The Providence St. Peter Hospital
BoldtDiabetesCenter & 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.
BoldtDiabetesCenter
Providence St. Peter Hospital
Olympia, WA98506
Family Medicine and BoldtDiabetesCenter 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
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 BoldtDiabetesCenter
Special thanks to:
Carol Brownson, Robert Wood Johnson Foundation Diabetes Initiative at WashingtonUniversity in St. Louis.
Sharon Fought RN, PhD at University of WashingtonSchool of Nursing.
Stephen Luippold, RN, MSN, BostonUniversity.
Janet Primomo RN, PhD, Univeristy of WashingtonSchool of Nursing.
Melissa Rickert, MPH, Saint LouisUniversitySchool 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
- “Survivor”--Essential Diabetes Self Management Skills……………….27
- “Another World”--Expanded Role of the MA in the CCM………….....38
- “The Young and the Restless”--Exercise and Diabetes ……..………....28
- “Concentration”--Didactic Diabetes Information……………………….33
Day Two:
- “Days of Our Lives”--MA Self-Management Log Review……………..48
- “Wheel of Fortune”--Practice with the SMGC…….…..………………..57
- “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.
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 betweentwo 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’sAdvancing Diabetes Self-Management 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 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 WashingtonState 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, 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!
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 AmericanAcademy 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 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 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.
Curriculum Content and its Relationship to the Expanded Role of MAs in Implementing the Self-Management Goal CycleCurriculum
Content / MA Job Functions within the Self-Management Goal Cycle
Data Registry Entry / Telephone
Interaction / MA Planned Visits / Provider Visits / Group Visits / SMGC
Tracking
Age, Race, Gender, Diversity Awareness / X / X / X / X
Diabetes Pathophysiology / X / X / X / X / X
Diabetes Treatments / X / X / X / X / X / X
Acute Complications / X / X / X / X
Long-Term Complications / X / X / X / X
Goal Setting / X / X / X / X
Reporting / X / X / X
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 WesternWashingtonAreaHealthEducationCenter. Documents were reviewed from the Washington State Society of Medical Assistants including the Health Care Assistant Law 18.135 RCW, 1984 (2002).
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 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.
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 Self-Management 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.
“Survivor” 3 Essential Self-Management Skills for Diabetes90 Minutes
MA will demonstrate self-blood glucose monitoring. / Purpose of blood glucose testing.
Normal blood glucose ranges.
Techniques for glucose testing. / 25 minutes / New glucose test kits for each seat.
Sharps Container / PPT
Demonstration
Return Demonstration
Discussion
MA will demonstrate the proper filling of an insulin syringe using hospital aseptic technique with 100% accuracy / Proper insulin administration. / 20 minutes / Insulin start kit for each seat.
Vial of normal saline for each seat.
Sharps Container / Demonstration
Return Demonstration
Discussion
MA will name the carbohydrate food groups with 100% accuracy on a quiz / Introduction of the food components: carbohydrates, fat, and protein.
Introduction of carbohydrate containing foods. / 5 minutes / USDA Food Pyramid or Chart / PPT
Lecture
MA will properly match the digestion process of carbohydrates with the digestive organ sites on a quiz. / The digestive process.
The absorption of glucose into the blood. / 5 minutes / PPT
Lecture
MA will notate the serving size and total gram of one food label with 100% accuracy on a quiz. / Carbohydrate identification on food labels / 5 minutes / Food label Examples such as Yogurt Container / PPT
Lecture
Demonstration
Return Demonstration
Discussion
MA will count the carbohydrate content of common breakfast foods with 80% accuracy on a quiz using a carbohydrate guide. / Carbohydrate counting / 30 minutes / Breakfast Foods
Carbohydrate Cards / Demonstration
Return Demonstration
Discussion
Quiz
III. Curriculum Outline
Objectives / Content Outline / Time Frame / Materials / Teaching MethodsWelcoming 15 Minutes
MA will state reason for being at the session. / Review the course outline.
Review the Notebook Material
Collect MA completed Surveys / 5 minutes / Laptop
LCD Projector
Notebook Material / Lecture
PPT
MA will identify a favorite personality who has/had diabetes. / Icebreaker and introduction of people in the class.
List of famous people with diabetes. / 10 minutes / Pictures of Personalities with Diabetes / PPT
Discussion
“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. / The Chronic Care Model (CCM).
The MA job responsibilities within the CCM. / 20 minutes / LCD Projector
Laptop / PPT Slides
Lecture
Discussion
List the elements of the Self-Management Goal Cycle with 80% accuracy on a quiz. / The Self-Management Goal Cycle (SMGC).
The MA job responsibilities within the SMGC. / 20 minutes / Laptop
LCD Projector / PPT Slides
Lecture
Discussion
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. / The MA scope of practice within any respective state. / 15 minutes / Laptop
LCD Projector / PPT Slides
Lecture
Discussion
Quiz / Quiz / 5 minutes / Quiz / 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 / PPT Slides
Lecture
Discussion
List three barriers to physical activity on a quiz. / Barriers to physical activity.
Solutions to these barriers. / 10 minutes / Laptop
LCD Projector / PPT Slides
Lecture
Discussion
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. / 5 minutes / Laptop
LCD Projector / PPT Slides
Lecture
Discussion
List two components shown to reduce the incidence of Type 2 diabetes. / The Diabetes Prevention Program (DPP).
Recommendations from the DPP to prevent diabetes. / 5 minutes / Laptop
LCD Projector / PPT Slides
Lecture
Discussion
Quiz / Quiz / 5 minutes / Quiz / Quiz
References