diabetes Association.
Franz, M.J. (Ed.). (2003). A core curriculum for diabetes education (5th ed.). Chicago: American
Association of Diabetes Educators.
Improving Chronic Illness Care
http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18
Institute for Healthcare Innovation, Chronic care model, Retrieved April 10, 2006.
http://www.ihi.org.
Institute for Healthcare Innovation (2003). Rapid cycle improvement process, testing changes.
Retrieved March 23, 2003.
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/testingchang
es.htm
Lorig, K., Halsted, H., Sobel, D., Laurent, D., Gonzalez, V., & Minor, M. (2000). Living a healthy
life with chronic conditions. Boulder: Bull Publishing Company.
Miller, W.R., & Rollnick S. (2002). Motivational Interviewing (2nd ed.). New York: Guilford
Press.
Piatt, G. A., Orchard,T.J., Emerson, S., Simmons, D., Songer, T.J., Brooks, M.M., et. Al. (2006).
Translating the chronic care model into the community. Diabetes Care, 29, 811-817.
Providence St. Peter Family Medicine Residency Program (2004), Diabetes initiative advancing
diabetes self-management in a primary care setting phase I: 2/03 to 6/04. final narrative report
for robert wood johnson foundation. Unpublished Report. Providence St. Peter Hospital.
Rickheim,P., Flader J., Carstensen, K. (2000). Type 2 diabetes pre/post knowledge test
Minneapolis: International Diabetes Center.
Rickheim,P., Flader J., Carstensen, K. (2000). Type 2 diabetes basics, a complete curriculum for
diabetes education. Minneapolis: International Diabetes Center.
First Edition 2006, Copyright 2006 Janet Wolfram janet.wolfram@providence.org
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Wagner, E.H., Austin, B.T., Von Korff, M. (1996). Organizing care for patients with chronic
illness. The Milbank Quarterly, 74, 511-545.
Washington State Society of Medical Assistants. (2002). Scope of practice and health care
assistant law. Retrieved March 27, 2004, from http://www.wssma.org
Wolfram, J.F., Primomo, J. (Submitted for Publication 2007). Preparing the Medical Assistant
Chapter 18.135 RCW
Health care assistants
Chapter Listing
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RCW Sections
18.135.010 Practices authorized.
18.135.020 Definitions.
18.135.025 Rules -- Legislative intent.
18.135.030 Health care assistant profession -- Duties -- Requirements for certification -- Rules.
18.135.040 Certification of health care assistants.
18.135.050 Certification by health care facility or practitioner -- Roster -- Recertification.
18.135.055 Registering an initial or continuing certification -- Fees.
18.135.060 Conditions for performing authorized functions -- Renal dialysis.
18.135.062 Renal dialysis training task force -- Development of core competencies.
18.135.065 Delegation -- Duties of delegator and delegatee.
18.135.070 Complaints -- Violations -- Investigations -- Disciplinary action.
18.135.090 Performance of authorized functions.
18.135.100 Uniform Disciplinary Act.
18.135.110 Blood-drawing procedures -- Not prohibited by chapter -- Requirements.
18.135.010
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