Community Nurse Diabetic Clinic
One of the hallmarks of economic progress is ironically the fact that certain kinds of diseases become far more common. Diabetes is one of these diseases. The causes for diabetes are complicated, including genetic as well as environmental factors: It is linked to the abundance of food in modern American society, culinary traditions brought from cultures of origin, lack of easy access to healthy foods to many working-class Americans, lack of education about diabetes, and lack of access to health care by many Americans.
The problem is so complex — and the personal consequences for those individuals with diabetes — that it can seem overwhelming. Where does one start in trying to address the problem of the widespread nature of diabetes? And specifically how can one as an individual begin to help individuals fighting the disease?
This thesis explores one possible answer to the problem of an appalling high rate of diabetes in the Hispanic community in Allentown, Pennsylvania. The establishment of a clinic that is aimed at the specific needs of Hispanic patients with diabetes and primarily Type II diabetes. The care given at this clinic will be comprehensive, providing instruction in blood-sugar testing, discussion of the range of drug treatments that are possible, nutrition information, advice on the ways in which exercise can help dramatically increase the health of diabetics, and a variety of types of support that will help promote both behavioral changes and a sense of personal control over each individual’s sense of their own health. The clinic will incorporate best practices derived from science and medicine blended with cultural sensitivity to this particular patient population.
Scope of the Problem
It would be difficult to exaggerate the degree of the problem of the rates of diabetes in the Hispanic population in the United States today. Hispanics are a growing segment of the U.S. Population, representing one in seven Americans. There are currently about 47 million Hispanics in the United States today, according to the 2008 American Community Survey 1-Year Estimates by the U.S. Census Bureau, a figure that it certain to rise after the 2010 decennial Census.
Although Hispanics are generally referred to as if they composed a homogeneous group, it is important to note that a number of different communities are classified as Hispanics (or Latinos/as). This proposal uses the definition of Hispanic that is used by the U.S. Census and so focuses on how people self-identify themselves. Generally those who so self-identify are either immigrants from or have forebears who were immigrants from the Spanish-speaking countries of North, Central, and South America as well as the Caribbean or (less often) Spain. Hispanics can be of different races, although most have both European and Native American ancestry.
Because Hispanics have such varied backgrounds, clinical approaches to treating them must be culturally sensitive to this range of social variation. Medicine is — as we all know — both science and art, and part of the art of medicine is being able to work with Hispanics within the context of their specific American sub-cultures while instituting all the best practices of medicine.
According to the U.S. Department of Health and Human Services’ National Institute of Diabetes and Digestive and Kidney Diseases (which conducts and supports basic and clinical research on many of the most serious diseases affecting public health), diabetes is the sixth leading cause of death for Hispanics and the fourth highest death rate for Hispanic women and elderly (http://www2.niddk.nih.gov/
). According to a 2003 U.S. Centers for Disease Control and Prevention report, more than 1.5 million Hispanic-Americans had diabetes, up from less than 1.2 million in 1997. This high rate of diabetes does not include undiagnosed cases.
The National Institute of Diabetes and Digestive and Kidney Diseases (http://www2.niddk.nih.gov/
) describes some of the issues of particular concern regarding diabetes in the U.S. Hispanic population. Among these factors are the fact that diabetes has an earlier onset in Latinos than in other populations, with the age of onset among Puerto Ricans and Mexican-Americans, between 30 to 50 years old.
Even more disturbing is the fact that Hispanics “are almost twice as likely to have diabetes as non-Hispanic whites of similar age, while diabetes is two to three times more common in Mexican-American and Puerto Rican adults than in whites.” Some Hispanics have slightly lower rates: For example, Cuban Americans have lower rates of diabetes than do Mexican-Americans and Puerto Ricans, but their rates are still higher than those of non-Hispanic whites.
The overall rate for diabetes for people aged 45-74 in different ethnic groups (still using statistics from he National Institute of Diabetes and Digestive and Kidney Diseases, (http://www2.niddk.nih.gov/
15.8% for Cuban Americans
12% for non-Hispanic whites
These figures have been steadily rising and there is no evidence that they have peaked yet.
Another very important aspect of diabetes in the Hispanic population is the fact that many Hispanics do not know that they have diabetes: This is true of all ethnic groups, in fact, but especially so for minorities. According to the American Diabetes Association, the rates of undiagnosed diabetes are as follows:
Total: 23.6 million children and adults in the United States — 7.8% of the population — have diabetes.
Diagnosed: 17.9 million people
Undiagnosed: 5.7 million people
Pre-diabetes: 57 million people
New Cases: 1.6 million new cases of diabetes are diagnosed in people aged 20 years and older each year. (American Diabetics Association, http://www.diabetes.org/diabetes-basics/diabetes-statistics/)
The seriousness of these figures is underscored — and exacerbated — by the fact that so many Americans either do not have any insurance at all or are under-insured. This is especially true for minorities, in large part because they are more likely than are whites to work in jobs that do not offer benefits. Until the just-enacted health-care reform law, people with diabetes were often denied insurance because it qualified as a pre-existing condition. The combination of factors — the growing number of Hispanics in the United States, the increasing rate of diabetes in Hispanics, the lack of access to quality medical care for many Hispanics, the cost in both money and personal well-being of lack of state-of-the-art medical care for diabetics — lead to the pressing need for the kind of comprehensive diabetes treatment clinic aimed at Hispanics being proposed here.
The problem in Pennsylvania mirrors that of the nation as a whole. According to the Pennsylvania Department of Health (http://www.portal.state.pa.us/portal/server.pt?open=512&objID=11200&mode=2&PageID=560279
), Pennsylvania has had a significant rate of increase in diabetes hospitalizations, accounting for more than ten per cent over the last two years. Eight per cent of adults of this state are affected by diabetes, which is higher than one per cent above the national average. Moreover patients from various counties in Western Pennsylvania have high rates of end-stage kidney disease, one of the more serious complications of diabetes.
In 2004, diabetes was the principal diagnosis in 23,725 admissions in Pennsylvania hospitals, accounting for 132,000 hospital days and more than $673 million in hospital charges (Pennsylvania Department of Health, www.dsf.health.state.pa.us/health/lib/health/diabetesfastfacts.pdf). Of these 2004 hospitalizations, 15.4% of patients with diabetes were hospitalized two or more times. Multiple hospitalizations were more common among certain populations, such as Hispanics and including Medicaid and Medicare recipients.
In the United States, probably the most important determinant of access to care is whether or not one has health-care benefits. In 2005, there were 46 million uninsured people in the United States (about 16% of the population). The uninsured rate increased from 2002 to 2003 for non-Hispanic Whites (from 10.7% and 20.8 million to 11.1% and 21.6 million). The number of uninsured Hispanics increased from 12.8 million to 13.2 million, which is equivalent to an increase in the rate of uninsured rate of 32.7%. (All figures are from the U.S. Census report “Income, Poverty, and Health Insurance Coverage in the United States,” www.census.gov/prod/2005pubs/p60-229.pdf).
The development of community-based diabetic clinics aims to focus on those that are at the greatest risk; the uninsured and under-insured. This project will aim to address those needs by providing free diabetic health care.
This project is designed to develop a business plan targeting the Hispanic Community of Allentown, Pennsylvania. This business plan will guide the development of a community nurse-managed diabetic health care center. This project will serve as a basis for further DNP work and implementation of this business plan.
Diabetes is a chronic disease affecting approximately 760,000 Pennsylvanians . Many people with Type II and gestational diabetes have no symptoms and learn they have diabetes only when they seek help for one of the many complications. At the present time there is no cure for diabetes, but research has shown that complications of diabetes can be greatly reduced with proper blood sugar control through healthy eating, physical activity, and use of medications. Still, diabetes is one of the leading causes of death in the United States and is responsible for nearly 3,600 deaths in Pennsylvania each year. (Pennsylvania Department of Health, Bureau of Health Statistics and Research, www.hhs-stat.net).
Type I diabetes is usually diagnosed in children and young adults and results from the body’s failure to produce insulin. Type 1 account for 5% to 10% of all diagnosed cases of diabetes (Centers for Disease Control, National Diabetes Fact Sheet, www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf). The most common form of diabetes is Type II, which accounts for about 90 to 95% of all diagnosed cases of diabetes (Centers for Disease Control, National Diabetes Fact Sheet, www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf). Pre- diabetes is a condition often present prior to the development of Type II diabetes. In pre-diabetes, blood glucose levels are higher than normal, but not high enough to be considered diabetic.
Pre-diabetes does not have to lead to the development of diabetes if a person diagnosed with this condition: Patients who work to control their weight and increase their physical activity can often prevent or delay the onset of diabetes. There are 41 million Americans who have pre-diabetes (Centers for Disease Control, National Diabetes Fact Sheet, www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf). There is extensive documentation regarding the correlation between diabetes and the increased death rates among Hispanics.
Diabetes has been increasing for years among Latinos, they say, not only among adults but also teenagers and young children. The diabetes death rate is at 10.4% for Hispanics because people with the disease often die from other conditions. In those cases, diabetes would not be listed on the death certificate as the cause of death, although it often is a contributing factor (American Diabetes Association, www.diabetes.org / ). Diabetes is an urgent health problem in the Latino community. The rates of deaths are almost double those of non-Latino whites. Disbursement of information to the Hispanic community about the seriousness of diabetes, risk factors and ways to manage the disease is essential. The proposed clinic would do just this.
The Pew Hispanic Center released an extensive study of young Hispanics, those aged 16 to 25 and their uneven assimilation into mainstream American society (pewhispanic.org/). The Pew Hispanic Center reports that Hispanics accounted for roughly 60% of the growth of America’s uninsured between 1999 and 2008. By the end of this period, Hispanics represented less than 16% of the overall U.S. population but 31.4% of those who lacked health insurance at any given time, according to the Census Bureau (“Income, Poverty, and Health Insurance Coverage in the United States,” www.census.gov/prod/2005pubs/p60-229.pdf).
According to the Pew Hispanic Report, “six-in-ten Hispanic adults living in the United States who are not citizens or legal permanent residents lack health insurance. The share of uninsured among this group (60%) is much higher than the share of uninsured among Latino adults who are legal permanent residents or citizens (28%), or among the adult population of the United States (17%).” (Pew Hispanic Center, http://pewhispanic.org/reports/report.php?ReportID=113
). The 2008 National Health Interview Survey (www.cdc.gov/nchs/nhis/released200906.htm) found that 34% of non-elderly (under age 65) Hispanics reported being uninsured, compared with just 14% of non-elderly non-Hispanics. About 43% of uninsured Hispanics reported that they had never been insured, compared with only 15% of the non-Hispanic uninsured.
The new health-care reform law prohibits illegal immigrants from receiving Medicaid. It also prohibits them from buying health insurance through the insurance exchanges that will be set up. Given that many illegal immigrants — indeed probably most — work in jobs that do not provide health-insurance coverage coupled with barriers to federal insurance and buying private insurance, there will be tens of thousands of Hispanics who will remain uninsured even after all of the provisions of the new health-care act have been put into effect.
There are also other barriers to Hispanics seeking health insurance. Accordin to the Pew Hispanic Center, those Hispanics who mainly speak Spanish, who lack U.S. citizenship, or who have had only short tenures in the United States are less likely than other Latinos to report that they have a usual place to go for medical treatment or advice.
Six-in-ten Hispanic adults living in the United States who are not citizens or legal permanent residents lack health insurance. The share of uninsured among this group (60%) is much higher than the share of uninsured among Latino adults who are legal permanent residents or citizens (28%), or among the adult population of the United States (17%).
Hispanic adults who are neither citizens nor legal permanent residents tend to be younger and healthier than the adult U.S. population and are less likely than other groups to have a regular health care provider. Just 57% say there is a place they usually go when they are sick or need advice about their health, compared with 76% of Latino adults who are citizens or legal permanent residents and 83% of the adult U.S. Population. (Hispanics, Health Insurance and Health Care Access, http://pewhispanic.org/reports/report.php?ReportID=113)
Recent immigrants, because of their youth, do tend to be healthier than Hispanics overall. (Young people are generally healthier than older people, regardless of ethnicity or country of origin.) However, there are tens of thousands of elderly Hispanics. Moreover, while young Hispanics will be generally healthy because of their age, they often work doing manual labor and so are more subject than the American population at large to be injured on the job. Although they should thus be eligible for benefits under workers’ compensation, they may not be if they are not in the United States legally or if they are working off the books.
The Pennsylvania Commonwealth Fund 2002 report states that Hispanics are less involved in their health care than they would like and that Hispanics find it harder to understand instructions from their doctors, especially in terms of not fully understanding their treatment plans. These on-going plans in terms of medication, diet, and exercise are essential for diabetics to maintain the highest quality of life and to avoid long-term complications from diabetes (http://www.commonwealthfund.org/Content/Grants/2002/May/Evaluating-Strategies-to-Fill-Gaps-in-Health-Insurance.aspx),
Given the increasing growth of the Hispanic population in the United States, it is imperative that the American health system continue to develop cultural competence policies that address attitudes, knowledge and skills about cross-cultural education. Hispanics have demographic trends, historical traditions, traditional medicine knowledge, fundamental values and beliefs, legal status, language/communication needs that must be addressed.
The Pew Hispanic Center’s 2007 Latino Health Survey (pewhispanic.org/reports/report.php?ReportID=91) explores not only their differential access to health care by different sub-populations, but also their sources of health information and their knowledge about diabetes. This is the most comprehensive national survey done to date on the issue and provides a snapshot of the ways in which Hispanics are currently accessing health carfe.
The survey finds that among Hispanic adults, the groups least likely to have a usual health care provider are men, the young, the less educated and those with no health insurance. (A similar demographic pattern applies to the non-Hispanic adult population that lacks a regular health care provider.) Four-in-ten (41%) non-citizen, non-legal permanent resident Hispanic adults state, that their usual provider is a community clinic or health center. Some 15% of Latino adults who are neither citizens nor legal permanent residents report that they use private doctors, hospital outpatient facilities, or health maintenance organizations when they are sick or need advice about their health.
An additional 6% of Latino adults who are neither citizens nor legal permanent residents report that they usually go to an emergency room when they are sick or need advice about their health while 37% of Latino adults who are neither citizens nor legal permanent residents have no usual health care provider. More than one-fourth (28%) of the people in this group indicate that financial limitations prevent them from having a usual provider.
The above conditions demonstrate how nurse-managed centers and free community clinics could play a crucial role in the delivery of diabetic preventative care.
Nurse-managed centers, working collaboratively with physicians, clinical nurse specialists and other health-care providers provide care for the uninsured. Federal and state funding along with corporate grants assist in providing primary, non-emergency-care services that vary according to the needs of the communities served.
Among those treated at nurse-managed centers are people of low income who cannot afford health insurance, the under-insured, homeless people and those who have immigrated to the U.S. without financial resources or English-language skills. The promotion of disease prevention and wellness are universal clinic goals, as health teaching is central to care delivery systems (Rose, 2009). In response to this problem, hundreds of communities across the country have found solutions by developing and supporting free clinics. The Free Clinic in Doylestown is an example of a successful clinic. Social worker Peggy Dator is the executive director and founder of the clinic. Dator said that this clinic, founded in 1994, was one of the first free clinics in Pennsylvania. From the start it was organized to meet the medical needs of low income uninsured and under-insured, adults and children residing in the central Bucks County community.
The Free Clinic of Doylestown provides free medical care to adults and children. Ms. Dator is the only paid full time staff and there are five nurse practitioners who volunteer in the clinic and two of which provide free care in their offices upon referral. Annually they serve 1,000 adults and children. To date they have served over 7,300 individuals and have provided almost 30,000 patients visits in their free clinic program (Dator, personal communication, 2010).
Another example of a free clinic is the “Diabetes Drive-Thru.” This may conjure up images of fast-food indulgences and insulin overload, but the blood-sugar screening program at King’s Daughters Hospital in Temple, Texas, actually serves up something sweeter. In about five minutes, “customers” drive through three nurse-staffed stations and receive free tests, results, and information without leaving their cars (Nursing Spectrum Staff, 2009).
Nurse-managed health centers have been the catalyst for providing care to those who would not otherwise have it. They proved that they are effective, that they provide high-quality care. Over the past two years there has been a lot of local political support that recognized the importance that providers such as nurses can help strengthen the safety net. Funding is crucial for a successful clinic. Federal funding is limited; however donations and grants are available through private sources. For example, Dator reported that nearly all of her center’s funding came from foundation grants and private donations.
There are numerous examples of nurse-managed centers that can be used as models for everything from fund-raising to staff organization for the clinic described in this proposal. Pennsylvania Gov. Ed Rendell spoke in favor of nurse-managed health centers, a component of his state health-care reform plan, at the same briefing. “Greater nurse practitioner involvement in chronic care and rapid response is the inoculation we need to prevent rising health-care costs and ensure greater access to health care,” Rendell said (George, 2009 ).
Nurse managed centers of primary health care have emerged as one of the newest innovative models. With Managed care systems and state level reforms being introduced in an attempt to control health care costs, the nursing profession has increasing opportunities to demonstrate, the ability to contribute in the area of health care access, quality and cost effectiveness. This project will provide quality comprehensive diabetic health serviced to all people served with special attention to the uninsured Hispanic community of Allentown, Pennsylvania.
American Diabetics Association. Retrieved 22 March 2010 from http://www.diabetes.org/diabetes-basics/diabetes-statistics/
Centers for Disease Control, National Diabetes Fact Sheet.Retrieved 18 March 2010 from www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf
2010 from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf www.cdc.gov/nchs/nhis/released200906.html
National Institutes of Health. Retrieved 18 March 2010 fromhttp://www2.niddk.nih.gov / http://www.commonwealthfund.org/Content/Grants/2002/May/Evaluating-Strategies-to-Fill-Gaps-in-Health-Insurance.aspx
Pennsylvania Department of Health. Retrieved 23 March 2010 from (http://www.portal.state.pa.us/portal/server.pt open=512&objID=11200&mode=2&PageID=560279
Pennsylvania Department of Health, Bureau of Health Statistics and Research. Retrieved 21 March 2010 from http://www.hhs-stat.netrts/report.php?ReportID=113
Pew Hispanic Center report Hispanics, Health Insurance and Health Care Access. Retrieved 22 March 2010 from http://pewhispanic.org/reports/report.php?ReportID=113
Pew Hispanic Center’s 2007 Latino Health Survey. Retrieved 21 March 2010 from pewhispanic.org/reports/report.php?ReportID=91.
Rose, J.F. (2009)
Nurse-run clinics offer hope to nation’s tired, poor and uninsured. Retrieved 28 March 2010 from http://nursing.advanceweb.com/editorial/content/editorial.aspx?CC=204382
U.S. Census. American Community Survey 1-Year Estimates by the U.S. Census Bureau. Retrieved 28 March 2010 fromhttp://factfinder.census.gov/servlet
U.S. Census. “Income, Poverty, and Health Insurance Coverage in the United States,”