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Healthcare Without Walls (Pt. 2)

Moving patient education into the community

by Ginger Kanzer-Lewis RN, BC, EdM, CDE

This is the second of two articles that talk about new ways to deliver patient education. Part 1 presented a new model for moving patient education from traditional healthcare settings into the community. In this article, I test those concepts and share my recent experiences as a diabetes educator in the Florida Keys.

It’s not often you get to try a project that you have believed in for years. Does what you believe actually make sense and, more importantly, can your goals be accomplished? This winter I got to begin such a project that is very important to me. I call it Healthcare Without Walls.

My 5 goals for Healthcare Without Walls are clear and concise:

  1. Develop a diabetes self management education program (DSME) for the rural Florida Keys in community settings.
  2. Involve community leaders and healthcare professionals in the process.
  3. Conduct DSME group classes in various settings throughout the Keys.
  4. Measure and evaluate patient outcomes.
  5. Evaluate the effectiveness of this “new community model.”

The setting

The Florida Keys are a chain-like cluster of islands that begin about 15 miles south of Miami and extend in a gentle westward arc to Key West just 94 miles from Cuba.  The 125 miles of small islands are connected by bridges, so driving west you have the Gulf of Mexico on your right and the Atlantic Ocean on your left. It’s a wonderful, beautiful place, very rural and I live there 6 months of the year. (Now you probably hate me, sorry. To make it worse I live on a boat in Marathon, fifty miles from Key West.)

Tourism is essentially the only industry in the Keys. The people are mostly fisherman, dock hands, restaurant employees, hotel workers, and bartenders. Very few have health insurance, or extra funds and that’s a major problem.

For half the year, the secondary tourist population outnumbers the locals. From November 1st  to April 30th we have the snowbirds, mostly retired people from the Midwest and East Coast, who move down for the winter. Many have diabetes and little or no connection with medical care in the Keys.

There’s another group of residents on the islands who work full time, living in beautiful homes on the water. They use available healthcare and go to Miami for major concerns.

Several excellent physicians provide services to the community, but the numbers are limited. There’s a wonderful dietitian, Billie McGuire, RD, based at Fisherman’s Hospital in Marathon.  Billie is a certified diabetes educator (CDE) and is very involved in holistic care.

I’m the only CDE, RN in the area and my partner, Richard Arena, RPh, is a pharmacist and also a CDE. Last November we fulfilled the AADE’s  Diabetes Education Accreditation Program (DEAP) standards. We now offer the only nationally accredited DSME program in the Florida Keys.

Unfortunately, I’m only there half the year and that concerned me greatly when I set up the program. Please remember that this project is in process and not completed. I am writing this while in New York where I live during the summer.

Networking with local healthcare professionals

After arriving back in Florida last fall, it was necessary to conduct a more formal assessment while applying for accreditation of my new program.  

Meeting with local physicians was very interesting. Some were excited, some were concerned, and one or two thought their patients didn’t need a diabetes education program as long as they “stayed away from white food.”

Justifiably they wanted to make sure I knew what I was doing. Everyone got copies of my CV, one of my DVDs that shows me actually teaching a course, and copies of my books. That really helped a lot.

They were also given copies of my course outline and the assurance that they would sign education order sheets and get reports about their patients’ goals and competencies post course. The skeptical ones were put on my wait and see list which is fine. I accept that they need to learn about the program before trusting their patients to a stranger.

The meetings with healthcare professionals, from the public health clinics, was wonderful and very productive. They had patients that needed help and were delighted to find a colleague willing to provide it. So their patients were my first referrals. Public clinics operate 7 days a weeks and the calls started coming immediately.

The clinics are staffed by nurse practitioners and I have been asked to do a program for their group this fall when I return south. That is very important so we can collaborate on materials and language as part of Healthcare Without Walls. As I said in the first article, one of the objectives of this program is to make sure everyone speaks the same language and has the same goals. It is much less confusing for patients.

It was interesting when referrals started coming from the local mental health center. I shouldn’t have been surprised, as depression is common with diabetes. In retrospect, it was exciting to see these patients coping much better after attending classes and getting their diabetes under control. It wasn’t something I had considered as a goal of the program, but we all learn from new projects.

Partnering in the community  

Before starting classes, it was important to identify the best locations to meet patients’ needs. Where are the people with diabetes?

Since Marathon is centrally located in the Keys, has a diverse winter population, and is where I live, I decided to start there. I met with the president of the local AARP chapter, the local pharmacists, and my colleague, Billie McGuire, CDE .

I approached the manager of the wonderful resort where I live and he offered me the use of their conference room free of charge. In return, I agreed to list the resort as a co-sponsor on our marketing materials.  This proved to be a wonderful pattern.

After speaking to Rabbi Shimon Dudai at Temple Bnai Zion in Key West, I was allowed to use their common room for classes. The AARP Center in Plantation Key volunteered their site as well. The library at Outdoor Resorts at Long Key was the fourth location, co-sponsored by their women’s club who went door-to-door to solicit class participants.

These are beautiful locations with great facilities that took us out of the sterile medical or hospital setting that can be frightening. Sometimes I had to close the window shades to avoid the distracting water views.

The partnership now included the leaders of the communities and they were more than supportive. One of the major selling points to all involved was that I would only charge what Medicare and private insurance would pay and there would be no fee above that. I also built in openings in each class for people without health coverage of any kind. This was my contribution to the communities that co-sponsored the program.

I also offered to conduct classes for healthcare providers in the area. Because of the tight time constraints, I will be scheduling those next fall when I return to the Keys.  

I’m planning to schedule one through the Florida Keys Area Health Education Center (AHEC) in Marathon for the physicians. They can offer CEs and attract a larger audience. The nurse practitioners in the Keys have spoken to me about a fall meeting and I plan on offering them a diabetes update at the local community college.

I did a diabetes awareness program at the local yacht club for the public and have been asked to do one at several AARP Centers next season. In the 5 months I was there, I couldn’t get all of my goals scheduled but I believe the program is off to a good start.

Classes begin

The first class was held in Marathon in January 2010 with 8 people, most of whom were dock mates I convinced to sign up. Before classes began, each person had a one hour individual assessment which helped me plan more effectively for the group classes. The three hour classes were held once a week and ran 3 weeks. The group quickly became supportive and very involved in the learning process.

There were 3 additional class groups and this was to be the accomplishment of each group at each location. They learned, changed behaviors, and were a joy to work with. At the conclusion of each program, they jointly set goals. Each person identified 1 or 2 personal goals they’d like to accomplish over the next 3 months. We also set a date for me to call them and follow-up on their progress. It was a wonderful experience.

First year payoffs

All four classes were concluded by the middle of April and documentation completed. Let’s look at the payoffs we expected and accomplished:

We updated and educated other healthcare professionals
As previously stated, meeting with healthcare professionals and giving them educational materials was accomplished. A relationship was developed with colleagues in the community and I have built trust with many doctors who now refer patients to me. While away in NY, I’m still getting calls to see patients. I’ve done some phone consulting and have been told they are anxiously waiting for my return in October.

We satisfied the needs of patients and their families
I have called many of my patients for their 3 month follow-up consult and they’re doing very well. Several have lowered their A1Cs and many have lost the weight to their set goal. One patient who was experiencing frequent hypoglycemic reactions has now had his insulin adjusted, is eating much better, and tells me he feels healthier and in control. Another called recently and has now reached his goal of getting off insulin and onto oral medications. His A1C is down to 6. Good for him! I’ll continue to follow their progress. Several are planning to send me new patients next fall.

We satisfied accrediting agencies requirements
Last November my company, the East Coast Diabetes Education Program, was granted a DEAP accreditation by the AADE. They were very encouraging about my plans.

First year roadblocks

Now here is the problem, big time. I have yet to receive compensation from any of my third party payors. It’s very frustrating because unless the problem is resolved, I don’t know if I can continue the program

Insurance blues
Although Blue Cross/Blue Shield granted us provider status, we still have not been paid. While part of this is my fault as I have never done billing or coding, they are having difficulty knowing what to do about us.

Since we are the only accredited diabetes teaching program in the Keys, my partner is a pharmacist and not a physician, and we are not affiliated with a hospital, they don’t know which category to place us in. They treat us as aliens and in their words,
“they are investigating the problem.” They agree that patients need classes, which they cover, but the problem is that I am an educator only billing for education.

Medicare red tape
My Medicare application is still in the same position and I have spent days and weeks working on the paperwork. My calls often aren’t returned as they do not know what to tell me.

Medicare admits that the Northeast Region handles this, but since I’m the first in southern Florida, the Southeast Region is confused. They don’t know how to handle me since I don’t work at a hospital or at a physician’s office. They don’t recognize the codes for diabetes education or the G codes that the rest of the country knows about. Amazing. I’ve hired a billing person and hope her expertise can solve the problem.

The good, the wonderful, the frustrating and the ugly

Looking back on the start of Healthcare Without Walls, here’s what I see. It was good for the patients and their families. It was wonderful for me and exciting to administer. It is frustrating trying to get paid for work I consider worthwhile and important. It will be ugly and terrible if I have to cancel the program because no one is willing to step outside the box and figure out how to make it viable.

If the Diabetes Self-Management Education (DSME) bill HR2425 going through Congress is passed and certified diabetes educators become Medicare providers in their own right, it should solve the problem.

I will keep you informed.

Watch and learn how Ginger takes diabetes education out of the classroom to the real world, and of her new honor and credential, FAAD

Joy Pape Interviews Ginger Kanzer-Lewis at the 2010 AADE from Alan Sherman on Vimeo.

About the author

Patient Education: You Can Do It!, by Ginger Kanzer-LewisGinger Kanzer-Lewis RN, BC, EdM, CDE has spent over 25 years as Director of Education, Staff Development and Patient Education in New Hampshire, New York, New Jersey, and Massachusetts. From 1980 to the present, she worked as a consultant for health care agencies throughout the United States and is a past president of the American Association of Diabetes Educators. She is currently managing her own firm, GKL Associates, and conducts programs nationally and internationally in diabetes, patient and adult education, motivation, and various subjects in health care management.

Ginger's book Patient Education: You Can Do It! is based on her course of the same name which she has taught for over 20 years. To contact Ginger at GKL Associates, write to her at GKanzerlewis@aol.com.

Fall 2010