Final Program Development Paper

DIABETES SELF-MANAGEMENT 1
Diabetes Self-Management Program
An Occupation-Based Community Program
Gareth Loosle
Department of Occupational and Recreational Therapy
University of Utah
Introduction
The purpose of this project is to assess the needs of a community and student-based
health clinic and to utilize the unique skills and knowledge of an occupational therapy student
to develop a program that will enhance the quality of care provided. A needs assessment was
completed over multiple weeks and included one-on-one interviews, surveys, observation and
general interactions with clients, students, and health professionals. After synthesizing the
gathered data and completing a thorough review of relevant literature, a formal occupational
therapy program was developed and presented to the clinic to bridge the current gap in the
services provided.
Description of setting
The University of Utah Health clinic is located in the city of Midvale, Utah. It is one block
west of State Street and sits right next to a UTA Tax station. The clinic is a small four room
building that was converted from a real estate office and has been in operation since 2014.
History
The City of Midvale approached the School of Medicine at the University of Utah and
wanted their educators and physicians to provide a free clinic to underserved populations
within their city limits. The School of Medicine declined. However, one of the physicians saw an
opportunity; he agreed to proctor the clinic if he could set it up as a student-run clinic geared
towards education and training. It began as a basic clinic with medical students present two
nights a week and quickly expanded to include pharmacy students. About a year after
beginning, the physician wanted to include other health professionals and invited other
disciplines to join once a month for a diabetes treatment night. He subsequently helped create
interdisciplinary teams, something he constantly calls the “future of healthcare.”
Consequently, the mission statement for the Interdisciplinary (IP) diabetes treatment
nights has two main themes. The first is to address healthcare needs of the Salt Lake
community through assessment and provision of current evidence-based practice. The second
is to develop and maintain a learning laboratory where teaching, education, and mentorship
can be fostered between students, clinicians, and community members.
Target Population
According to the Utah Department of Health, there are about 145,000 people, or about
8% of the adult population, in Utah diagnosed with diabetes (Utah Department of Health,
2017). Utah currently has underserved medical care in Garfield county, Sevier county, Midvale
City, South Salt Lake, West Valley City, and parts of Salt Lake City (Utah Department of Health,
2015). Another survey concluded that Salt Lake County was one of the state’s health
professional shortage areas for part of the county. It found that 35.1% of Utahans making less
than $25,000 per year reported cost of as a barrier to health care (Utah Department of Health,
2017).
About 14% of Utah speaks a language other than English at home. Of those, about
130,000 speak English “less than well”. About 9% of the population speak Spanish as their
primary language (Okada, 2016).
The clinic’s client data is currently disorganized due to multiple student groups and the
hopeful / eventual transition to an electronic medical record (EMR). The clinic does not keep
any running records beyond individual patient charts. However, one Microsoft Excel sheet
found from Spring 2017 had basic patient data for eight patients. That Data, combined with
data gathered from client interviews was combined. The Average height is 66.4 inches tall and
the average weight is 173.8 lbs. and the average body mass index (BMI), a common way to
measure obesity and overweight is 28.1. This fits into the “overweight” category and suggests
higher risk of diabetes, heard conditions and other health complications. The average age is 43
with a range of 30 to 61 years old. Every patient interviewed and every patient on the Excel
sheet took between 500mg and 1000mg of the drug Metformin twice per day (BID). Every
patient spoke Spanish and one interviewed spoke fluent English as well. The clinic seeks to
provide healthcare to underserved populations in the Salt Lake area. The typical clientele is
underserved Hispanic males who speak Spanish and ultimately need help managing their
diabetes.
External factors on diabetes patients
Policy
The major policy affecting quality health care for this population with diabetes is that
you must be a US citizen to get an Affordable Healthcare Act plan.
While it is a law that medical facilities provide translation services, the service delivery
quality is contingent upon the specific facility. Not every facility will use present translation.
Instead, they use a remote translation service provided through the phone.
Sociocultural and Economic
Often, the patients who come to the clinic are under financial pressure to support
themselves and their family. Because they are not English speaking, they are under pressure to
fit into the general American society. Family is highly valued. They typically are of low
socioeconomic status who work long hours or multiple jobs. As stated above, 35.1% of those
making less than $25,000 believe cost as a major barrier to quality healthcare (Utah
Department of Health, 2017). The overall poverty level in Salt Lake as of 2016 is at 19.1% and
current unemployment is at 3% (U.S. Census Bureau, n.d.)
The clinic does not keep statistics on current socioeconomic status of patients and the
attending physician stated that they don’t turn anyone away, but the clinic has been optimized
to serve a specific population.
Demographic
According to the U.S. Census Bureau, Midvale City, the location of the clinic, has a total
population of 33,208. The population of Midvale includes 79.6% White (Compared to 72.8% in
Salt Lake City) and 23.5% Hispanic (compared to 21.6% in Salt Lake City). 26.6% of people in
Midvale are college graduates, but 88.8% are high school graduates. The percentage of
population without health insurance is 19.9% which the U.S. Census Bureau highlights as
concerning is above the national average.
As stated earlier, the typical patient clinic is a male between 30-61 years old, non-
English speaking and requires help managing their diabetes. Patients are classified as
overweight according to their BMI calculated off their height and weight. The clinic is located in
Midvale, Utah, which, as stated earlier, is an area identified in Salt Lake County as underserved
and is an area of lower socioeconomic status.
Current Services Provided
Those that have the most contact with the patients at the clinic include health
professional students from School of Medicine or Pharmacy, nursing, occupational therapy,

physical therapy, dietician, and physician’s assistant. There are also established professionals
such as a physician, pharmacist and sometimes an occupational therapist on site to provide
mentorship to students and to help finalize treatment.
The current role of the occupational therapist (OT) is to serve as a proctor for students
in order to provide mentorship for clinical reasoning development. The occupational therapist
proctor has been at one of three clinics this fall.
Patients at the clinic are scheduled for one-hour long visits. There is one student from
each health professional discipline mentioned above in examination room. Each discipline has
an opportunity to gather medical history and relevant information to help treat the patient. The
OT student gathers data on medication adherence, daily routine, current work, hobbies, family
life, physical activity and what barriers or supports there may be. Patients are then given
recommendations from students, and attending physician as seen fit, given prescriptions for
medication as needed and are schedule for a periodic follow-up.
Related services
In addition to the IP diabetes treatment nights, there are weekly treatment nights with
the medical and pharmacy students every Tuesday and Wednesday. There are periodic pro-
bono physical therapy and dentistry clinics at this location as well.
Funding sources
In the early days, the clinic was partially funded by the city of Midvale. The clinic is a
nonprofit “charity” or pro bono clinic currently funded through three avenues. The main source
of funding is grants. Current grants the clinic has received include the State Primary Care Grant
(Medical and Dental Programs), CHG Grant (Dental Program), Office of Disparities Reduction
(UDOH) grant, (Dental Program- Mobile Dental Clinics), Health Children Healthy Smiles grant
(Pediatric Dental Program). The clinic was unable to provide me exact dollar amounts for each
grant.
The second funding source is through donations. This includes donations from the
Sorenson Legacy Foundation (for Dental equipment upgrades) The Mexican Consulate (for
Midvale Health Fair), the Health Choice for Utah (for Midvale Health Fair), Beisley Family
Foundation, the LDS Church (for Medical and Dental)
The third, and smallest portion of funding comes from Fee for services. The clinic
charges $15 copay per visit. Medical lab required are provided at cost thanks to ARUP
(approximately $3-$10 each). The Dental Program provide full restorative services usually
prices are 75% below market value.
The funds are used to pay for rent, utilities, supplies, equipment, maintenance and
repair, staff, liability and other costs.
Future Plans
The program is still “in its infancy” according to the attending physician. As such, the
clinic has a multitude of idealistic future plans. But currently the clinic has prioritized finding an
EMR that is both effective and affordable. The clinic has stated that it simply cannot afford a
mainstream EMR like EPIC. The clinic is still researching what, if any, EMR it will migrate to.
The clinic is currently working on research projects for both student and patient
outcomes, both are in their infancy still and are currently being refined. The student outcome
survey was adapted from the School of Pharmacy in order to understand student competence,
confidence, bias, and overall experience at the clinic.

The patient outcome research has only been discussed in student coordinator meetings,
but currently is looking into patient adherence to their goals given at the end of treatment
(professional recommendations). The means are still being explored.
Programming strengths and areas for growth
Professional Clinician perspective
Attending physician
An informal interview was conducted with the attending physician and information
gathered during ongoing interaction during time spent at the clinic was included. He is the one
that helped develop this clinic. He stated that his goals are basically the same as the mission
statement. He wants to provide high quality, cutting edge healthcare in a team environment,
while also providing a safe place for students to gain hands on experience treating a real client.
He believes that there is no better experience that getting interaction with a real patient with
needs. He stated that both of his and the clinics objectives were a strength; he believes the
future of healthcare is team treatment and says that we are creating that scenario right here.
He constantly says, “give me a physician, pharmacist and occupational therapist / physical
therapist and we can solve any problem.” He believes that by providing team treatment with
multiple health professional students he is providing high quality care to patients.
The areas of growth discussed mainly included expanding and streamlining what is
currently in place. He wants to make it an even better environment for student learning
including creating streamlined student training, and better division of students during
treatment nights to allow for more patient student interaction. When probed further, the
attending physician did not know exactly how he wanted to streamline student training yet and
was open to ideas. He stated that it was “just something I think would help create a stronger
environment.”
He also wants to improve the consistency with patients by finding ways to improve
commitment to appointments, adherence to medication, and clinical recommendations. He
says that some patients are good about tracking their blood glucose, exercise, and diet. Others
are not. Some patients show up every three, six, or nine months and only because they need
medication refills. This program aims to target this area for growth by providing diabetes self-
management education through a variety of service delivery options and examining patients’
daily routines and barriers to success in order to provide the best opportunity for clients. This
will be further discussed in part II and III.
Attending Pharmacist
The attending pharmacist was informally interviewed. She believes current strengths of
the IP clinic is empowerment for the client. They get 5-7 different health professional screens,
evaluations, and professional recommendations. She says that many clients leave feeling
motivated to make changes. She says that many patients often enjoy interacting with students
and feel that they get to be a part of a student learning experience. She continued that this can
also be an area of weakness. Many clients leave with so much information that they have
information overload, idealistic instead of realistic goals and expectations and consequently do
not make any permanent long-term changes.
She mentioned that the population at the clinic is great for students because they
typically have a low reliance on medications for health, and thus being more open to routine
and habit changes. It provides hands on opportunity for students to become highly skilled at
physical examinations.
Students
An informal interview was conducted with the head student coordinator for the IP
diabetes treatment night and other students who have frequented the clinic. She said that the
biggest area for growth is better balance between providing quality care for patients and
creating a good environment for students. She said that often, with all the different health
professional students in the room trying to get experience trying can create a difficult
environment for a student and patient. She mentioned wanting to change the order of
operations within the clinic: First, obtain a brief medical history and background on the patient.
Students then then leave the treatment room and coordinate with the attending physician,
pharmacist, and occupational therapist on how to approach treatment. Then the students
reenter the room and complete more thorough evaluation and treatment, followed by leaving
the room and coordinating with the attending physician, pharmacist, and occupational
therapist once again on their results. The attending physician will then facilitate education and
feedback on student’s report and enter the treatment room with the patient for the final
evaluation and treatment. Under the current approach, the students gather all information,
perform screens and evaluations in one sitting without consulting the health professionals
present. The head student coordinator believes that allowing time to interact with the
attending physician, pharmacist, and occupational therapist provides more room to process
how to best approach a patient.

She also talked about wanting to increase the consistency of clients coming to the clinic
and adhering to the three goals written with them at the end of each session. She mentioned
that anyway we can help the patient adhere to medication, diet, and exercise goals is a positive
thing and an area that can be improved upon in the clinic and in healthcare in general.
Client perspective
To create a complete understanding of the needs of the clinic, data was gathered on
clients including unstructured interviews, survey sheets, observation, actual treatment, and
past experiences at the clinic were included. During the semi-structured interviews, clients
were asked about their perspective on their ability to manage their diabetes and their
satisfaction with how they are doing. They were asked what their biggest barriers and
successes were. Questions were designed to be open ended and lead clients to think about
what occupations they engage in, would like to, or would like to improve their performance in.
The semi-structured interviews included a list of prewritten questions that helped guide the
interview, but the interaction was more organic allowing for conversation and interaction. The
questions were not read off verbatim but served as data points that should be gathered. The
specific questions used in the semi-structured interviews can be found in appendix A.
Overall, seven clients were interviewed. All were male, the youngest was 35 years old,
and the oldest was 60 years old. One lived alone, while the rest had families at home. Six of
seven reported that they are open to, and enthusiastic about receiving additional help with
their diabetes. Five of seven reported that they wanted more education and more reminders
about healthy eating. Four out of seven reported that they think they eat well, but would like
more education on what is appropriate stating that on average their satisfaction with their diet
is six out of ten. Four of seven reported that they would like to interact with students more if it
will help them stay healthy. The most common reported barriers to success include poor diet
and exercise routine due to a lack of time. Despite six of seven reporting not checking blood
glucose at the recommended amount, only three of seven reported this as a major area of
concern. Of the returning patients, zero out of six remembered their specific goals from their
last visit. Overall the average satisfaction with their overall diabetes management was six out
of ten. Patients reported they wanted the most help with diet and exercise and ultimately
finding a routine to follow to increase adherence to an action plan.
Graduate Student Perspective
The gathered data between clients, professionals, and students involved with the IP
diabetes clinic was analyzed. As a result, certain strengths, barriers, and areas for growth were
identified. Because the IP clinic is still developing, there is plenty of opportunity to examine
deficits and strengths in the current service delivery for unreserved patients. The findings will
be outlined in the following sections.
Strengths
Strengths include a young clinic with a solid foundation that is willing to examine new
ways to expand quality healthcare. This clinic is full of enthusiastic students from many health
professional programs. Students reported a desire to increase the experience and quality for
patients. The clinic is already proficient in serving underserved clientele to benefit both
professional students and clientele in a primary care setting. The willingness of the IP clinic to
find the best way to provide quality care provides a strong platform to test different
approaches to healthcare.
Every patient interviewed except one expressed interest in finding ways to make them
healthier. The patients at the clinic understand that they would benefit from more education
and were open to the possibility of expanding the care provided.
Weaknesses and Barriers
Because there are numerous health professionals present at the clinic, with background
in the classic medical model, there is a general medical approach and a focus on medication
and prescribing treatments. This presents a few problems. First, it is difficult for an individual to
be client-centered in practice. A client-centered practice focuses on the client being part of the
decision-making process regarding their own health. Many of students wish to be involved in
treatment, leaving little room for others to participate at times. It is difficult to be occupation
based in evaluation and in practice because of the number of students present and the given
amount of time. A full occupational profile and history during treatment times is unrealistic
given the parameters. Understanding the client’s values, habits, routines, roles is difficult. In a
group treatment setting, it is difficult to screen fine motor skills, memory, and cognitive status.
An occupation-based program to compliment the IP treatment nights developed by an
occupational therapist can help to bridge this gap in understanding the client.
The clients are inadequately educated on how to appropriately manage their wellness
outside of the clinic according to the attending physician. The client’s average BMI and A1C
charts supported this claim. Many patients agreed that they were not managing their diabetes
as well as they could. Patients tend to struggle adhering to long-term recommendations over
diet changes and exercise, per patient report and attending physician. While some patients did
consistently check and document their blood glucose, when levels were hyper or hypoglycemic,
patients would not react appropriately.
There is little follow up and accountability for patients to follow through with goals and
recommendations. Patients are handed a small piece of paper with three goals for them. The
patient may or may not have been involved in the goal writing process, depending on the
students present. One goal is written for medication adherence, one for diet, and one for
physical activity. In past observations at the clinic, many of these goals are idealist instead of
realistic and attainable, especially when the patient is not involved with the goal writing. In
addition, there is no clinic recording of the patients
Patients do not regularly come to the clinic. Some come every month, some come every
six or nine months. This makes it difficult to provide quality care and quality recommendations.
It also presents a more complex problem to the lack of adherence to goals and
recommendation: patients may or may not follow through with changes in their lifestyle.
Combined with the possible length of no contact, this becomes a risk for patients who are not
managing their diabetes well.
The current program does not have a successful way to help the patients between their
visits to the clinic. Patients consistently reported that they would like additional help in
maintaining adherence medication, physical activity, and diet recommendations
Occupational therapists (OTs) could have a larger role in primary care for diabetes
management. OTs are one of many health professionals that can become certified diabetes
instructors (National Certification Board for Diabetes Educators, n.d.) and diabetes
management, and all the components involved in successful management fit into the
occupational therapy domain of practice (AOTA, 2014). The role of occupational therapy and
diabetes management will be further explored in the following sections.
Evidence-based practice
A literature review was completed in order to gain a better understanding of the
occupational needs for diabetes patients who attend the IP diabetes treatment nights. The
American Journal of Occupational Therapy, Google Scholar, and the University of Utah Library
online catalogs, including databases such as PubMed and CINHAL, were searched for relevant
articles. Searches included combinations of the following terms: occupational therapy, diabetes,
medication management, clinic, self-care, self-management, education, adherence,
nonadherence, medication, Hispanic, underserved, Latino, literacy, health, socioeconomic
status, telehealth, DSM, classroom, education, telerehabilitation. Only articles that contained
relevant and comprehensive information for this project were used. Overall, 39 total sources
were used, including 29 peer reviewed articles, one presentation at a professional conference,
and nine government websites.
Characteristics and Deficits of Patients with Diabetes
In order to better understand the needs of the population, Literature was reviewed to
gain a more evidence-based perspective on characteristics and potential deficits in the typical
patients seen at the diabetes clinic.
Diabetes is different for men and women. This includes gender differences in
management, history, and general perception. Women with diabetes are more likely to have a
history of diabetes in their family, better diabetes education, and higher expectations of
diabetes self-management. Women also report higher levels of social support from health
professionals, whereas men have fewer depressive symptoms, lower body mass index (BMI),
and lower levels of high-density lipoprotein cholesterol (Gucciardi, 2008).
Because nearly all of the patients at the diabetes clinic are male, it is important to
understand the unique needs of males in order to ensure successful diabetes management.
Gucciardi (2008) concluded from their findings that men should attend diabetes self-
management educational courses that emphasize the benefits of appropriate self-care
(Gucciardi, 2008).
Diabetes often comes with co-morbidities. Druss (2001), reports that about 55% of
those with diabetes also have diagnoses of mood disorders, asthma, hypertension, or heart
disease (Druss, 2001). The American Diabetes Association also reports that hypertension,
hypoglycemia, cardiovascular diseases, heart attack, stroke, low vision, kidney disease,
depression, and peripheral amputations due to neuropathy are common co-morbid conditions
(American Diabetes Association, 2016).
Although diabetes is primarily a condition related to metabolic dysfunction, it is
surprisingly complex to treat and manage. This program will address the lack of diabetes self-
management education through the mixed use of individual treatment, group intervention, and
telehealth. These three modes of service delivery will provide a high-quality program aimed at
diabetes self-management education for underserved men. In addition to education, this
program will provide hands-on training and skills that patients can incorporate into their daily
routines.
Hispanic population characteristics

Underserved Hispanic diabetes patients are prone to problems related to managing
their diabetes and often present with higher A1C values and consequently, more severe
diabetes complications (Kirk, 2008). A1C refers to a blood test that reflects average blood
glucose levels over the past three months and provides insight into consistent diabetes
management over time. Underserved Hispanics in America with diabetes have a 40% higher
mortality rate than non-Hispanic white Americans (U.S. Department of Health and Human
Services, 2016; Rowley, 2017).
This higher-than-average incidence of diabetes is paired with higher healthcare costs.
Yearly cost for Hispanics with diabetes was $49.8 billion in 2015, and is estimated to reach
$109.9 billion by 2030. This is primarily due to an increase from 6.8 million cases to 13.1 million
cases of Hispanic diabetes between 2015 and 2030 (Rowley, 2017). One of the major reasons
for these high costs is poor medication adherence (Parada, 2012). Between 30% and 50% of
people do not take their medication as it was prescribed (Osterberg, 2005). Medication
nonadherence is commonly caused by forgetting to take the medication, running out of the
medication, or being careless about medication dosage and scheduling (Gadkari, 2012). There
are other common underlying factors that impact medication nonadherence, including lowered
perceived needs for the medication, medication affordability issues, decreased self-rated
health, and age (Gadkari, 2012; Osborn, 2011). One article argued that unintentional
nonadherence can be predictably explained by understanding a patient’s medication beliefs,
their chronic disease, and sociodemographics (Gadkari, 2012).
Osborn (2011) argued that medication nonadherence can be attributed to minorities
having less health literacy than Whites in America. (Osborn, 2011) Health literacy is defined as
“the degree to which individuals have the capacity to obtain, process, and understand basic
health information and services needed to make appropriate health decisions” (U.S.
Department of Health and Human Services, n.d.). According to the U.S. Department of Health
and Human Services, 65% of Hispanics have a “basic” or “below basic” level of health literacy.
This decreased health literacy makes it less likely that an individual will make safe and
appropriate choices in instrumental activities of daily living (IADLs) such as health management
and maintenance (medication management and physical activity) and meal preparation.
Socioeconomic status
The majority of Hispanic Americans living in Utah have low socioeconomic status (Utah
Department of Health, 2017). According Morales (2002), lower socioeconomic status is an
important health factor and is associated with unhealthy behaviors such as smoking,
overweight or obesity, and low engagement in physical activity (Morales, 2002).
Obesity
Obesity is a growing problem in the United States, affecting nearly 40% of Americans
(Hales, 2017). Finkelstein (2009) suggests that 42.8% of people between 40 and 59 years of age
are obese. According to the same report, Hispanic Americans have an even higher prevalence of
obesity (47%). Overall, obesity causes significant strains on the health care system, costing
Americans $147 billion in 2008. According to Finkelstein (2009), the cost of medical care for
those who are obese is $1,429 per year higher than Americans within a normal weight range
(Finkelstein, 2009).
Occupational therapy’s role in diabetes management

Occupational Therapists (OTs) currently are one of eight health professionals that can
become a Certified Diabetes Educator (CDE). The other professionals that can become CDEs
include: Clinical Psychologists, Registered Nurses (includes Nurse Practitioners, CNS),
Optometrists, Pharmacists, Physical Therapists, Physicians, and Podiatrists (National
Certification Board for Diabetes Educators, n.d.) All of these health professionals have a unique
and important skillset for the treatment and management of diabetes. OTs, in particular, look
at “occupation” as a means for driving client-centered therapy. Occupational therapists define
occupation as follows:
Occupation is used to mean all the things people want, need, or have to do, whether of
physical, mental, social, sexual, political, or spiritual nature and is inclusive of sleep and
rest. It refers to all aspects of actual human doing, being, becoming, and belonging. The
practical, everyday medium of self-expression or of making or experiencing meaning,
occupation is the activist element of human existence whether occupations are
contemplative, reflective, and meditative or action based (Wilcock, 2014).
OTs address client factors, performance skills, performance patterns, context and
environment, and understand the interaction between all of these domains (American
Occupational Therapy Association, 2014). OTs are highly trained in facilitating health-promoting
lifestyle changes by addressing the patient from a holistic position (Pyatak, 2015), which
involves examining the person and their supports and barriers within their context and
environment. Although occupational therapists are in a strong position to provide quality care
for patients with diabetes, the current literature regarding occupational therapy treatment for
diabetes as a primary condition is limited (Pyatak, 2015). This provides opportunity for
occupational therapists to explore new areas for intervention through creation of new research
and evidenced-based practice. Occupational therapy’s impact in diabetes management is well
researched, but occupational therapists’ roles are still being defined.
The statistics on the number of OTs working primarily with diabetes self-management
in America are limited, and no specific numbers were found. OTs currently working with
diabetes patients note deficits in maladaptive occupational choices, including medication
nonadherence, poor physical activity, and inappropriate meal preparation. There are also
patterns of poor problem solving and signs of impaired cognition in some patients (Pyatak,
2018). OTs work on making small changes, using cognitive or visual strategies, fine motor skills,
client education, social participation, time management, and energy compensation. Areas of
relevant occupational therapy intervention will be further addressed in the following sections.
Client Evaluation
Occupational Therapists utilize function and occupation-based evaluation methods in
addition to observation to complete formal evaluations. The literature on occupational therapy
evaluations for diabetes is limited. However, there are evaluations that an occupational
therapist can use to assess different factors. To evaluation cognition, occupational therapists
use occupation-based evaluations such as the Performance Assessment of Self-care Skills
(PASS). The Pass has many subsections to it, including a medication management portion that
simulates real-world pill management to assess problem solving, use of strategies, memory,
fine motor skills, and bilateral coordination (Chisholm, 2014). There are similar medication
management subsections of the Allen Cognitive Level assessments. OTs can also use
monofilament testing for peripheral neuropathy and visual acuity tests for potential vision
deficits found in mismanaged diabetes patients (Dieterle, 2012).
Patient Education and Interventions
The need for appropriate education for Hispanic diabetic men is well-documented. One
study found that appropriate self-care education is the biggest deficit in diabetes self-
management (Gucciardi, 2008); a meta-analysis found that patients who received diabetes self-
management education had improved glycemic control compared to those who received no
training (Gary, 2003). The American Association of Diabetes Educators state that there are
seven essential behaviors involved in successful diabetes self-management: healthy eating,
being active, monitoring blood glucose, taking medication, problem solving, reducing risk, and
healthy coping (The American Association of Diabetes Educators, 2018). OTs contain a skillset
that incorporates all seven behaviors and how to address a client’s daily routine and positively
impact overall health.
One of the diabetes clinics in Salt Lake proper provides self-management and education
is the Utah Diabetes and Endocrinology Center within the University of Utah health network. It
provides courses in: diabetes self-management, carbohydrate counting, medical nutritional
therapy, gestational diabetes education, insulin pump training, and continuous glucose
monitoring training. Each of these courses are within the scope of occupational therapy
education. In addition, occupational therapists can provide clients with education regarding
how to appropriately use cognitive strategies and how-to problem solve in order to increase
adherence to professional recommendations. Examples include the use of visual cues, phone
applications, and memory banks. Occupational therapists can also provide strategies to
compensate for low vision through increased contrast and magnification (Dieterle, 2012; Pyatak
2018). Additionally, clients can be educated on recognizing symptoms of hypoglycemia or
hyperglycemia and how to react accordingly.
Occupational therapists can provide education on how overcome barriers in order make
small occupational changes in order to promote a healthy lifestyle. Although the American
Heart Association recommends 30 minutes of moderate exercise per week, any amount of
physical activity is beneficial for patients with diabetes (American Heart Association, n.d.). An
occupational therapist can help a patient make small changes in their daily routine, such as
walking or biking to work or taking breaks to conserve energy throughout the day in order to
have energy for physical activity (Dieterle, 2012).
A Randomized Control Trial (RTC) by Lorig (2009) examined the effectiveness of
community-based and peer-driven diabetes self-management education. It used a Diabetes
Self-Management Program (DSMP) as a model for service delivery. It included trained non-
health professional educators and was conducted in a community setting. During a six-week
program, participants created a goal-directed “action plan”, were given a copy of the book
Living a Health Life with Chronic Conditions, and were presented with education, personal
problem-solving and group problem solving. This study found positive results at six-month and
twelve-month follow-up for decrease in depressive feelings, increase in self-efficacy,
communication with physicians and other health providers, healthy eating, and knowledge of
diabetes (Lorig, 2009).
An occupational therapist can work with patients on improving medication adherence to
better integrate medication into their daily routine through training patients using visual and
cognitive strategies. Schwartz (2016) looked at the effectiveness of the Integrative Medication
Self-Management (IMedS) intervention, which was developed by OTs. It has three components:
first, it encourages reflection on past successes or failures with medication management.
Second, it asks clients to set a medication management goal. Third, with the help of an
occupational therapist, the client develops strategies to complete their goal. This method uses
motivational interviewing and requires the patient to use critical thinking skills while the patient
is able to maintain control of the situation which can create “buy-in.” This study found that 50%
of the intervention group significantly increased their medication adherence and 75% improved
performance in managing their medications (Schwartz, 2016).
Modes of service delivery
OTs provide skilled intervention in a variety of modes including individual, group, and
telehealth. The Schwartz study (2016) used individual treatment designs for occupational
therapy intervention. Although it has a small sample size, and as seen in the previous section,
the results are promising. Additionally, Pyatak (2018) designed her Resilient, Empowered,
Active Living with Diabetes intervention (REAL diabetes) around providing confidentiality and
promoting a trusting relationship between occupational therapist and client. In a randomized
control trial (RTC), The REAL diabetes intervention was adopted from the Lifestyle Redesign
model that uses activity analysis to further understand prevention and management of chronic
conditions. The intervention was designed to promote client autonomy and use of a narrative
process to promote healthy routines. The modules taught included OT assessment and goal
setting, basic self-management knowledge and skills, access and advocacy within healthcare
and community, social support, managing stress and coping with diabetes burnout for
emotional wellness, and finally long-term health (reflection on current progress and planning
for the future). OTs met either in the client’s home, school, or other private location over a
period of six months. Results of this study suggest that occupational therapy individualized
intervention needs to be included with diabetes self-management. The intervention group
reduced A1C levels by 0.57% overall (Pyatak, 2018).
Another RTC utilized the individualized REAL diabetes intervention with an occupational
therapist providing “customized, activity-based sessions based on four core intervention
principles and seven modules of manualized intervention content” (Carandang, 2015). This
study also concluded that individualized community-based intervention using the REAL diabetes
approach is effective in addressing participants’ challenges with diabetes self-management
(Carandang, 2015). Both the IMedS and REAL interventions have evidence supporting
individualized occupational therapy intervention.
The literature on occupational therapy and diabetes in group settings is more limited
than individualized care. The Centers for Medicaid and Medicare Services (CMS) developed the
Medicare Diabetes Prevention Program expanded model (MDPP). The intervention includes
sixteen or more intensive “core” sessions “of a Centers for Disease Control and Prevention
(CDC) approved curriculum furnished over six months in a group-based, classroom-style setting
that provides practical training in long-term dietary change, increased physical activity, and
behavior change strategies for weight control” (Centers for Medicaid and Medicare Services,
2018). A metanalysis examined the effectiveness of the primarily classroom-based intervention
and determined that effectiveness in the real world is mixed. The metanalysis noted that even
across diverse setting, contexts, and environments, lifestyle intervention programs that
incorporated MDPP saw significant weight loss. However, the researchers concluded that there
are significant barriers to overcome, including poor attendance, high costs of class, and limited
availability of programs (Ali, 2012).
Arseneau (1994), An RTC directly compared classroom activity to an individualized
learning activity package. At baseline and at 2-month follow up, there was not any significant
difference between the two groups. At the 5-month follow up, the learning activity package
increased their “behavior score” (10 questions primarily focused on diet) and decreased their
body weight. In comparison, the classroom group increased behavior score as well and
exhibited decreased glycosylated hemoglobin levels (Arseneau, 1994). While this is an older
article, it was the only RTC found that compared classroom versus individualized treatment for
diabetes. This study highlights that there are benefits of both individualized and classroom
work. Similarly, Lorig (2009) used a peer-drive classroom setting for diabetes self-management
education and found positive results for the DSMP program as mentioned in a previous section.
Both the MPDD and DSMP programs provide evidence supporting the use of classroom
and group-based intervention to increase diabetes self-management. While the MPDD had
barriers of cost, the DSMP was constructed to keep costs low and access high, both reached
their desired outcomes (Lorig, 2009; Ali, 2012). It is important to understand the strengths of
each of these programs in order to provide quality service delivery to underserved patients.
Telehealth is another means for service delivery. Cason (2014) states that as technology
has grown to be an integral part of healthcare, new opportunities have arisen to provide quality
healthcare remotely with the patient and occupational therapist in different locations (Cason,
2004). There is not any current literature using occupational therapists and telehealth for the
treatment of diabetes. However, there is relevant research regarding the effectiveness of
telehealth and diabetes management. A prospective observational pre and post intervention
study by Shane-Mcwhorter (2014) found that for patients with uncontrolled diabetes, average
A1C levels dropped from 9.73% at baseline to 7.81% and participants’ knowledge of diabetes
improved significantly after receiving the intervention. Medication adherence improved
minimally. This study used two different telemonitoring methods: the Authentidate Electronic
Housecall, a proprietary remote monitoring device with a touch screen and built in vital
readings for blood pressure and heart rate. The other device was an interactive voice response
system (IVR). Daily sessions were completed for eight weeks collecting blood pressure, heart
rate, and mood. Seventy-nine percent of patients reported better medication adherence due to
the telemonitoring program (Shane-Mcwhorter, 2014).
A follow-up to the previous study, Shane-Mcwhorter (2015), completed a prospective
observational study with a control group examining telemonitoring with higher participant
numbers. This study involved patients doing daily documentation of their blood glucose, blood
pressure, and heart rate. Pharmacists followed up with patients by phone if there were no
values reported, or if values did not appear within the predetermined parameters. The
pharmacist provided education as necessary over the phone. This study found that A1C levels
decreased by 2.07% from baseline. Results also included increased self-efficacy, knowledge
about diabetes and medication adherence (Shane-Mcwhorter 2015).
Shane-Mcwhorter (2016) examined telemonitoring interventions in an underserved
Hispanic population. This study had similar designs as the previous two. The participants
received daily education, but the interaction was left intentionally brief to reduce the risk of
overwhelming participants. Participants were also periodically called. This study also found
that A1C decreased 2.07% from baseline reading, and blood pressure dropped by 8.02 mmHg.
When participants had values that were not ideal, a pharmacist worked with and educated the
patient on importance of medication. The pharmacist would explain the purpose of each
medication, why, and how it was helping them in order to increase adherence. This helped
patients overcome barriers of being overwhelmed with, and afraid of, too many medications.
Education was also provided on disease states and on problem-solving techniques (Shane-
Mcwhorter, 2016).
The three studies examining telehealth paired with the growing prevalence of diabetes,
busy lives, and growing integration of technology into daily routines provides a big opportunity
for telehealth to become an important player in the delivery of quality healthcare. This program
will incorporate strengths of individualized treatment, group settings, and telemonitoring in
order to facilitate successful diabetes management. Those who have poor access to healthcare
could see the biggest benefits, such as rural patients, patients in low SES, and patients who
work jobs with long and irregular hours (Cason, 2004).
Effectiveness of occupational therapy in diabetes care
In each of the studies that involved occupational therapy in the intervention process,
the outcomes were positive across several domains including self-efficacy, A1C levels, overall
knowledge of diabetes self-management, and medication adherence. The strong support for
occupational therapy and occupational therapy-like lifestyle interventions is a positive sign for
furthering occupational therapy’s role in diabetes care.
Expanding the role of occupational therapy

Not many OTs work with patients who have diabetes as a primary diagnosis. Those that
do often focus on secondary conditions such as peripheral neuropathy (Hwang, 2009). Hwang
(2009) examined community-dwelling older adults with diabetes found that 13.7% had received
occupational therapy. This care was often for personal care training (ADLs), low vision therapy,
assistive devices, or energy conservation (Hwang 2009). Similarly, a study investigating referral
rates for patients with chronic diseases found that less than 4% of occupational therapy
referrals in institutional settings and only 2.7% of referrals in non-institutional settings were for
diabetes management (Rijken, 1998).
The incongruence between the evidence and the amount of occupational therapy
involved in diabetes care leaves plenty of room for role expansion. Because OTs view the
patient from a broad perspective, including their context and environment, OTs are uniquely
situated to expand into more primary care for diabetes management for analyzing daily
routines and how they impact function.
Summary
The mission of the IP diabetes clinic in Midvale is to provide high-quality and evidence-
based health care to the Salt Lake community. The clinic currently provides industry-leading,
student-run interdisciplinary treatment for underserved Hispanics and other populations in Salt
Lake County in primary care, physical therapy, and dentistry work. After completing a needs
analysis, there is no individualized, group, or telehealth service delivery for diabetes self-
management care. From the literature review it was learned that diabetes is a complex medical
condition with high financial burden on patients, and comorbidities, and has a major impact on
every day function and life satisfaction (Gucciardi, 2008; Druss, 2001; Kirk, 2008). The Midvale
clinic would benefit from an occupation-based program that draws strengths from three
different service deliveries to maximize the reach of the program: individualized care, group
interventions, and telehealth (Schwartz, 2016; Dieterle, 2012; Shane-Mcwhorter 2016). An
occupational therapist would be best suited to implement this program because of their
training in using a client-centered approach and their holistic understanding of the person,
environment, and context to address deficits in function. This program has great potential to
improve medication adherence, reduce A1C levels, increase knowledge on diabetes, physical
activity, daily routines, increase self-efficacy, problem solving skill, use of cognitive strategies to
overall improve their diabetes self-management. The data from the needs analysis and the
current literature was synthesized and the appropriateness of a diabetes self-management
program was found. This program would fill a need identified by both the physician,
pharmacist, and students involved with the clinic and through the data gathering process of the
needs assessment. This program will help the clinic further serve the health-care needs of the
male Hispanic population in greater Salt Lake.
Program Proposal: Diabetes Self-Management Program
Program overview
The occupational therapy program proposal for the IP diabetes clinic in Midvale is an
empowering self-management program that will compliment and improve current services
provided. A program that focuses on the development of diabetes-self management skills will
benefit the IP diabetes clinic as they strive to increase patient outcomes and overall health.
Such a program will address the service gaps identified in the needs analysis and will address
the data extrapolated from the literature review that examined the role of occupational
therapy, different programs including the risks and barriers, and the different most effective
modes of service delivery. This program will support the IP diabetes clinic’s already established
client-centered focus on providing holistic and high-quality care to underserved populations in
Midvale. This program will provide new skills and training that is necessary to increase
successful diabetes self-management.
The proposed program emphasizes the development of increasing patients’ self-
efficacy, diabetes knowledge, and self-management skills including improved diet and physical
activity. This will be done in accordance to the literature review’s findings on what a successful
program requires. One of the major reasons for poor diabetes self-management skills stems
from a lack of knowledge and training. Consequently, this program will utilize an occupational
therapist to facilitate group-based interventions and individualized care, and will borrow
components from telehealth care in the form of remote daily and weekly data collection.
Program Value
A diabetes self-management program is valuable at the IP diabetes clinic in Midvale to
both the underserved clientele population and to the facility itself. This program will increase
client outcomes and overall successful diabetes self-management. This program will make
patients healthier, more confident, and more competent. Patients will find the program
valuable as they will be empowered to take charge of their diabetes self-management through
individualized care, group-based learning, and telehealth components.
The proposed program will allow the clinic to potentially discharge current patients as
they increase their diabetes self-management and consequently seek out new underserved
patients. As stated earlier in the paper, parts of Midvale and greater Salt Lake is underserved.
This will increase the visibility of the Midvale clinic, increase and provide services to a wider
population, and have a minor positive impact on the profit margin through the $15 copay.
Occupational Justice
The value of the proposed program is further demonstrated from an occupational
justice view. Occupational justice is defined as “the right of every individual to be able to meet
basic needs and to have equal opportunities and life chances to reach toward her or his
potential but specific to the individual’s engagement in diverse and meaningful occupation”
(Wilcock, 2014). As examined earlier in this paper, many of the patients at the IP diabetes clinic
are suffering from occupational injustice. This injustice may be real or perceived, and may
make it difficult to overcome barriers that is preventing them from engaging in meaningful
occupations and overall health. Adverse effects of occupational injustice include isolation,
alienation, incarceration, and overall low opportunities for success (Wilcock, 2014). According
to the needs analysis, many underserved populations cite money and a lack of education as
barriers to healthcare. This proposed program will address occupational injustice by working
directly with underserved patients on enhancing their skills and knowledge about how to
successfully self-manage their diabetes.
Prevention
This program is being implemented at a pro bono and student-run outpatient clinic in
Midvale to complement the diabetes treatment nights. This program will follow a tertiary
approach to disease prevention. The program will focus on maximizing current function,
increasing quality of life, and reducing further decline. The program will address disease from
this standpoint utilizing group-based problem solving and learning, creating individualized care
and action plans, and telehealth monitoring.
Rationale for Occupational Therapy Role
Occupational therapists should have an integral role in diabetes self-management.
Occupational therapists are one of the health professionals that can become certified diabetes
educators. Successful diabetes self-management involves most occupations named in the
Occupational Therapy Practice Framework (OTPF), including ADLs, IADLs, leisure, work, social
participation, and rest. Occupational therapists have a strong understanding of the person as a
holistic being. Occupational therapists consider the emotional, psychological, psychosocial,
cognitive, physical aspects and how they impact daily performance. Occupational therapists
are the only professionals that look at the relationships between the person, the environment,
and the occupation to support health and well-being in everyday activities (AOTA, n.d.). It is for
these reasons that an occupational therapist is best suited to guide the proposed program.
Theoretical Foundation
Two practice models will serve as a theoretical base for the program, with ideas also
borrowed from other theories and practice models. The Person-Environment-Occupation (PEO)
model will serve as a broad occupation-based model, and the Cognitive Orientation to Daily
Occupational Performance model (CO-OP) will serve as the theoretical base for service delivery.
PEO is a model that is well-suited for individuals who are not happy with their current
occupational performance. PEO states that poor occupational performance and poor
occupational satisfaction stems from an incongruence between the person, their environment,
and their current occupations. Changes in the transaction between the three components are
made in order to create occupational performance and satisfaction. Usually, the environment
and occupation are more easily changed than the person (Law, 1996). This model is ideal for
the proposed program because it will help the patients change their occupational performance
through education, increasing self-efficacy, and helping patients analyze their own
performance.
The CO-OP model is a problem-solving and performance-based model that focuses on
performance acquisition through therapist-guided discovery of strategies that enable
acquisition of new skills. The CO-OP model uses patients’ strengths and strategies to increase
occupational performance. The CO-OP uses an action plan cycle that includes 4 steps: 1. Create
a goal 2. Create a plan 3. Do it; carry out the plan 4. Review the plan. This is often condensed
into goal, plan, do, check (Scammell, 2016). This model will help to guide how this program will
facilitate learning for the patients.
Goals and Objectives
The goals and objectives of the proposed program are as follows:
● Goal 1: Increase client diabetes self-management by educating clients on appropriate
diet, exercise, and medication adherence.
○ Objective 1: In 3 months, 80% of participants will independently report
improved A1C levels demonstrating improved self-management.
○ Objective 2: In 3 months, 80% of participants will independently demonstrate a
decrease in BMI.
● Goal 2: Increase participant confidence and self-efficacy in their diabetes knowledge
and management.
○ Objective 1: In 3 months, 80% of participants will independently demonstrate
improved diabetes knowledge compared to baseline.
○ Objective 2: In 3 months, 80% of participants will complete one CO-OP “goal,
plan, do, check” cycle.
Diabetes Self-Management Program
The diabetes self-management program is a comprehensive program designed based
upon evidence and observation aimed to empower, educate, and provide new skills and
training. This program will be offered to any patient that has been to the IP clinic in Midvale
and would benefit from further professional care for diabetes management, and any other
underserved person that would benefit. The program will be advertised within the clinic for
one month before it begins. Students will be encouraged to educate patients on the program
and fliers and handouts will be visible and available throughout the facility. Patients will sign up
with the secretary.
The program is three months long. Three months was selected because it is the length
of A1C cycle that provides insight into diabetes management. Patients will meet at the IP
diabetes clinic twice a month (in addition to the current one time a month interdisciplinary
treatment night). One of those nights will be a group-based learning experience for two hours,
and the other one will be individualized care with sessions lasting approximately 30 minutes
each. Patients will sign up for a time on a sign-up sheet during the group-based session. Details
of each will be examined in the following sections.
Before the program begins, patients will be given the COPM and will fill out a
questionnaire (see appendix A) that will gather basic data on their understanding of diabetes,
their self-efficacy, and their current management of it. The medication management section of
the Performance Assessment of Self-care Skills will be administered. During this initial
assessment, patients will sign up for one of the individualized care session times.
The group-based sessions will last a total of about two hours. The first hour will include
education, lecture and discussion, followed by a short break. The second hour will involve
group-based problem solving and activities that will further internalize the lecture material and
new skills. There will be a total of three group-based sessions during the three-month program.
Part of the philosophy of the group-based sessions will be to actively include the patients as
much as possible through open-ended questions, encouraging them to speak up and teach their
peers and to share their experiences.
The first session will be a quick introduction to the program and a meet-and-greet. The
attending occupational therapist will be present, but the session will be run by an occupational
therapy student. There will be a brief demonstration on how to use the telehealth software to
log their data. Participants will be given a folder with information on the program including
outlines on the three lectures, take home notes, strategies they can use, suggestions for
iPhone/Android apps they can use, instructions on using the telehealth component, and blank
documents to help them take notes and organize their priorities.
This session will focus on diabetes as a medical condition and the importance of
medication adherence. There will be a group discussion on the physiology of diabetes including
the difference between type I, type II, the role insulin, glucose play in diabetes. Next, the
importance of managing medication (questions like “What is the hardest thing about taking
your medication on time?” will be used to facilitate open discussion), and strategies they can
use to manage their medication. The second half of the session will include group work to
complete a worksheet that has fill-in-the-blanks and basic case studies that reflect the
information from the lecture and discussion.
The second session will focus on diet, exercise, and lifestyle choices. This will be set up
similar to the previous session. There will be time given at the beginning and end for any
questions, concerns, or issues that participants are having. It will begin with a learning activity
that discusses the importance and impacts of appropriate diet and exercise. Then the session
will include a group discussion about the barriers to appropriate diet and exercise. This will be
followed by an overview of what the American Heart Association recommends for exercise, and
group discussion will be focused on problem-solving ways to include more exercise into their
daily routine. The occupational therapy student will provide some possible solutions during the
discussion, such as educating clients on energy conservation.
Afterwards, the discussion will focus on healthy food choices. We will discuss what fat,
carbs, and proteins are and what a typical meal could and should look like. In addition to
discussing what an ideal meal looks like, we will discuss barriers and supports to successful
healthy eating, including planning ahead and making choices before hunger happens. We will
discuss how environment, such as kitchen cleanliness or work environment, can support or
hinder healthy choices.
The third session will focus on teaching participants basic activity analysis, problem-
solving and strategies for success. This session will include open space for questions like the
other two sessions. This session will wrap together the previous two and provide participants
with more support going forward to be successful. In this session we will talk about making
plans such as changing routines to facilitate success such as a medication (or food, or exercise)
schedule. This session will have patients write down their normal day in as much detail as
possible and break down where they may have barriers and supports to success, such as
working long hours and not planning ahead for lunch so they get fast food. Group discussion
will focus on how each participant was successful (or not) solving a problem during the
program. This will provide participants with ideas on how to be successful going forward.
The individualized care will also meet once a month during the three-month program.
Sessions will last approximately half an hour each and will be led by the occupational therapy
student. The individualized care will focus on creating rapport with each patient. Some
participants may be hesitant to engage in group discussions regarding their diabetes and
according to the literature review, there are noted benefits of individualized care. This will
focus on developing each participant’s critical reasoning, problem-solving and use of strategies
centered around the CO-OP model of “goal, plan, do check.” During the first session,
participants will write one goal for themselves regarding their diabetes management. They will
then create an action plan on how they will accomplish the goal. They will then “do” the goal
between this and the next session. Basic medical data will also be gathered at each session
including blood pressure, resting heart rate, height, and weight.
The second and third sessions will focus on reflecting on how the participant met or did
not meet their goal. They will reflect with the occupational therapy student guiding the
discussion. If the participant did not meet their goal, then we will discuss their action plan and
why they did not achieve it; the action plan will be rewritten. If the participant did meet the
goal, then a new goal and action plan will be written. The participant will be encouraged to
achieve both goals. There will also be time for participants to discuss any issues they have, ask
questions, or receive additional training from the materials learned in the group work.
The telehealth portion will be utilized to create more accountability when the patient is
not at the clinic in order to increase adherence to goals. This program will use a free HIPPA-
compliant telehealth software platform called ClockTree. It works on PC, Mac, Android, and IOS.
This platform allows for setting reminders, shared documents, and video calling.
Each participant will be set up with a unique login during the initial evaluation. Once
the program starts, participants will be required to log in every evening and open their shared
document and log yes/no to 4 questions: Did you exercise today? Did you eat well today? Did
you take your medication as prescribed? Did you actively work towards your goal(s)? Only the
participant and the occupational therapy student is able to read this document. Every Sunday
during the program, participants will also log their weight and how they felt the past week on
the shared document.
ClockTree is able to set up individual reminders and this will be used to remind
participants daily to log their information and for their scheduled group or individual
appointments. Participants will also be able to set additional reminders themselves throughout
the day for reminders to complete a goal, have a meal, take a break, or for whatever they may
need. The reminders can come in the form of a text, email, or automated phone call and is up
to user discretion. If desired, participants can also reach out to the occupational therapy
student and complete a video call upon request and appointment.

At the end of the program, participants will complete the PASS medication
management, COPM, questionnaire, and feedback form so the program can be strengthened
for the future.
If successful, there is room to create more classroom content for the next iteration of
the program including more detail on education, and including collaboration with other health
professional students including physical therapy for the exercise portion, nutrition students for
diet education, and pharmacy students for medication adherence.
Program considerations
As previously stated, this program is designed for underserved population in Midvale
and the surrounding area who need or want additional help managing their diabetes and will
accept anyone that fits those requirements.
The majority of the participants are expected to be Spanish speaking. It is important to
take this into consideration when planning the program and content. As such, it is expected
that all health professional students are bilingual or are able to obtain a translator. It would be
ideal for the occupational therapy student to speak fluent Spanish in order to create a
smoother teaching and collaborative environment.
The resources provided during the program to participants will be available upon
request to anyone who visits the diabetes clinic. This will allow those who are not able to
complete or engage in the program to access to the materials.
Program Start-up
Before an IP diabetes treatment night, an in-service will be given to all students and
present attending professionals to introduce the program as an option for patients seen at the
clinic. Here, the fliers will be distributed and students and professionals will be encouraged to
refer patients to the program. There will not be a need for any direct training of staff for the
program since it will be run by an occupational therapy student under the supervision of an
occupational therapist. During future iterations of the program, this may change depending on
successful outcomes.
Time Requirements
The program will consist of a total of about four to five hours per month, depending on
how many participants are. The occupational therapy student will be involved for about ten
hours per month with additional time dedicated to client contact, checking ClockTree, and
treatment planning. Individual sessions will be the first Thursday of the week for 30 minutes
each and will subsequently take longer for the occupational therapist with a larger participant
population. Individual sessions will be scheduled starting at 6:00 p.m. Group sessions will
happen on the last Thursday of each month. Group session will go from 6:00 to 8:00 pm.
Thursdays were chosen because they are currently the only day where a room is available at
the IP diabetes clinic.
Staff Involvement
As noted earlier, there is currently little staff involvement outside of occupational
therapy during the initial iteration of the program. The occupational therapist and occupational
therapy student will provide direct services. Students and professionals will be educated on the
program and its expected outcomes and will be asked to refer patients as they see fit. As the
program matures and participant population increases, there will be a push to make it more
interdisciplinary and involve other health professional students.

Space Requirements
Both individual and group sessions will transpire at the IP diabetes clinic in Midvale,
Utah. Space requirements are basic. This program is designed for adaptability and minimal
needs. There needs to be a table with chairs for participants to sit and room for a white board
and/or projector in order to present material. Individualized care sessions will require a small
room with a place for the participant to sit. This may be an examination table, a chair, or desk.
A drawer in an existing filing cabinet at the IP clinic will be required to store files and handouts
related to the program.
Program Marketing and Promotion
The marketing and promotion of the program will be primarily done within the IP clinic
itself. The students, staff, and professionals present will be encouraged to promote the
program to patients that visit the clinic. There will also be fliers and information pamphlets at
the IP clinic. It is expected to get enough participants through these means for the first
iteration of the program. Because the clinic already relies on reputation and word of mouth, it
is expected that the program will follow a similar pattern following the first iteration. In
addition, the occupational therapist and student will actively engage in the community and
clinic to recruit participants.
If additional marketing is needed, a separate venue at the annual Midvale health fairs
will be set up promoting the clinic. Calls from past patients at the clinic will be made. Facebook
and online advertising will be used, but only if needed due to the additional funding
requirement.
Budget
Since the IP diabetes clinic is already established, this additional program will have
minimal annual expense increases. Since the clinic is pro-bono, overhead costs are designed to
be as minimal as possible. This program is designed to be in line with that. The majority of the
operating costs will be in-kind contributions from the clinic including space for group and
individual sessions, tables, chairs, whiteboard, projectors, markers, pens, and printer. The main
expense will come from the wages for the occupational therapist, but due to the design of the
program this will be kept minimal and the occupational therapist will work between 4-5 hours a
month. Other expenses include gathering materials for a PASS kit. The clinic charges $15 copay
for each visit, so there will be minimal revenue from the program. For more specific itemized
budget, a detailed budget sheet can be found in appendix B. The following is a basic overview
of yearly operating costs:
● Start-up costs
○ One-time purchased items $40
○ Occupational Therapy Evaluation $160
● Direct Cost
○ Materials and resources needed for education classes $200
○ Part-time occupational therapist wages $384
Funding Options
The IP diabetes clinic is a student-run pro bono clinic that serves the population of
Midvale and the surrounding area. Based upon this description and the needs of the program,
two potential funding sources were identified to help fund the diabetes self-management
program. The first funding source is the George S. and Dolores Dore Eccles Foundation. This
funding sources was found on www.foundationcenter.org using the advanced search with the
following key search words: diabetes, Utah. Most grants from this foundation are about
$10,000 and are awarded in the state of Utah. Those seeking a grant or more information can
use the phone number: 801-246-5340 or visit their website:
http://www.gsecclesfoundation.org
The second potential funding source found is the Sorrenson Legacy Foundation. This
funding source was found using a Google search using the following keywords: diabetes, Utah,
underserved, grant. Most grants from the Sorrenson Legacy Foundation are between $10,000
and $25,000 and have been given out in the past for diabetes programs in Utah. There is no
listed phone number for this grant, but those seeking a grant can apply online at this website:
https://www.sorensonlegacyfoundation.org
Program Outcomes
The desired outcome of the diabetes self-management program is multifaceted. The
program aims to increase participants knowledge of diabetes, self-efficacy and overall diabetes
self-management including medication adherence, improved diet, exercise, and daily routines.
The training, education, and empowerment components of the program aim to increase
occupational performance and satisfaction of the participants over their lifespan. These
outcomes will be objectively measured in multiple ways and will be reviewed below.
Program Evaluation
Both qualitative and quantitative data will be gathered regarding the effectiveness and
perception of the program. There will be a qualitative questionnaire that will be focused on
examining the effectiveness of the program itself. It will be administered during the final
session and will include open ended questions such as: What do you think about this program?
What Impact did this program have on you? How do you feel about diabetes self-management?
In addition, Pre and post A1C levels will be gathered to understand the changes in
diabetes management. Data will be gathered through the COPM, PASS, telehealth documents
(weight, adherence to goals), and data gathered during each individual session (heart rate,
blood pressure, weight) and the same questionnaire the participants filled out before the
program, which can be found in detail in Appendix A.
Attendance to group and individual sessions will be tracked in order to understand
potential outliers and confounding factors. Adherence to telehealth data entry will also be
analyzed. Both of these may provide insight into the motivation and “buy-in” for the program.
Overall, the data will be use to examine the effectiveness of the program and its overall
strengths and areas for improvement.

References
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American Association of Diabetes Educators. (2018). AADE 7 self-care behaviors. Retrieved from
https://www.diabeteseducator.org/living-with-diabetes/aade7-self-care-behavior
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Appendix A: Client Interview & Survey
I would like to gather some information about you…
1. What is your age?
2. What is your gender?
3. How tall are you?
4. How much do you weigh?
5. Marriage status?
6. Where do you live?
7. Who lives with you?
8. How many hours a week do you work?
I would like to gather some information from you regarding your diabetes…
9. Beyond diabetes, do you have any diagnoses that I should know about?
10. (if returning client) Do you remember the three goals from your last visit? If so, what are
they?
11. (if returning client) On a scale of 1-10 how satisfied are you with your progress towards
your goals?
12. How many times a week do you check your blood sugar?
13. How many times a week do you engage in physical exercise? And for how long?
14. What type of physical activity do you engage in?
15. On a scale of 1-10, how satisfied are you with your current physical activity?
16. How satisfied are you on a scale of 1-10 on your current eating habits?
17. If you could change one thing about your diet what would you change?
18. On a scale of 1-10, how satisfied are you with your diabetes management?
19. What is the most difficult part of managing your diabetes?
20. What would you like to do that you currently do not due to your diabetes?
21. Regarding your diabetes, where do you want the most help?
22. Do you feel that periodic check-ins from a health professional student would be helpful
for you? If not, please state the reason.
23. If yes to previous question, how often would you like to be contacted?
Appendix B: Line-Item Budget Detail
Source of Specific costs or Cost

sources of income
Start-up
Costs
Printed Materials including $200
patient packets, fliers,
information pamphlets. Design,
print, distribute
Occupational Therapy Evaluation $160
$32/hr x 5 hours
PASS kit $40
Total= $364
Direct Costs
Part time OTR salary $480
5 hours per/month x 3 months =
15 hours x$32/hour
To Proctor OT student clinicians
Total= $480
Indirect
Costs
In kind Paper and other general $60
supplies: whiteboard tools ($10 /
per session)
In kind Large and small rooms in clinic $6000
(Clinic’s rent is $2000/month)
In kind Utilities ($150/month) $450
In kind Housekeeping and maintenance $600
($200 month)
Income $7160
Copay Fee for Service $15 per $540 with target
visit, depends on participant
numbers, target 6 patients.
Total= $540
Budget Summary
Total costs $844
Total income $7700 (combined in-kind with

or in-kind income)
contributions
Net cost of $304
program

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DIABETES SELF-MANAGEMENT 1

Diabetes Self-Management Program

An Occupation-Based Community Program

Department of Occupational and Recreational Therapy

interdisciplinary teams, something he constantly calls the “future of healthcare.”

can be fostered between students, clinicians, and community members.

primary language (Okada, 2016).

External factors on diabetes patients

you must be a US citizen to get an Affordable Healthcare Act plan.

Sociocultural and Economic

current unemployment is at 3% (U.S. Census Bureau, n.d.)

to serve a specific population.

concerning is above the national average.

and is an area of lower socioeconomic status.

Current Services Provided

professional students from School of Medicine or Pharmacy, nursing, occupational therapy,

such as a physician, pharmacist and sometimes an occupational therapist on site to provide

mentorship to students and to help finalize treatment.

proctor has been at one of three clinics this fall.

medication as needed and are schedule for a periodic follow-up.

bono physical therapy and dentistry clinics at this location as well.

Foundation, the LDS Church (for Medical and Dental)

prices are 75% below market value.

repair, staff, liability and other costs.

confidence, bias, and overall experience at the clinic.

(professional recommendations). The means are still being explored.

Programming strengths and areas for growth

Professional Clinician perspective

He constantly says, “give me a physician, pharmacist and occupational therapist / physical

multiple health professional students he is providing high quality care to patients.

commitment to appointments, adherence to medication, and clinical recommendations. He

will be further discussed in part II and III.

not make any permanent long-term changes.

how to best approach a patient.

specific questions used in the semi-structured interviews can be found in appendix A.

finding a routine to follow to increase adherence to an action plan.

Graduate Student Perspective

be outlined in the following sections.

and were open to the possibility of expanding the care provided.

Weaknesses and Barriers

An occupation-based program to compliment the IP treatment nights developed by an

patients would not react appropriately.

addition, there is no clinic recording of the patients

managing their diabetes well.

maintaining adherence medication, physical activity, and diet recommendations

diabetes management will be further explored in the following sections.

A literature review was completed in order to gain a better understanding of the

medication management, clinic, self-care, self-management, education, adherence,

nonadherence, medication, Hispanic, underserved, Latino, literacy, health, socioeconomic

and nine government websites.

Characteristics and Deficits of Patients with Diabetes

patients seen at the diabetes clinic.

and lower levels of high-density lipoprotein cholesterol (Gucciardi, 2008).

management educational courses that emphasize the benefits of appropriate self-care

(American Diabetes Association, 2016).

Although diabetes is primarily a condition related to metabolic dysfunction, it is

diabetes self-management education for underserved men. In addition to education, this

Hispanic population characteristics

Underserved Hispanic diabetes patients are prone to problems related to managing

Services, 2016; Rowley, 2017).

This higher-than-average incidence of diabetes is paired with higher healthcare costs.

nonadherence can be predictably explained by understanding a patient’s medication beliefs,

their chronic disease, and sociodemographics (Gadkari, 2012).