The business case for a diabetes self-management intervention in a community general hospital.

There is a growing and increasingly compelling body of evidence that self-management interventions for persons with type 2 diabetes can be both effective and cost-effective from a societal perspective. Yet, the evidence is elusive that these interventions can produce a positive business case for a sponsoring provider organization in the short term. The lack of a business case limits the enthusiasm for provider organizations to implement these proven quality-enhancing interventions more widely. This article provides a case example of a self-management intervention in a community general hospital targeting an underserved population who have significant barriers to receiving regular health care. The 3-component program sought to improve meaningful access to care, increase health literacy related to type 2 diabetes, and partner with the enrollees to make long-term lifestyle changes. The intervention not only resulted in significant improvements in HbA1c levels (-0.77%) but saved the hospital an average of $551 per active patient per year, primarily by reducing hospital visits. With only 255 actively enrolled patients, the hospital can recover fully its total direct annual personnel and operating costs for the program. Because the program serves patients who would have been seen at other hospitals, it also enhanced care quality and reduced costs for the broader community in which the program is embedded.

The concept of leakage in threat assessment.

Leakage in the context of threat assessment is the communication to a third party of an intent to do harm to a target. Third parties are usually other people, but the means of communication vary, and include letters, diaries, journals, blogs, videos on the internet, emails, voice mails, and other social media forms of transmission. Leakage is a type of warning behavior that typically infers a preoccupation with the target, and may signal the research, planning, and implementation of an attack. Nomothetic data suggest that leakage occurs in a majority of cases of attacks on and assassinations of public figures, adult mass murders, adolescent mass murders, and school or campus shootings: very low-frequency, but catastrophic acts of intended and targeted violence. Idiographic or case data illustrate the various permutations of leakage. We discuss the operational importance of the concept, place it in the context of other warning behaviors, emphasize the need for further research, and outline risk management strategies for the mitigation of such acts of violence in both law enforcement and clinical mental health settings.

A diabetes self-management program designed for urban American Indians.

BACKGROUND: Although the American Indian population has a disproportionately high rate of type 2 diabetes, little has been written about culturally sensitive self-management programs in this population. CONTEXT: Community and clinic partners worked together to identify barriers to diabetes self-management and to provide activities and services as part of a holistic approach to diabetes self-management, called the Full Circle Diabetes Program. METHODS: The program activities and services addressed 4 components of holistic health: body, spirit, mind, and emotion. Seven types of activities or services were available to help participants improve diabetes self-management; these included exercise classes, educational classes, and talking circles. CONSEQUENCES: Ninety-eight percent of program enrollees participated in at least 1 activity, and two-thirds participated in 2 or more activities. Program participation resulted in a significant improvement in knowledge of resources for managing diabetes. INTERPRETATION: The Full Circle Diabetes Program developed and implemented culturally relevant resources and supports for diabetes self-management in an American Indian population. Lessons learned included that a holistic approach to diabetes self-management, community participation, and stakeholder partnerships are needed for a successful program.

Patient-centered goal setting as a tool to improve diabetes self-management.

PURPOSE: The purpose of this article is to describe the process of collaborative goal setting as a means to improve diabetes self-management in primary care. METHODS: The Self-Management Goal Cycle framework illustrates a model of care for patients with diabetes. The Big Bad Sugar War is an approach to patient counseling that includes background, barriers, successes, willingness to change, action plan, and reinforcement. RESULTS: Planned visits occur when a medical assistant performs routine health checks and laboratory tests prior to traditional individual appointments. Mini-group medical visits occur when a provider and medical assistant meet with 3 patients at one time. Open office group visits occur when 7 to 12 patients attend 2-hour sessions staffed by a provider. DISCUSSION: Collaborative goal setting is a valuable tool for improving self-management skills among patients with diabetes. By implementing goal setting techniques, members of the patient care team are better equipped to help patients manage their chronic conditions by making them valued partners of the health care team.

Integration of a promotora-led self-management program into a system of care.

PURPOSE: The purpose of this article is to describe the integration of a promotora-led self-management component into a system of care and assess the influence of this program on indicators of metabolic control over time. METHODS: Gateway Community Health Center is a federally qualified health center in Laredo, Texas, that serves a predominantly Hispanic population. Gateway integrated self-management support into care for people with diabetes by incorporating promotora-led self-management services into the clinic structure, operations, and patient visits. The self-management program included education, goal setting, depression screening with symptom follow-up, and support groups after course end. Indicators of metabolic control, HbA1c, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides were compared at baseline and at 12 months. RESULTS: The integration of promotora-led self-management services into the system of care allowed for continual improvements of self-management services in response to patient needs. Patients enrolled in the self-management course showed improved indicators of metabolic control that were sustained over time, and they reported a high level of goal achievement. CONCLUSIONS: The integration of the promotora-led self-management program into diabetes care at Gateway generated a system of referral, follow-up, feedback, and documentation that produced consistently high-quality clinical care.

Starting a diabetes self-management program in a free clinic.

PURPOSE: The purpose of this project is to develop and implement a system of care for people with type 2 diabetes in a free clinic setting. METHODS: This project was conducted in the Homestead/Florida City community at the Open Door Health Center (a free clinic for the uninsured poor). Through a grant from the Robert Wood Johnson Foundation Diabetes Initiative, organizational and programmatic changes were made to improve care for patients with type 2 diabetes. Program participation and clinical data, incorporation of healthy practices and programs in other community organizations, and the success of collaborations were evaluated to judge program success. RESULTS: Critical factors for providing health care for persons with type 2 diabetes in a free clinic setting were identified. These included reviewing and organizing medical records of patients with diabetes, developing a system that made efficient use of limited staff resources, finding an educational approach appropriate for the population served (ie, Popular Education), involving patients in self-management support roles by providing them the opportunity and training to become peer mentors, and developing strong community partnerships to complement and reinforce self-management. CONCLUSION: Creation of a successful system of care for patients with diabetes in a free clinic setting is possible through innovative collaboration and creative program design.

The impact of promotoras on social support and glycemic control among members of a farmworker community on the US-Mexico border.

PURPOSE: The purpose of this study is to describe the effect of a promotora-driven intervention to build social support as a means to affect self-management behaviors and clinical outcomes in a farmworker community on the US-Mexico border. METHODS: Promotoras implemented a community-based intervention that included support groups, home/hospital visits, telephone support, and advocacy to people with diabetes. A 12-month pre/post study design was used to investigate the relationship between promotora contact, perceived support, and clinical outcomes. Clinical data were gathered from 70 participants during routine physician visits. A pre/post questionnaire was used to measure perceived support and self-management practices. RESULTS: Glycosylated hemoglobin (HbA1c) levels decreased 1% among high-risk participants. Improved HbA1c level was associated with promotora advocacy and participation in promotora-led support groups. Participants reported increased support from family and friends and more comfort speaking about diabetes (la enfermedad) with family and friends. CONCLUSIONS: These findings document improvement in both clinical and social health indicators for Mexican Americans in a farmworker community when a promotora model is used to provide and facilitate culturally relevant support for diabetes self-management practices.

Move More Diabetes: using Lay Health Educators to support physical activity in a community-based chronic disease self-management program.

PURPOSE: The purpose of this article is to describe Move More Diabetes (MMD), which is used by Lay Health Educators (LHEs) to promote physical activity and improve diabetes self-management among individuals with type 2 diabetes. METHODS: Move More Diabetes used social marketing strategies to choose and segment the target audience, develop messages, and determine message delivery. Based on market research results, MMD chose natural peer support from LHEs as the main intervention strategy. RESULTS: Move More Diabetes built a sustainable volunteer network of 35 LHEs who recorded 1500 contacts with enrollees from 2004 to 2006. Participation improved when the program was not specific for diabetes. CONCLUSION: The MMD program demonstrated benefits of partnership and natural peer support and the utility of social marketing in planning and implementing a community-based chronic disease self-management and physical activity promotion program. This low-cost program can serve as a model for other rural communities interested in increasing physical activity to address chronic disease.

Use of the transtheoretical model to enhance resources and supports for diabetes self management: lessons from the Robert Wood Johnson Foundation Diabetes Initiative.

PURPOSE: The purpose of this article is to describe how Resources and Supports for Self Management (RSSM) and strategies of the transtheoretical model (TTM) intersect to produce a comprehensive approach resulting in cutting-edge diabetes programs. METHODS: Specific components of RSSM, especially individualized assessment, collaborative goal setting, and enhancing skills, are reviewed in terms of contributions to the TTM. RESULTS: Specific examples from the Diabetes Initiative of using TTM constructs from 5 projects are shown to illustrate the first 3 RSSM constructs: individualized assessment, collaborative goal setting, and skill building. CONCLUSION: Diabetes Initiative grantees have demonstrated that the TTM enhances RSSM and facilitates the adoption of good diabetes self-management behaviors.

Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative.

PURPOSE: The purpose of this article is to identify approaches to providing ongoing follow-up and support for diabetes self-management based on the experience of 14 self-management projects of the Diabetes Initiative of the Robert Wood Johnson Foundation. METHODS: This study is a collaboration with grantees of the Diabetes Initiative of the Robert Wood Johnson Foundation, a program focused on diabetes self-management in primary care and community settings. Grantees and national program staff identified key functions that ongoing follow-up and support need to fill and key features of programs that do so. RESULTS: Key functions of ongoing follow-up and support include monitoring of status and self-management, encouragement and facilitation of regular clinical care, encouragement and motivation of self-management, and facilitating skills for coping with changes in circumstances or emergent problems. Key features of ongoing follow-up and support to fill these functions are being available on demand; being proactive in maintaining contact and preventing individuals from "falling between the cracks"; having personal, motivational, and consistent key messages; not being limited to diabetes; and being inclusive of a wide range of resources and settings. CONCLUSIONS: Initial characterization of key features of ongoing follow-up and support has been accomplished. This should facilitate research to clarify how it may best be provided and systematic approaches to doing so. These should lead to health service and policy initiatives supporting this critical dimension of programs to promote self-management and lifelong healthy living patterns.

Teaching how, not what: the contributions of community health workers to diabetes self-management.

PURPOSE: The purpose of this study is to describe ways in which community health workers (CHWs) are used in various clinic and community settings to support diabetes self-management. METHODS: Descriptive quantitative data were collected from logs completed by CHWs. Logs described mode, place, type, duration, and focus of individual contact between the CHW and the patient. Qualitative data were collected from semistructured interviews with patients. Interviews were conducted on site from June to August 2006. Interviewees included a purposeful sample of 47 patients who perceived being helped by CHWs. RESULTS: CHWs reported providing assistance and teaching or practicing skills as the focus of most of the 1859 individual contacts. The assistance CHWs reported providing was most often in the form of encouragement/motivation. During interviews, patients shared that CHWs were helpful in demonstrating how to incorporate diabetes self-management (DSM) into their daily lives. The information patients shared also provided insight into what they perceived as encouragement/motivation from the CHWs. Quotes from interviews provide specific examples of how support from CHWs was different from that received from family and health care team members. CONCLUSIONS: Both CHWs and patients perceived assistance being provided in similar ways, with consistent emphasis on encouragement/motivation. Interviews with the patients revealed that a personal connection along with availability and provision of key resources and supports for self-management made the CHW-patient interaction successful for DSM. Examples provide insight into the valuable contributions of CHWs to DSM. This insight should encourage guidelines that make CHWs a routine, standard part of the diabetes care team.

Perspectives on self-management from the Diabetes Initiative of the Robert Wood Johnson Foundation.

PURPOSE AND METHOD: Review and highlight findings from the projects of the Diabetes Initiative of the Robert Wood Johnson Foundation described in this special supplemental issue. RESULTS: The broad framework for self-management around which these programs were developed, "Resources and Supports for Self Management," includes individualized assessment, collaborative goal setting, building skills for self-management, ongoing follow-up and support, community resources, and continuity of quality clinical care. Lessons learned include the central role of community health workers in self-management, the importance of ongoing follow-up and support to sustain self-management, varied program approaches to depression and negative emotion, the importance of organizational infrastructure to support self-management programs, and the contributions of clinic-community partnerships. Several emergent themes include the value of providing choices among "good practices" as opposed to one best practice, the role of the physician as part of the self-management team, and the importance of broad efforts in promoting dissemination of self-management programs. Finally, self-management will benefit from replacing categorical distinctions, like good and bad control, proven and unproven treatment, with thinking in terms of key dimensions, like level of control and continued quality improvement. CONCLUSIONS: Diabetes Initiative projects have shown that diabetes self-management can be promoted in the "real worlds" of community agencies and primary care settings serving diverse and disadvantaged populations.

Intellectual impairment and sexual health: information needs.

Inclusion into the wider community for people with learning disabilities and intellectual impairment has been problematic for many people and in some cases the result has been an exacerbation of mental health problems or a reduction in adaptive functioning. Research has found that people who have chronic mental illness or intellectual impairment are a sexually active group although they might not always be perceived as such. Therefore, there are questions that may be raised over an identified lack of sexual health promotion and practices surrounding safe sex. This short article will examine particular barriers to sexual health care for this patient group in the areas of consent (to sexual acts, screening and treatment), communication and health promotion in this field. Implications for future practice are discussed.

The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

PURPOSE: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS: Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS: The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

The motivation behind serial sexual homicide: is it sex, power, and control, or anger?

Controversy exists in the literature and society regarding what motivates serial sexual killers to commit their crimes. Hypotheses range from the seeking of sexual gratification to the achievement of power and control to the expression of anger. The authors provide theoretical, empirical, evolutionary, and physiological support for the argument that serial sexual murderers above all commit their crimes in pursuit of sadistic pleasure. The seeking of power and control over victims is believed to serve the two secondary purposes of heightening sexual arousal and ensuring victim presence for the crime. Anger is not considered a key component of these offenders' motivation due to its inhibitory physiological effect on sexual functioning. On the contrary, criminal investigations into serial sexual killings consistently reveal erotically charged crimes, with sexual motivation expressed either overtly or symbolically. Although anger may be correlated with serial sexual homicide offenders, as it is with criminal offenders in general, it is not causative. The authors further believe serial sexual murderers should be considered sex offenders. A significant proportion of them appear to have paraphilic disorders within the spectrum of sexual sadism. "sexual sadism, homicidal type" is proposed as a diagnostic subtype of sexual sadism applicable to many of these offenders, and a suggested modification of DSM criteria is presented.

Reliability of the 7-Day Physical Activity Recall in a Biracial Group of Inactive and Active Adults.

BACKGROUND: Physical activity recall (PAR) reliability was estimated in a three-site sample of African American and white adults. The sample was sedentary at baseline and more varied in physical activity 24 months later. Intraclass correlation coefficients (ICCs) were used to estimate the number of PAR assessments necessary to obtain a reliability of 0.70 at both timepoints. METHODS: The PAR was administered ≤ 30 d apart at baseline (n = 547) and 24 months (n = 648). Energy expenditure ICC was calculated by race, gender, and age. RESULTS: Baseline reliability was low for all groups with 4-16 PARs estimated to attain reliable data. ICCs at 24 months were similar (ICC = 0.54-0.55) for race and age group, with 2-3 PARs estimated to reach acceptable reliability. At 24 months, women were more reliable reporters than men. CONCLUSION: Low sample variability in activity reduced reliability, highlighting the importance of evaluating diverse groups. Despite evaluating a sample with greater physical activity variability, an estimated 2-3 PARs were necessary to obtain acceptable reliability.

Walking may be related to less vascular stiffness in the Activity Counseling Trial (ACT).

BACKGROUND: The ACT was a clinical trial of various patient education and counseling interventions to increase physical activity in sedentary primary care populations. It provided the opportunity to measure the effect of increasing physical activity on aortic pulse wave velocity (APWV), a measure of vascular stiffness, in a relatively healthy middle-aged population. The effects of the interventions, as well as the impact of walking and correlates such as older age and maximal oxygen uptake (VO2max), on APWV were assessed. METHODS: The participants in this study were a subset of the 874 persons recruited for the ACT. Information about self-reported physical activity and disease status was collected at baseline (464 persons), 6-month (528 persons), and 24-month (555 persons) intervals. Physiological measures included APWV, systolic blood pressure, and other correlates. RESULTS: In multivariate analyses, the various treatment arms did not have a significant effect on APWV. However, walking in hours per day was associated with slower APWV times or less stiffness (P = .03). This was significant for women and consistent but not significant for men. In addition, age, clinic site, race, systolic blood pressure, and VO2max were independently associated with APWV. CONCLUSIONS: Increased walking frequency over a 24-month period was predictive of reduced vascular stiffness in ACT. The more significant result for walking frequency in women than in men might be caused by the presence of a low Vo2max or physical activity threshold for an effect of walking on APWV, which most women achieved but most men had surpassed at the start of the study. Although needing confirmation because this was a secondary analysis, modest physical activity may have a beneficial effect on large vessel structure.

Ecological approaches to self-management: the case of diabetes.

In the Diabetes Initiative of The Robert Wood Johnson Foundation, an ecological perspective helped identify the following key resources and supports for self-management (RSSM): individualized assessment, collaborative goal setting, skills enhancement, follow-up and support, access to resources, and continuity of quality clinical care. These RSSM reflect the grounding of diabetes self-management in the context of social and environmental influences. Research supports the value of each of these key resources and supports. Differences among self-management interventions may be seen as complementary, rather than conflicting, ways of providing RSSM. This way of understanding differences among interventions may aid development of varied programs to reach diverse audiences. In contrast to the "5 A's" model of key provider services (Assess, Advise, Agree, Assist, and Arrange), RSSM articulate self-management from the perspective of individuals' needs. Both approaches emphasize identification of goals, teaching of skills, and facilitation and reinforcement of the use of those skills.

Cortical effects of quetiapine in first-episode schizophrenia: a preliminary functional magnetic resonance imaging study.

BACKGROUND: Quetiapine improves both psychotic symptoms and cognitive function in schizophrenia. The neural basis of these actions is poorly understood. METHODS: Three subject groups underwent a single functional magnetic resonance imaging (fMRI) session: drug-naive (n = 7) and quetiapine-treated samples of patients with schizophrenia (n = 8) and a healthy control group (n = 8). The fMRI session included an overt verbal fluency task and a passive auditory stimulation task. RESULTS: In the verbal fluency task, there was significantly increased activation in the left inferior frontal cortex in the quetiapine-treated patients and the healthy control sample compared with the drug-naive sample. During auditory stimulation, the healthy control group and stably treated group produced significantly greater activation in the superior temporal gyrus than the drug-naive sample. CONCLUSIONS: Quetiapine treatment is associated with altered blood oxygen level-dependent responses in both the prefrontal and temporal cortex that cannot be accounted for by improved task performance subsequent to drug treatment.