Abstract
Viva la Vida (Live Your Life) is a call to action for older Latinos to take charge of their diabetes and live life to the fullest. Lumetra, California’s federally designated Medicare quality improvement organization, developed the Viva la Vida project to improve diabetes care among Latino Medicare beneficiaries in 4 Southern California counties. After researching barriers to good diabetes care among Latino seniors, Lumetra designed a multifaceted program targeting health care providers and Medicare beneficiaries through bilingual, low-literacy health education materials and tools, community and provider partnerships, and the mass media. The project succeeded in helping to reduce the disparity in glycosylated hemoglobin testing between White and Latino Medicare beneficiaries in the 4 program counties.
THE CENTERS FOR MEDICARE & Medicaid Services has funded quality improvement organizations in each state to monitor and reduce health care disparities in the Medicare population.1 The quality improvement program works to ensure that Medicare patients—particularly patients from underserved populations—receive appropriate care at the appropriate time. Lumetra, the Medicare quality improvement organization for California, developed the 3-year Viva la Vida (Live Your Life) project to improve diabetes care for Latino Medicare beneficiaries and decrease the disparity in annual glycosylated hemoglobin (A1C) testing rates between White and Latino beneficiaries in 4 counties. The program targeted Latinos because they are the largest and fastest growing minority group in California2 and they suffer from a high prevalence of diabetes and associated complications.3–7 The A1C test gives an integrated picture of blood glucose levels over the past 2 to 3 months and is an important tool for diabetes management.8 Lowering A1C values can prevent or delay the development of many diabetes-related complications.8
PROGRAM DESCRIPTION
The purpose of the Viva la Vida project was to improve diabetes care for Latino Medicare beneficiaries and decrease the disparity in A1C testing between Whites and Latinos. Viva la Vida calls older Latinos to take charge of their diabetes and live life fully. Lumetra implemented it in 4 contiguous counties in Southern California (Los Angeles, Orange, Riverside, and San Diego) selected because of large Latino populations, low A1C testing rates, and large disparities in annual A1C testing rates between Whites and Latinos. The project had a full-time project manager with part-time assistance from analytic, quality improvement, and marketing and communications staff.
The most effective interventions are multifaceted, well-integrated, and tailored to removing specific barriers.9–10 The first project task was to identify barriers to good diabetes care among Latino seniors (See the box on page 206) through literature review and meetings with health care providers and Latino community organizations. We then designed a multifaceted intervention program to address these barriers that included outreach to both health care providers and Medicare beneficiaries through health education materials and tools, community and provider partnerships, and the mass media.
BARRIERS TO GOOD DIABETES CARE AMONG LATINO MEDICARE BENEFICIARIES.
Patient factors
Low literacy
Poor knowledge about diabetes
Language barriers and low acculturation levels
Limited “preventive attitude”
Low knowledge about Medicare benefits
Low socioeconomic status
System or Provider factors
Inadequate provider–patient communication
Poor coordination of chronic care and low utilization of community resources and team care
Overstressed physicians and systems
Lack of culturally appropriate diabetes material to share with patients
Program staff designed low-literacy, culturally appropriate, bilingual materials and tools to address the patient and provider barriers11–12 (See the box on page 207 and Figures 1 ▶ and 2 ▶). We posted all materials free on our Web site. We cultivated relationships with health plans, physician groups, diabetes organizations, and Latino community organizations already working to improve diabetes care. These partner organizations distributed program materials to their providers and Latino constituents. We disseminated program materials and messages at cosponsored community events.
VIVA LA VIDA PROGRAM MATERIALS AND TOOLS.
Diabetes self-management booklet with simple graphics and easy-to-follow instructions for disease management to help Latino Medicare beneficiaries, their caregivers, and families take charge of their diabetes
Physician–patient diabetes prompt card to facilitate physician–patient communication by helping patients formulate questions for their health care providers about diabetes care (including the A1C test) and record important test results
Colorful,1-page fact sheet listing the diabetes supplies and services Medicare covers
Evidence-based Diabetes Resource Guide for Quality Improvement for providers, with comprehensive intervention tools and materials to improve diabetes care, including a section on cultural competency
FIGURE 1—
Sample page from the Viva la Vida diabetes self-management booklet.
FIGURE 2—
Viva la Vida physician–patient diabetes prompt card.
Viva la Vida used the media to augment outreach to Latino Medicare beneficiaries and physicians and to reinforce program messages. Mass media are among the most important information sources for Medicare beneficiaries with low reading skills.13 Spanish-speaking Latinos rely heavily on Spanish radio and television for information.14 Program staff developed public service announcements for radio and participated in live interviews on Spanish radio and television stations in the targeted counties. We placed ads and articles in Spanish and bilingual community newspapers. Media messages raised awareness about the importance of proactive diabetes control and encouraged Latinos to discuss A1C testing with their physicians. We placed program messages for providers in physician trade magazines.
EVALUATION AND DISCUSSION
We used Medicare claims data to assess the program’s effectiveness in decreasing the disparity in A1C testing between White and Latino fee-for-service Medicare beneficiaries. We calculated the proportion of fee-for-service Medicare beneficiaries with diabetes aged 18 to 75 years who had received an A1C test during the preceding 12 months starting 18 months before and continuing until 18 months after initiation of program interventions. Measurements were taken every 6 months (June and December) for the entire population of eligible beneficiaries (10444 Latino and 46660 White beneficiaries in June 2004). Beneficiaries with diabetes were identified from Medicare billing claims recording a diagnosis of diabetes during either 1 inpatient or 2 outpatient physician encounters during the 12-month measurement period. Because Viva la Vida targeted counties with the lowest A1C testing rates in the state, we were unable to identify control counties with such low testing rates and demographic characteristics. Therefore, we limited the evaluation to the reduction in the A1C testing disparity between Whites and Latinos in the program counties.
A1C testing rates increased for both White and Latino beneficiaries in the program counties during the 3-year measurement period (Figure 3 ▶). The disparity in A1C testing between White and Latino beneficiaries decreased slightly (from 9.6% to 7.1%) before initiation of program interventions but narrowed considerably (from 7.1% to 3.0%) during the 18 months of program interventions, when the annual A1C testing rate among Latino beneficiaries increased from 70.6% to 77.5%. Most of this increase occurred after June 2003, corresponding to the most intense period of interventions. We devoted the earliest project months to preparatory work and implemented the bulk of the interventions after June 2003, when most program materials had been completed. The increasing slope in Latino testing rates after June 2003 suggests that our project contributed to the improved A1C testing rates and decreased disparity between White and Latino beneficiaries getting tested.
FIGURE 3—
Annual glycosylated hemoglobin (A1C) testing rates among fee-for-service Medicare beneficiaries with diabetes in Los Angeles, Orange, Riverside, and San Diego Counties, Calif: June 2001–June 2004. Note. Annual (12-month) A1C testing rates were calculated every 6 months.
The project was successful because of the multifaceted, culturally appropriate approach to its design and implementation. We reached beneficiaries and providers with health messages through bilingual printed materials, mass media, and program partners. Partnerships with organizations that shared similar goals and had a vested interest in outcomes enabled us to reach targeted providers and beneficiaries and extend our project dollars. We found that working with health plans or medical groups was an effective and efficient way to reach busy physicians. The targeted beneficiary population’s response to the program materials was favorable; they won several national media awards. Providers’ high demand for the printed tools underscored the need for these materials in the community.
NEXT STEPS
We are using our established partner relationships in new quality improvement projects and continue to distribute project materials. The next step in evaluating the project is a process and outcome evaluation to determine which interventions in our multifaceted approach were the most successful in reaching and affecting the targeted beneficiaries and providers.
Acknowledgments
The authors thank Susan Merrill for her valuable editorial insights and Evelyn Rupp for her assistance in developing and implementing program tools and interventions. We also thank Joan Thompson for her contributions as primary author of the diabetes self-management booklet used in the Viva la Vida project.
Note. The analyses upon which this publication is based were performed under Contract number 500-200-CA02 titled “Utilization and Quality Control Peer Review Organization for the State of California,” sponsored by the Centers for Medicare & Medicaid Services (CMS), Departments of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does the mention of trade names, commercial products, or organizations imply endorsement by the US Government.
The authors assume full responsibility for the accuracy and completeness of the ideas presented. The article is a direct result of the Health Care Quality Improvement Program initiated by CMS, which has encouraged identification of quality improvement projects derived from analysis of patterns of care and therefore required no special funding on the part of this contractor. Feedback to the authors concerning the issues presented is welcome.
Human Participant Protection No protocol approval was needed for this secondary data analysis of Medicare billing data.
Peer Reviewed
Contributors R. Olson designed the evaluation, conducted the data analysis, and led the writing of this report. F. Sabogal and A. Perez designed the program interventions and contributed to the writing and editing of this report.
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