Prioritizing the Community at Montefiore Health System
JUNE 12, 2018
Promoting better adherence to medications can make physicians feel like a broken record—repeating the same thing over and over, without much change.
Treatment adherence has become a struggle for countless conditions, with diabetes chief among them. Low adherence to prescribed medications not only hurts outcomes, but studies have shown it is associated with increased use of health care resources and higher medical costs, as well as marked increases the risk of mortality.1-3 Despite numerous available therapies and a robust pipeline of drugs in development, diabetes remains the seventh leading cause of death in the United States.4
Coupled with poor adherence is the fact that communication barriers brought forth by cultural and socioeconomic differences between patients and providers have made reaching consensus between them incredibly difficult. Due to this, a need for creative ways to reach high-risk individuals in US communities has developed. In turn, it’s prompted institutions such as the Montefiore Health System, located in the Bronx, New York—a diabetes hotspot in its own right—to find new methods of reaching these patients, including stepping out of the hospital and into the community to help improve outcomes.
Prevention in the Classroom
“We have the highest rate of diabetes burden in New York City, and we have the highest rates of obesity and residents drinking sugary beverages, and the lowest physical activity,” Amanda Parsons, MD, MBA, the vice president of Community & Population Health at Montefiore, and an assistant professor of Family & Social Medicine at the Albert Einstein College of Medicine, told MD Magazine.The proportion of people with diabetes is 1 in 5 in the Bronx, which is much higher than the national rate of 1 in 10. Worrisome however is the rate of prediabetes at 1 in 3.”
Parsons explained that not only are those with prediabetes are at an obvious high risk for diabetes, but the health care expenses for those with the condition are more than 2.5 times higher than those without diabetes. “Those with diabetes are faced with a huge burden, financially and for their health,” she said. “If all of those 1 in 3 prediabetics became diabetics, we’d bankrupt our health care system.”
That’s where Montefiore’s Diabetes Prevention Program comes into play. When a patient comes to the health system with a prediabetes diagnosis, they’re immediately referred to a prevention class focused on interventions that they can utilize outside of medications, with multiple options to suit their schedules. If they agree to the classes, they’ll join several other members of the community as well as an instructor, like Joy Sprenger, the project manager of the Diabetes Prevention Program, in the class.
“We carry a wide variety of topics, but the main focus is to change lifestyle and behavior with eating,” Sprenger told MD Magazine. One of the keys, she said, is to improve activity levels among patients with prediabetes. The goal for each member is 30 minutes each day, roughly 150 minutes per week, but the instructors understand that it can be difficult to achieve.
“We give them ideas to be more active, so if you’re working 10 hours a day and you’re tired, here’s how to squeeze in some activity,” Sprenger said. “We give them ideas and YouTube links for in-home exercise. We also teach them how to read food labels because they can get confusing—just to give them an education. Trigger control is big too. How to achieve portion control is a huge part, as well as managing stress and staying motivated.”
A challenge in getting the patients in the class is that due to requirements set by the Centers for Disease Control and Prevention (CDC), the class must meet once a week for 16 weeks. Although studies have shown that model works, the length can turn people off. But those who remain for the full course tend to shed between 3% and 4% of their body weight—equating to a 30% reduced risk of developing diabetes.
The struggle once they’re in the class, of course, is keeping the patients that do show up engaged. Parsons said that 25% of patients that are referred to the program attend it. “It sounds low, but studies have shown that fewer than half of patients take their meds as prescribed,” she said. “There is a fair amount of nonengagement in health care. For radiation and oncology, we have a 20% no-show rate. It’s not because patients don’t care, it’s because they have complicated lives.”
To keep the patients involved, Sprenger and company try to get creative, and never stop trying new things. They monitor which classes and instructors are most successful, examining everything from the energy of the educator to the connection made with the patients. In addition, each class attended earns the attendees a raffle ticket, with prize drawings every fourth class. As much of the local population speaks Spanish, Montefiore tends to look for bilingual instructors, some from the area, to ease communication. The program gets peer mentors involved as much as possible as well.
“It’s designed to be taught by laypeople,” Sprenger said. “It’s our experience that those that have studied the formal art of teaching are better than those right off the street, so we make sure there’s some level of training. But where we were willing to say education doesn’t matter is with the peers. They’re a great balance to the educator. We’re looking hard to see what’s the secret sauce, but we’re always mindful of our hires.”
Similar programs have shown success, too. A recent study of lifestyle classes in patients with prediabetes resulted in a reduction in diabetes development by over 53%, much higher than medications alone. “What that taught us is that we can’t sit around and wait for the medications to do the job,” Parsons said.
The Value for Physicians
When it comes to the physicians, the programs provide a plus side, as well. Joel M. Bumol, MD, a family practice physician who leads the Williamsbridge Family Practice Diabetes Group, part of Montefiore’s efforts that have been ongoing for more than 2 years, told MD Magazine that the groups have been impactful for him, too. The group visits he leads are similar to the classes run by Sprenger, but in a family practice setting.
“It has benefits for the providers, too. It gives me variety in my day and it’s still billable, and it’s another way to interact with patients,” he said. “It’s definitely a break in the mold. I’m very grateful for being given the time to develop it.”
Bumol’s group meets twice a month, and similarly to the classes run by Sprenger, topics of discussion have ranged from nutrition label reading, visits to farmer’s markets, and healthy meal prep to ways to get exercise, talk about exercise modalities, and management of diabetes. “As well as focusing on psychosocial things like stress management,” Bumol said. The group members even have the ability to dictate the topics for each visit.
One of the biggest benefits Bumol has found is that it’s truly educated his patients to the point that they can serve as educators themselves. “When someone asks me a question, I bring it to the group, and at this point, they’re able to answer the question the way I would,” he explained. “It’s more impactful when it comes from a peer.”
Another value for the physician is the peer-mentoring, something Bumol admits that he cannot provide. It’s especially true in New York, where the patients are often from underserved populations. “I can tell you to do these things all day, but if it’s coming from someone in the same circumstance and community, it has much more potential for impact for change,” he said.
“I would encourage anyone in primary care practice to [lead these classes],” Bumol added. “It’s a viable model and one that, especially as we try to diversify practices, is a great next step in the ongoing evolution of primary care.”
Bringing it to the Community
For the 75% of patients with prediabetes—and its eventual progressed form—that don’t attend the group meetings offered by Montefiore, something still needs to be done. The second prong of the system’s approach, called the Healthy Store Initiative, takes elements of the classroom approach straight to the community.
Specifically, straight to the bodegas.
“The Bronx has over 1000 bodegas, and in some neighborhoods it's people get much of the food they consume,” Parsons said. “Mostly snacks, but sometimes it can be an equivalent to their groceries when they don’t have a major grocery store nearby—we have food deserts in the Bronx. We went out to the blocks with obese Montefiore patients, and on the blocks with bodegas, we are working with them to increase their supply of healthier food and to promote those foods.”
While Parsons and her team can’t go to the bodegas and demand that they remove sugary drinks, they can make suggestions on better options to offer, which produces a similar result by default. “When they sell more healthy items, by definition, they have to use up shelf space [that would have been for unhealthier options]. We try to play good cop and not bad cop,” Parsons said.
The mainstays of the bodega program are to decrease the amount of sugary drinks people consume—somewhat of an arduous task, Parsons said, since many view diet sodas as too chemical or carcinogenic, preferring options with real sugar.
“It’s an uphill battle to convince them a diet soda is better for their diabetes—so we just skip it altogether and go to sparkling water,” Parsons explained. “People aren't initially familiar with sparkling waters, but once they try them, they tend to like them, so we do a lot of work promoting sparkling water options.”
Outside of drinks, the program also seeks to improve the food options. It helps bodega owners on the pricing and offering of combination meals, such as a turkey sandwich with an apple and water. Food option improvement in the program can get detailed, with Parsons and her colleagues getting as granular as adjusting the approach to presentation. The Montefiore program even offers signage for healthier options and partners with a nearby restaurant depot to provide a localized resource library for the owners.
“A lot of the bodegas go buy fruits that come in cardboard boxes and they’ll just plop them down on the floor,” Parsons said. “But it doesn’t sell well because it doesn’t look appetizing, so we give bodega owners baskets for them to put them in. We always try to encourage having a basket of fruit by the cashier, because those areas are always filled with candy. We’ll work with them to increase availability of for fresh fruits, veggies, and water.”
Of course, even bringing the solutions to the community can have its challenges. The nature of running a bodega often doesn’t make it easy to work with them. As many bodega owners have immigrated from other countries, with hopes of making some money to return with, there’s often quite a bit of turnaround. Thus far, they’ve partnered with about 15 shops in total, and are implementing a training program to help increase their efforts. The job doesn’t stop once a bodega agrees, Parsons said.
As a result, Montefiore’s members go to community boards and discuss how they can get involved. They also share resources, trainings, and materials with the Department of Health and Institute for Family Health, 2 other organizations trying to improve community outcomes.
“These guys work 7 days a week, long hours, and usually—if they’re successful—they own more than 1 bodega,” she explained. “They work tirelessly and don’t have a lot of time to do the things that we do in our industry, like conferences and such, so it’s hard to get them together. It’s going to be hand-to-hand combat, like going house-to-house. Bodega, by bodega, by bodega. But it’s important work to do and well worth doing.”
Making a Point
The programs are, at their root, about improving the quality of life and awareness of the community, Parsons said. That’s the reason the classes and educators take trips to local farmer’s markets, schools, and stores. It’s why they focus on training patients to read food labels and advertising. It’s less about the health of the individual, and more about the health of the community.
For Bumol, he just wants the best for his patients. He wants to educate them, and importantly, to empower them to improve their lives. “I think a lot of them think of it as very scary, and when patients [get involved], they find out it’s something manageable they can control. I hope patients have the empowerment,” he said.
Similarly, for Parsons, it’s become more than just about the outcomes—it’s about fairness to the patients. She explained that in recent research from the Albert Einstein School of Medicine, a team examined the plethora of unhealthy advertisements in the Bronx, codified them, and identified the intended targets of the ads. The findings, she said, were tragic.
“What the studies showed is the poor areas had a higher amount of unhealthy and hyper-targeted ads at monitories and kids. That’s important to understand,” Parsons said. “We’re not just saying it’s important for you to take accountability and take own choices, but it’s important to acknowledge that our communities are essentially victims of racism in advertising. In my neighborhood, I get healthy advertising, but those in the Bronx don’t get that, and it’s not fair. There have been a lot of really irresponsible ads in the food industry.”
“We owe our communities the availability of healthier choices, of promotional views that advertise and support their healthy decision making,” she added.
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2. DiBonaventura M, Wintfeld N, Huang J, Goren A. The association between nonadherence and glycated hemoglobin among type 2 diabetes patients using basal insulin analogs. Patient Prefer Adherence. 2014;8:873–88
3. Egede LE, Gebregziabher M, Dismuke CE, et al. Medication nonadherence in diabetes: longitudinal effects on costs and potential cost savings from improvement. Diabetes Care. 2012;35(12):2533–2539.
4. Statistics about diabetes. American Diabetes Association website. diabetes.org/diabetes-basics/statistics. Published 2017. Updated March 22, 2018. Accessed June 7, 2018.