Diabetes risk assessment in a senior retirement community

Diabetes Assessment and Identify of the Target Community Leisure World is a 610-acre gated retirement community based in Silver Spring, MD. Those that are 55 years old and older are qualified to join the community. They offer 24-hour security and maintenance-free living conditions with resort-style amenities. These amenities include an 18-hole golf course, 3 clubhouses, restaurants, in-house medical center, Giant food grocery store, tennis courts, and swimming pools. Common health concerns among the elderly include diabetes, pressure ulcers due to activity intolerance, hypertension, and musculoskeletal maladies. Other issues older adults face such as mental health include isolation, depression, anxiety, and loss of independence are commonplace (WHO, 2016). Specifically, older adults are at high risk for the development of type 2 diabetes due to the combined effects of increased insulin resistance and impaired pancreatic islet function with aging (Kirkman et al., 2012).

Is the target community geographic? Phenomenological? Both? Explain why.

The community is both geographical, being a fenced-in community, along with phenomenological, being a community for those that are greater than 55 years old. When choosing Leisure World, the residents share common goals such as access to an in-house health care facility, clubhouses and tennis facilities for recreation. There are even restaurants onsite for those that do not want to travel far. Identify the Surrounding Geographic Neighborhood The surrounding neighborhood includes the city of Aspen Hill, Olney, and Rockville. (https://www.redfin.com/city/33716/MD/Leisure-World). According to the USG census website, the Rockville and Olney area is characterized as being more affluent than the city of Aspen Hill when comparing median income ($100,129 and $133,121 vs. $83,115, respectively). https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk#

Aspen Hill: (2015 estimates) Median resident age is 37 years (47% Caucasian, 25% African American, 33% Hispanic, does not equal 100% ).
https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk

Olney: (2015 estimates) Median resident age is 42.5 years old (73% Caucasian, 12% African American, 10% Hispanic, 12% Asians, does not equal 100%). https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk#

Rockville: (2015 estimates) Median resident age is 40 years old (64% Caucasian, 10% African American, 16% Hispanic, 22% Asian, does not equal 100%). https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk#

2) Gather Community Data

A. Windshield Survey and Observations of Target Community
By driving or walking around the community and visiting community agencies, summarize your observations. Describe and summarize those that are the most relevant or unique and related to the target community. Data Collected from the Windshield Survey Tool Summary and Analysis
What are the health and social implications of the observations made? Most people are middle-aged to elderly, which can be attributed to the fact that it is a > 55 age housing complex. Caucasian, African American, Asian, and Hispanic peoples are seen. Caucasian seems to be the predominant race. There is an on-site Medstar health facility. There is an “interfaith chapel” that is actually on the community grounds, along with a number of denominations and religious buildings just outside of the community. There were advertisements and signs about health and wellness fairs. There are several buses, both public and private shuttles. Most industries within the community are run by Leisure World, including recreation centers and a few restaurants. There are several more restaurants, a Giant superstore, and a number of banks just outside the gates. People are exercising (walking/jogging/biking) or getting out to do errands. Several people are seen golfing and going in and out of recreation centers. There are several recreation centers in addition to an outdoor pool, a full 18 hole golf course and tennis courts which are all in decent shape. There are a number of sidewalks in the community. And a nearby Giant that is very close to the neighborhood that could potentially be walked to. However, it would be easier to drive. Food in Giant appears fresh (Fish, vegetables, fruits, meat, etc.) Community area has no noxious smells or emissions. The grass was cut recently. Community as a whole is fenced and gated. There is plenty of open spaces within the community leaving only a few fences cordoning off areas like the outdoor pool. These observations indicate a community that puts a lot of emphasis on convenience and easy access. They have a private medical facility, plenty of private recreation options, and a number of easy transportation options. Everything is fenced off from those outside the community, potentially leading to social isolation from those outside the community, but could lead to stronger in-community bonds.

There are plenty of health resources available for those who reach out to use them. The idea of independent living is one of the highest in importance to the residents, many of whom do not want to lose their independence and need something like a nursing home.

While striving to maintain independence is an admirable goal, some people may not be willing to accept the fact that they may no longer physically, or mentally, be able to properly care for themselves.

B. Demographic & Health Data
Create a table that compares and contrasts demographic and health data from the target community to neighborhood, city, state, and US data.
NOTE: Select and tailor those demographic and health status indicators that are most relevant for your target community or identified health problem. Not all indicators listed below must be included in your table if they are not relevant. Not all data will be available for the target community or comparable geographic areas.

Target Community
(Leisure World Residence)
City/County
(Silver Spring, Montgomery County)
State
(Maryland)
United States

Demographics (age, race, ethnicity, income, gender, education, employment occupations, population density, percent of the population living below federal poverty level, poverty, etc)
Median Age: 75.8

Race & Ethnicity: 70% Caucasian, 13% Black, 8% Asian, 7% Hispanic, 2% other groups

Median Household
Income: $53,175

Gender: 65.24% female and 34.76% male

Education: Bachelor’s Degree 26.4%, Some College 22.4%, Graduate Degree 21.9%, Associate Degree 7%, No High School 11.2%, Some High School 11.1%

Employment: 2,167

Occupations: White Collar 71%, Blue Collar 29%

Population: 9,227

Poverty Rate: 7.12%
Median Age: 34.3

Race & Ethnicity: 35% Caucasian, Hispanic 29%, Black 25%, Asian 8%, 3% other groups

Median Household
Income: $72,887

Gender: 51.32% female and 48.68% male

Education: Graduate Degree 29.9%, Bachelor’s Degree 27.6%, Some College 18.1%, No High School 10.3%, Some High School 7.3%

Employment:
44,795

Occupations: White Collar 72.9%, Blue Collar 27.1%

Population: 77,460

Poverty Rate: 4.6%

Median Age: 38.3

Race & Ethnicity: 52% Caucasian, 29% Black, Hispanic 9%, Asian 6%, 4% other groups

Median Household
Income:
$75, 847

Gender: 51.65% female and 48.35% male

Education: Bachelor’s Degree 26.8%, Some College 26.3%, Graduate Degree 21.7%, Some High School 10.6%, Associate Degree 8.6%, No High School 6%

Employment: 2.94 million

Occupations: White Collar 70.8%, Blue Collar 29.2%

Population: 6.01 million

Poverty Rate: 9.7%
Median Age:
37.8

Race & Ethnicity: 62% Caucasian, Hispanic 18%, Black 12%, Asian 5%, Other 3%

Median Household Income: $55,775

Gender:
51% female and 49% male

Education: High School Graduates- at least 88%; Some College 59%, Bachelor’s Degree or Higher 33%, Advanced Degree 12%

Employment:
143 million

Occupations:White Collar 60% and Blue Collar 40%

Population: 321 million

Poverty Rate: 14.7%

Health Status Indicators (morbidity and mortality data, infant mortality, health behavior data, general and specific to the health problem of focus)
Infant Mortality Rate: 5.6 deaths per 1000 live births.

Mortality Rate:

Life Expectancy: 81.3 years

Persons with Health Insurance: 100%

Adults with Diabetes: 6.5%

Adults with hypertension: 22.4%

Physical/ Social Environment (crime, retail, housing, air and water quality, walkability score, schools, health insurance, business plans, nutrition, neighborhood indicators, health disparities data)
Crime: 77 most frequent crimes this past year

Health insurance: Clinician to patient ratios
* 1 to 138 for primary care
* 1 to 118 for dentists
* 1 to 267 for mental health
* 1 to 68 for other

Top health disparities in order: Pneumonia (510 patients), Congestive Heart Failure (474), and Acute Myocardial Infarction (268 patients)
- In 2015, average household income: $53, 175

Housing: In 2015, 5,803 number of households
- In 2015, 78.4 % of the residents own a house
- 1 car in a household (average)

Schools: American Public University System, University of Maryland College Park, University of Maryland University College

Neighborhood: Leisure World (LW) plaza conveniently located adjacent to LW

Walkability Score: 56; it is somewhat walkable, and some errands can be accomplished on foot

Air and water quality: Air quality score is 43 which is okay. Water quality is 50 on a scale of 100

Nutrition: There is a nutrition and cooking kickstart class, and a food for life diabetes cooking class offered at leisure world
Crime: 1,739 total number of crimes, crime rate is 23.06 per 1,000 residents annually

Retail: Downtown Silver Spring has many grocery stores, a local farmer’s market, houseware and clothing stores

Walk Score: 60 with 71,452 residents (Silver Spring)

Housing: Average median home income in silver spring (SS) is $442, 684

Health Disparities data: Heart disease and Pneumonia

Air and Water Quality: the air quality index is 50 which is considered moderate. Water quality is a 50 on a scale of 100 (higher is better)

Schools: The education attainment in 2015 was 17%

Nutrition: The healthy diet rate is 49.4%. The grocery stores and farmers markets provides high quality fruits, vegetables, organic meats, artisanal cheeses, breads, pastries, eggs, herbs, and fish

Crime: 166,510 crimes in the past year

Housing: The Maryland Department of Housing and Community Development created programs that helps homebuyers, homeowners, and renters

Air and water quality: “There have been reductions in emissions from utilities and have significantly reduced the number of days that Marylanders breathe unhealthy air” (Fells Point Festival, n.d) *Air quality ranges from 21-35 (Eastern Shore, Western Maryland, Metropolitan Baltimore)

Walkability Score: The 78 largest cities in MD have an average score of 35. The best cities are langley park, and takoma park

Schools: University of Maryland College Park graduated the largest number of students in MD. Most common degrees are business administration, psychology, and biological sciences

Health Insurance: As of 2015, 93.3% of individuals have coverage.

Health Disparities Data: “Maryland is 16% below the national average for the number of physicians in clinical practice”

Nutrition: The healthy diet rate is 49.9%
Crime: 1.2 million crimes in the last year
- Air Quality: In 2013, the score was 74.7

Health Insurance: The percentage of people with health insurance coverage in 2015 was 90.9%

Nutrition: Americans are eating less than the recommended levels of calories from solid fats and added sugars, refined grains, sodium, and saturated fat. Also 23 million Americans are living in food deserts.

Health Disparities data: According to the CDC, the top 10 most common health disparities includes asthma attacks, fatal and non fatal work related injuries and illnesses, health related quality of life, periodontitis in adults, tuberculosis, access to healthier foods, and unemployment

Data Sources:

2016 Crime Statistics Released. (2017, September 25). Retrieved September 29, 2017, from https://www.fbi.gov/news/stories/2016-crime-statistics-released
Airnow. (n.d.). Retrieved from https://airnow.gov/index.cfm?action=airnow.local_state&stateid=21

Assessing the Impact of Healthcare Reform in Maryland. (2017). Department of Legislative Services. Retrieved from http://mgaleg.maryland.gov/Pubs/LegisLegal/2017-Impact-Health-Care-Reform.pdf
Maryland. (n.d.). Retrieved from https://datausa.io/profile/geo/maryland/#clinician_patient_ratio

Barnett, J. C., & Vornovitsky, M. S. (2016). Health Insurance Coverage in the United States: 2015. Retrieved https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

CDC Health Disparities & Inequalities Report (CHDIR). (2015). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/minorityhealth/chdireport.html

Crime Data in Leisure World. (n.d.). Retrieved from https://www.trulia.com/real_estate/Leisure_World-Maryland/crime/

Facts & Statistics. (2017). U.S. Department of Health and Human Services. Retrieved from https://www.hhs.gov/fitness/resource-center/facts-and-statistics/index.html

Fells Point Festival. (n.d.). Retrieved October 06, 2017, from http://news.maryland.gov/mde/2015/04/30/maryland-department-of-the-environment-releases-clean-air-progress-report/

Health Care Disparities in Maryland. (n.d.). Retrieved from http://www.medschool.umaryland.edu/ahec/Health-Care-Disparities-in-Maryland/

Homeownership and Renting. (n.d.). Retrieved October 06, 2017, from http://dhcd.maryland.gov/Residents/Pages/default.aspx

Kirkland, M.S.; Briscoe, V.J.; Clark, N.; Florez, H.; Haas, L.B.; Halter, J.B.; Huang, E.S.; Korytkowski, M.T.; Munshi, M.N.; Odegard, P.S.; Pratlet, R.E. & Swift, C.S. (2012). Diabetes in older adults.
Diabetes Care 2012 Dec; 35(12): 2650-2664. https://doi.org/10.2337/dc12-1801

Leisure World, MD. (n.d.). Retrieved from https://datausa.io/profile/geo/leisure-world-md/?compare=silver-spring-md#housing
A. (n.d.). Leisure World Plaza. Retrieved from http://lwliving.lwmc.com/leisure-world-plaza

Leisure World of Silver Spring, MD : Kickstart Your Health. (2017). Retrieved from https://www.pcrm.org/health/diets/ffl/classes/class-detail/117879

Leisure World Maryland Health Concerns. (2013). Retrieved October 06, 2017, from http://www.geostat.org/data/leisure-world-md/health-concerns

Life expectancy at birth, total (years). (2016). Retrieved October 06, 2017, from https://data.worldbank.org/indicator/SP.DYN.LE00.IN

Olokoba, A. B., Obateru, O. A., & Olokoba, L. B. (2012, July). Type 2 Diabetes Mellitus: A Review of Current Trends. Retrieved October 06, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464757/

Shopping and Services. (n.d.). Retrieved from http://www.silverspringdowntown.com/shopping

Silver Spring MD Crime Rates. (n.d.). Retrieved from https://www.neighborhoodscout.com/md/silver-spring/crime

Silver Spring neighborhoods on Walk Score. (n.d.). Retrieved from https://www.walkscore.com/MD/Silver_Spring

Silver Spring MD Real Estate Data. (n.d.). Retrieved from https://www.neighborhoodscout.com/md/silver-spring/real-estate

Silver Spring, MD. (n.d.). Retrieved from https://datausa.io/profile/geo/silver-spring-md/#conditions

Silver Spring, MD | Local Air Quality Index and Air Pollution Reports | WeatherBug. (n.d.). Retrieved from https://weather.weatherbug.com/life/air-quality/silver-spring-md-20902

Silver Spring, Maryland. (n.d.). Retrieved from http://www.city-data.com/city/Silver-Spring-Maryland.html

World Health Organization (WHO). (2016). Mental health and older adults. Retrieved from http://www.who.int/mediacentre/factsheets/fs381/en/

C. Trends

a) The Leisure World population in 2010 was 8,749 and increased in 2015 to 9,227 (Leisure World, 2012). Overall there is an increase in this community and an upward shift towards more minorities settling in this population.

Ethnicity Population Changes in Leisure World MD

White
African American
Hispanic or latino of any race
Asian
Native
American
Pacific Islander
Other Races
Two or more races

2000
83.15%
11.57%
4.43%
1.74%
0.04%
0.01%
1.81%
1.66%

2010
75%
17%
7%
4%
0.1%
0.1%
N/A
2%

b) Data indicator: Diabetes in Medicare population (65+). There is an upward trend over the current data set for 2013-2015 in Montgomery county compared to a fluctuating level in the U.S. population for the same years. However, overall there is an upward diabetes trend for the Medicare population in the United States using data from 1994-2015 (CDC, 2017).

Diabetes: Medicare population
2013
2014
2015

Montgomery County1
24.30%
24.70%
25.10%

U.S. National Statistics2
22.40%
24.40%
22.00%

1 Healthy Montgomery, 2015
2 CDC, 2017

c) Comparing our community and State data, we found that the top three mortality and morbidity were the same for the years 2013-2015. This is not very surprising considering the causes and types of death do not generally change much in consecutive years. During the 1900s, mortality and morbidity were caused by infectious disease, but since the advent of immunizations and health awareness, we have shifted to more chronic diseases.

Heart Disease
Cancer
Stroke

Data Sources for Trends:

Centers for Disease Control and Prevention. (2017). U.S. Diabetes surveillance system. Retrieved by https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html.

Centers for Disease Control and Prevention. (2017). National center for health statistics: Maryland. Retrieved by https://www.cdc.gov/nchs/pressroom/states/maryland/maryland.htm.

Healthy Montgomery. (2015). Diabetes: Medicare Population. Retrieved by http://www.healthymontgomery.org/index.php?module=indicators&controller=index&action=view&indicatorId=2059&localeId=1259.

Leisure World. (2012). Maryland Population:Census 2010 and 2000 Interactive Map, Demographics, Statistics, Quick Facts. Retrieved October 06, 2017, from http://censusviewer.com/city/MD/Leisure%20World.

Maryland Vital Statistics Annual Report 2015. (2015). Retrieved by https://health.maryland.gov/vsa/Documents/15annual.pdf.

Maryland Vital Statistics Annual Report 2014. (2014). Retrieved by https://health.maryland.gov/vsa/Documents/14annual_revised.pdf.

Maryland Vital Statistics Annual Report 2013. (2013). Retrieved by https://health.maryland.gov/vsa/documents/13annual.pdf.

D. Key Informant Interviews
Identify key informants such as formal and informal leaders within the community or staff at agencies that work with members of the target community. Plan your interview questions in advance and record the information provided below.
Key Informant Position/Title Organization, if relevant
Date of Interview
Summary of Main Points

Home health nurse
9/22/17
The main causes for visits to Leisure World include diabetes, wound care, and frequent falls. A number of the residents seem to have trouble paying for their health care, or seem to have trouble keeping their home in order. Many patients need help understanding both their disease process and their medications.

Home Health Nurse
9/8/17
The biggest problem in my nurses community (Germantown, Clarksburg, Damascus, Gaithersburg, and Montgomery Village) was patients with high chronic diseases (Diabetes, hypertension, ect.) who did not have enough education on their disease process/medications and as a result did not fully understand how to treat it. Some of the patient’s also had problems with being able to afford treatment.

Home Health Nurse

9/15/17
The main causes for our visit to Leisure World was to address a patient with immobility issues. She does not have family in the area and does not exercise enough even with PT. We needed to find a way to motivate her. Encourage her to attend social events at Leisure World or look into subscribing to social services such as Meals on Wheels for food and social support. She was not on depression medication, but seemed sad because of the loss of independence.

Home Health Nurse
9/29/17
The most common diseases my nurse comes across are diabetes and hypertension which is very common among people of a low socioeconomic status. Most of these people are unable to afford healthy food options because they are more expensive. The unhealthy food options are cost effective yet detrimental to health.

Home Health Nurse
9/22/17
The most common problem in our home visit is in older patients with chronic diseases such diabetes, hypertension, and pressure ulcer who are lack of knowledge and noncompliance with their medications and their conditions. These factors are the reasons of their hospital readmission.

Home Health Nurse
9/15/17
The most common problems my nurse addresses in her patient population (Rockville, Bethesda, Glen Echo) are Diabetes, CHF, and wound care. The population served is mainly elderly clients. The biggest challenges the nurse sees in the community are social determinants of health such as limited income, transportation, and access to care. Certain clients could really benefit from home health services, but just can’t afford it. In addition, many clients need a lot of education on their disease process and medications that are required for management of often co-morbid diseases. The education they receive in home health is vital in helping the client to manage their conditions at home.

E. Literature & Document Review

Leisure World is a 610 acre gated community that admits individuals of age 55 and above as members. In that sense, it is both geographic and phenomenological. The community is largely cosmopolitan, with the racial distribution of residents being wide and comprising of Caucasian, African American, Asian, and Hispanic individuals. There is, however, a predominant Caucasian population.
With the only those above age 55 being qualified to join the community, the relevance of the present recreation centers cannot be overstated – i.e. an outdoor pool and tennis court. This is more so the case given the need for this age group to engage in regular physical exercises so as to further enhance their health and wellbeing. The common health concerns among the elderly residents of this community are diabetes, hypertension, pressure ulcers, and musculoskeletal maladies. Other commonplace health concerns faced by the older adults elsewhere and are common in this particular community are identified as loss of independence, depression, and anxiety.
The relaxing and welcoming nature of the community is an indication of a community at peace with itself, which could in essence be the perfect place for those in their prime to live or spend most of their time. The community also seems well maintained and decent. This could be discerned from the readily available public garbage cans and proper maintenance of the lawns. In basic terms, the observations from the Windshield survey are indicative of a community that puts great emphasis on both convenience and easy access. Leisure World comes across as being relatively safe, peaceful, and being a gated community, well maintained.
Comparable geographic communities include Leisure World’s surrounding neighborhoods which comprises of Rockville, Olney, and Aspen Hill. Unlike Leisure World, which has a median age of 75.8 years, the median age of those residing in Rockville, Olney, and Aspen Hill is 37, 42.5, and 40 respectively. This demonstrates a significant median age difference. The national median age is 37.8. However, the racial distribution across the three comparable communities is rather similar, with the Caucasian racial category being predominant at 47% for Aspen Hill, 73% for Olney, and 64% for Rockville. Leisure World ranks lower on the median household income front. The community’s median household income as of 2015 was captured as $53,175. Rockville, Olney, and Aspen Hill’s median household incomes are $100,129, $133,121 and $83,115 respectively. The national median household income is $55,775, which is slightly higher than that of Leisure World.
With a private medical facility within easy reach of many, plenty of private recreation options, and a variety of transport options, Leisure World could be viewed as a model community for the elderly. The clear autonomy of the community, marked by its fencing off, could help foster stronger in-community bonds. The cost residents risk paying for this, however, is social isolation. It is also important to note that although residents could have the desire for autonomy and independence, it would be prudent for them to come to terms with the fact that their advancing age does not allow for complete independence. This is particularly the case given their declining mental and physical abilities, which at some point could call for the need for a caregiver. In the final analysis, it should be noted that with recreational facilities being in plenty at Leisure World for those who would wish to access them, residents should be encouraged to make active use of the said resources. This would help in the management of the common health concerns identified among the elderly residents of the community, i.e. diabetes and hypertension.

Analysis & Diagnosis

3. Analyze Community Data

Analysis Summary
Summarize and synthesize the important points from the data presented in the section above. Be sure to include analysis from all data services (windshield survey and observational data, demographic & health data, key informant interviews, and literature review and documents). Compare and contrast the demographic and health data from your target community to the comparable geographic or phenomenological communities and the trends over time. For all the data, describe the public health or social implications.
(1-2 pages)

Overall, our research suggests that this community, while having a great number of strengths, is still vulnerable to a number of issues. It is fundamentally a retirement community, and therefore has a significantly higher average population age, with all of the risks inherent. Elderly populations have always been at higher risk of a number of medical conditions, including hypertension, hyperlipidemia, stroke, and diabetes. They are also more susceptible to other factors, such as falls and skin breakdown due to the physiological changes that occur with aging. Elderly communities also have higher incidences of neurological conditions such as dementia and Alzheimer's.
According to both the data we found and our key informant interviews, diabetes is one of the more common problems facing both the elderly in general along with our target population of Leisure World. Rates of Medicare patients with Diabetes has been steadily increasing over the past few years, and it was estimated that in Montgomery County (2015) about 25.1% of the Medicare population was affected.
Type 2 diabetes is defined as a long term metabolic disorder that is characterized as having a higher than normal blood sugar, insulin resistance, and a relative lack of insulin (Olokoba, A. B., Obateru, O. A., & Olokoba, L. B. 2012). Common symptoms of an individual with an elevated blood sugar are increased thirst, increased hunger, and unexplained weight loss. Type 2 diabetics have insulin resistance due to poor diet that is high in carbohydrates and sugar. A type 2 diabetic can produce insulin, however with a diet high in sugar the body cells become resistant to insulin. This is because of the constant high production of insulin, which causes the cells to become resistant. Insulin allows cells to take in glucose so that it is no longer in the bloodstream; so when the cells cannot take up glucose, it sits in the bloodstream and results in a high blood sugar.
Diabetes, specifically Type 2, is an increasingly common health concern in America, and can influence and affect a number of comorbidities. With diabetes, patients will generally have elevated blood glucose levels, which can cause microvascular damage. This can either cause direct organ damages due to limited blood flow; or the vascular changes can be cumulative, resulting in hypertension, heart disease and strokes. Commonly, uncontrolled diabetes can cause neuropathies, nephropathies, and retinopathies. These comorbidities can decrease the overall health outcomes of patients as well as their quality of life, and can also be expensive and difficult to treat.
In addition to long term complications, diabetics are also at risk for more acute issues. Hypoglycemia can result from a combination of too much insulin and not enough carbohydrates, which can be life threatening if not treated immediately. Hyperglycemia is more common, particularly in type 2 Diabetics, and is the result of improper diet and inadequate treatment. This can also result in severe, potentially life-threatening conditions such as diabetic ketoacidosis or hyperosmotic hyperglycemic syndrome. Hyperglycemia also increases likelihood of long term complications.
A large concern for this patient population is the level of understanding of both their disease and the treatments they need. Diabetes is a complicated, multifactorial disease, and needs treatment on many levels. There needs to be dietary changes, increased exercise, and medication regimens, both injected and oral, along with constant monitoring of their blood glucose levels and symptoms that might indicate highs and lows. This is a lot to ask of a patient, and many do not fully understand their own treatment, or may forget important parts of it. This is particularly true for older adults who can be set in their ways and may be resistant to lifestyle changes.

Target Community Strengths
(Note: Make sure these are based on previously recorded data)
Target Community Problems
(Note: Make sure these are based on previously recorded data)

Plenty of health resources offered on site
Potential isolation (family and friends outside of Leisure World)

Abundant exercise and activities
Potential depression due to loss of independence or because of their disease (acute and chronic)

Like minded populations/peers
Diabetes rates are trending upwards

Easy and varied transportation options
Obesity is higher in the community than in the surrounding regions

4. Develop Priority Nursing Diagnoses

List and Prioritize 5 Nursing Diagnoses

1. *At risk for ineffective health maintenance of diabetes related to ineffective education about disease process and complexity of healthcare regimen.

2. Knowledge deficit related to lack of understanding about disease process as evidenced by high readmission rates.

3. At risk for skin breakdown related to diabetes, age related skin changes, decreased mobility and sedentary lifestyle.

4. At risk for depression related to social isolation and lack of motivation.

5. Fall risk related to age related changes in balance, strength, and sensory functions.

PLAN & IMPLEMENTATION

5. Develop Target Community Goals

Program/ Intervention Goal (Program Impact)
A broad statement of the desired future state or condition of the target community in 1-5 years from the time of the intervention
Our intervention, a 8x11 personalized kitchen magnet, will include patient-specific information about high and low blood sugar ranges, what to do if the blood sugar ranges are high or low, relevant numbers to call in case of an emergency, and encourages daily foot checks to prevent diabetic foot ulcers. By five years after our intervention, we hope to see an increase in patient control of diabetes, through a combination of decreased A1c’s, decreased hospital admissions and a decrease in comorbidities related to diabetes in our Type 2 diabetic patients such as stroke, heart attack, vascular disease and kidney disease.

6. Develop Target Community Outcomes

Program/Intervention Outcomes/Objectives, Activities, Process Evaluation Indicators, & Outcome Evaluation Indicators
Typically, there are 2-3 program objectives but it will depend on the size of the program.
(Note: this should be based on the agreed upon program goal, and should inform community intervention)

Outcomes/Objectives

What the target community will accomplish by the end of the intervention or shortly after. Will they change knowledge, behavior, attitudes, etc.?
Make objectives SMART: specific, measurable, achievable, realistic, and timely.
Activities

Elements of the intervention/program to meet the identified outcome/objective. There can be several activities for one outcome/objective.
Process Evaluation Indicator(s)

Plan for measuring how the program and activities are implemented
Outcome Evaluation Indicator(s)

Plan for measuring how the program reaches its identified outcomes/objectives

By the end of the visit, clients with diabetes will be able to demonstrate understanding of their diabetic care by teaching back treatment goals using their magnet as a source. They will be able to identify their target blood glucose ranges, as well as what to do if they are high or low.
After the nurse fills out the magnet with the client, the client will be able to teach back relevant diabetic care plan using this magnet as a resource. Important topics: ranges, what to do when low/high, when to call for help, and warning signs of lows/highs.
Encourage patient to keep a log of their glucose levels.
Check for patient understanding of chart and interventions therein. Have patient teach back with each step.
Patient should be able to teach back entire diabetic care plan, including glucose ranges, symptoms and interventions when low/high, and when to call their provider

After 1 year, the average A1c rate amongst diabetic clients in the community will be below 8%.
(Kirkman et al., 2012).

Increased testing and knowledge of interventions related to high and low blood sugars will lead to better control and will limit time spent in high ranges, lowering A1c
Monitor ongoing A1c values for diabetic clients to monitor for changes.
We will reassess average diabetic client A1c one year after intervention and compare it to baseline.

After 5 years, clients with type 2 diabetes will have a 20% decreased rate of diabetic comorbidities
(CVA, MI, venous disease, kidney disease).
-Educational workshops focusing on increasing knowledge on DM
-Magnet intervention to remind diabetic clients of their personal care plans for high and low blood sugar.
We will keep track of rates of diabetic comorbidities(CVA, MI, venous disease, kidney disease) in our diabetic client population to keep track of trends.
Reassess average rates of these comorbidities diabetic clients after five years. Compare to baseline county, state, and national rates to evaluate impact. Goal is at least a 20% decrease.

7. Describe the target community intervention / program

Description of Intervention/Program
If this is a health education intervention, include a teaching plan as an appendix
Rationale & Supporting Evidence
Include literature providing evidence that this intervention will work with this population. Link to HP2020 goals and objectives.

Our intervention tool is a large personalizable refrigerator magnet that contains on it patient specific information regarding treatment and care for their diabetes. Included are reminders of when to test, what constitutes a low, good, and high blood sugar level, and what to do for each of these levels. Additionally, it has a reminder to perform diabetic foot checks and has an area for their emergency contact numbers, including endocrinologists and primary care. This information will be filled out with the nurse and client together, in large, easily readable handwriting.
This is designed to be a supplement to normal diabetic care education. Additional teaching is needed regarding appropriate diet and exercise strategies, when to take their medications, important symptoms to watch out for, and all other relevant considerations.
It has been proven that posters are some of the more effective methods for increasing knowledge and changing both attitudes and behaviors (Scientifically Proven: The Effectiveness of Posters 2016).
It is also important to consider the average age of our population (>55) and relevant concerns. Large print materials and special learning tools have both been found to help with elderly populations (HCPRO, 2013). Leaving a tool to provide pertinent information to the elderly client has also been found to enhance learning(HCPRO, 2013).
...MAGNETS... Comment: source about magnets specifically?

Comment: need APA style still
http://www.hcpro.com/HOM-288902-6962/10-Tips-for-Educating-Elderly-Patients.html (teaching strategy for elderly patients.)

Describe Community Partners and a Plan for Program/ Intervention Sustainability
(if applicable)

Diabetes is a disease that affects people on many levels, and clients may need help from a variety of sources. They may need social work to help them with healthcare bills to pay for the variety of medical equipment they require. A nutritionist consult could help them adjust to a healthier diabetic diet or to provide recommendations on good food choices. Physical therapy may be needed based on the physical condition of the patient or to provide advice on exercising with diabetes. Psychiatric consults could be considered to help clients adjust to sudden changes in their lifestyle or possible depression, which can be a common occurence with diabetes (NEED SOURCE). Comment: source!!
In order for our intervention to be sustainable we have to continue to engage members of our targeted community and receive feedback from them related to how well they think our intervention is working and establish new program standards based on that. We also need to make sure that we have the appropriate funding in order to receive assistance from the different community partners.
https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/pdf/sustainability_guide.pdf

Policy Development and Advocacy: Identify two issues within your community that may benefit from CPHN advocacy. Provide examples of CPHN advocacy for a position that you believe will have a positive impact on the health of your population/community. Describe the decision maker you would address, the specific request, and the rationale.

CPHN= Community Public Health Nurse.
1. Within the community of Leisure World, many in the the population may be able to afford health care but hey are still at high risk for a number of conditions. While the residents can go to the hospitals and doctors, or have home health aids come to them, this is merely treating the symptoms, rather than preventing the diseases. One of the Healthy People 2020 (SOURCE) goals is to push medicine towards more prevention, and this could be very useful for our community. Rates of comorbidities and diseases increase (SOURCE) as patients grow older, and prevention is much more sustainable than treatment. A CPHN could organize outreach and workshops within the community. These could focus more on educating about healthy behaviors or actions. Flu drives, healthy cooking classes, etc. Have people who participate in these events work on the outreach to try to get everyone involved. A population with healthier habits will be healthier in the long run. Comment: Not totally what this wants...I based it off this paragraph:Communication? Non Consistent public health messages in the Leisure World community? If you have money or able to afford home health then a nurse will drive to your house and visit you. This is treating the symptom, but overall is not helping with public health promotion. A better way might be to start workshops on public health promotion. Need to plan in advance.