Introduction Zach Root Grant Developer Aging S ervices Oklahoma - - PDF document

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Zach Root Zohre Salehezadeh, PhD

2015 AS A Conference Chicago, IL

Oklah Oklahoma’s Suc ’s Success in ss in Delive Delivering CDSM CDSME Pro Program rams in Co in Correctio rrectional F al Facilities cilities

Introduction

Zach Root Grant Developer

Aging S ervices Oklahoma Depart ment of Human S ervices

 Obj ectives  Chronic Disease S

elf-Management Program (CDS MP)

 CDS

MP in Oklahoma

• Partnerships
• Program Reach and Participants

 CDS

MP in the Prison S ystem

• Trainers and Participants
• Expected Benefits

Objectives of this Presentation

Gain insight into: 1) How Oklahoma has successfully implemented CDS MP into the prison system; 2) How the inmates at the Oklahoma Department of Corrections (ODOC) facilities across the S tate have benefitted from this program; 3) The challenges and obstacles faced along the way; and 4) What lessons we have learned from this process.

Chronic Disease Self-Management Program (CDSMP)



Lay-led participant education program offered in communities in the United States and several other countries



Participants are adults experiencing chronic health conditions such as hypertension, arthritis, heart disease, stroke, lung disease, and diabetes (family members, friends and caregivers can also participate)



Provides information and teaches practical skills on managing chronic health problems



Gives people the confidence and motivation they need to manage the challenges of living with a chronic health condition

CDSMP in Oklahoma

Target populations and their settings



60+ or living with chronic conditions



S tarted with rural areas located in the Northern, Central, S

• uth

and S

• utheast regions, then extended the programs to urban and
• ther areas



Low-income and high poverty rate:

• Median income (65+ householders): $35,005
• (Median in OK 2013-general population: $43,777)
• Poverty rate for 65+: 9.5%
• (Rate in Oklahoma 2013- general population: 16.9%

)



Funder: U.S. Administration on Aging



Oklahoma Department of Human Services (OKDHS)



Oklahoma State Department of Health (OSDH)

• Local County Health Departments



Oklahoma Department of Corrections (ODOC)



Oklahoma Health Care Authority (OHCA)



Area Agencies on Aging, local community-based and faith-based

• rganizations (grant-funded and non-grant-funded)

CDSMP in Oklahoma

Our partners

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

Participants and Workshops To Date:

• ODOC CDSMP:
• Workshops: 391
• Participants: 4,594
• S

ites: 18

• Non-ODOC CDSMP:
• Workshops: 222
• Participants: 2,504



Grand Total S erved: 7,098 CDS MP participants in 613 workshops since 2006

• Additionally, 17 DS

MP workshops (207 participants) and 2 Tomando Control de su Salud workshops (21 participants)

CDSMP in Oklahoma

Our numbers so far

CDSMP Reach in Oklahoma

Living Longer, Living Strong with Chronic Conditions: Workshop Sites, Participants, and Population Over 65

Notes: There have been 391 ODOC workshops and 222 community workshops. Only community participants who listed a zip code are included. Data presented as of 3/18/2015. The number of LLLS participants (n = 4,594 for ODOC; n = 2,504 for community) by county are provided when appropriate.

CDSMP Workshop Participants’ Race

Community Workshop Participants: 2,504 ODOC Workshop Participants: 4,594 NOTE: 349 of the respondents indicated they are of Hispanic or Latino descent

200 400 600 800 1000 1200 1400 1600 1800

Native American Asian Black Pacific Islander White Multi‐Racial Unknown 122 (5.8%) 27 (1.4%) 448 (20.8%) 4 (0.2%) 1430 (65.9%) 127 (5.9%) 346 (13.5%) 464 (13.9%) 8 (0.2%) 886 (26.5%) 4 (0.1%) 1,754 (52.5%) 228 (6.8%) 1,250 (27.2%) Community ODOC

CDSMP in the Prison System

(Differences from regular CDSMP)



Incarceration is like a chronic condition with its own set of stressors

• "Inmates don't come to us in good health to start with” , Director

Justin Jones said. "After years of substance abuse, when they get into their mid-50s, they have an array of chronic illnesses."



Different approaches needed with leaders



“ Prison Culture” and earning the respect and trust of the participants



S ecurity procedures

 ODOC obtained a S

tanford CDS MP license

 Offenders and community volunteers were trained  LLLS

Master Trainer oversees workshops and provides fidelity monitoring and program updates

 ODOC Annual Report S

tatistics:

• In 1980, the system had 85 inmates who were age 50 and older,

a figure that has grown to 5,120 in 2014 (2014 Annual ODOC Report)

• ODOC reports that older offenders have contributed to increases

in health care expenditures

• For instance, ODOC spent $60.8 million on medical care in

2005 versus $84.0 million in 2014

CDSMP in the Prison System

(Workshop trainers and target population)

CDSMP in the Prison System

(Participants and leader considerations)



How are inmates recruited to the program?

• Referrals by Medical Staff
• Automatic selection due to certain illnesses
• Age (60+)
• “ Request of Staff” initiated by inmate (for all of the above)



Waiting list



Orientation for new prisoners



S election of inmate leaders



Workshop size is limited to 16 participants with facilities conducting as many as 6 workshops/ week

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 Participants are encouraged to practice self efficacy

• Apply positive life style principals to relationships with family

members and loved ones,

• Focus phone calls on positive achievements
• Include healthy life lessons when writing letters
• Discuss concerns over loved ones’ health and wellness during

visits

• Take the focus off self and utilize materials from the

workshops to encourage loved ones to seek wellness

• Problems that develop as a result of a chronic condition tend to

dwindle as the workshop progresses

Expected Benefits to Family Relationships

 Offenders who are aware of healthcare role  Offenders who are solution-oriented  Offenders aware their actions create +/ - outcomes  Reduction in write-ups and misconducts  An offender with an positive action plan for his/ her life  Reduced staff stress and anxiety  Increased offender releases, reduced staff turn-over

Expected Benefits to Department of Corrections

 Individuals who promote the need for self-awareness through

self-efficacy and self-advocacy

 A possible reduction in the cost of ODOC Medical care for long

term offenders

 Offenders who have been certified and conducted workshops

will be available to serve their communities after release

Expected Benefits to the State of Oklahoma

 “ Living Longer Living S

tronger taught me a better way of handling my chronic pain and ways to help deal with every day life while having Lupus. My teachers gave me a better understanding than most doctors ever have.”

 “ Living Longer Living S

tronger taught me a lot about my health and the importance of my medication. I learned how to set goals and stick to them. S ince the class I have lost 21 pounds. This was a great class.”

Offenders Are Talking

 “ Living Longer Living S

tronger has had a tremendous impact on my life. I learned exercises that I never would have thought to do and learned to set goals and was given the tools to be able to achieve those goals each week. I would like to thank the people that offered this class to me.”

 “ When I call home I feel like I am giving back. I ask about

my families health and tell them I am eating better and exercising.”

Offenders Are Talking

Zohre S alehezadeh, PhD Research Manager

Oklahoma Depart ment of Human S ervices Office of Planning, Research and S t at ist ics



Research Questions



Intervention



Data Collections’ Tools, Methods and Timeframe



S tudy Participants



Pre/ Post S urvey



S cale construction



Findings



Conclusions and next steps

Evaluation of the Chronic Disease Self-Management Program Offered to the ODOC Inmates

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3/30/2017 4 Why This Study- The Research Questions



We were inspired by the anecdotal stories from the instructors about amazing things happening in various ODOC sites that were beyond the program expectations.



A review of the literature indicated that there were no prior studies about this topic and so we decided to conduct a study to examine the effects of CDS MP on the DOC inmates.



Research Questions:

• What is the impact of the Program on the participants’ health

behavior, self-efficacy, health status, and diet?

• What is the impact on medical services utilization?
• What is the impact on participants’ social behavior?



The research proposal involving inmates (human subj ects) was approved by the Institutional Review Board (IRB) of Oklahoma City University.

The Intervention

• CDSMP is a 6-week, small group intervention program for

individuals with various chronic conditions.

• It is a highly structured training, taught largely by peer

instructors -lay leaders- and overseen by Master Trainers for fidelity.

• The instructor should closely adhere to the workshop manual,

Living a Healthy Life with Chronic Conditions, developed by Dr. Kate Lorig and her colleagues (Stanford University).

• The program is based on the self-efficacy theory (confidence in
• ne’s ability to deal with health problems) and emphasizes

problem solving, decision making, and building confidence.

Data Collection: Tools, Methods, Timeframe

 Tools

• Program Quality (Process) Measures
• Participant Satisfaction Survey
• Attendance Sheet
• Fidelity Checklist
• Partner’s Quarterly Report
• Benefits (Outcome) Measures—focus of this presentation
• CDSMP Pre/Post Surveys (along with participant demographic data collected using a Registration Form)
• ODOC Administrative data (Pre/Post data)

 Methods

• Participant recruited through the medical office or request of the inmate
• Participants completed a consent form on the first session of the workshop
• Paper & pen surveys
• The surveys were conducted by the workshop instructors

 Timeframe (Dec. 2011 – Dec. 2012)

• Baseline survey was conducted in the beginning of the workshop
• Follow-up surveys: On the last session and six to nine months after the workshop

The Participants

• 230 inmates participated in our study but only 135 of them responded to the

baseline and the two follow-up surveys. They have attended workshops in three ODOC minimum security sites from Dec. 2011 through June 2012:

S ite # of Participants Percent Clara Waters Correctional Center 8 5.9 Eddie Warrior (female facility) 45 33.3 Jess Dunn 82 60.7 Total 135 100.0 Mean Age 38.0 Median 36.5 Minimum 20.1 Maximum 67.4 Range 47.4

• The participants’ age varied

greatly.

• Generally much younger

population than community workshops’ participants.

The Participants Demographic Characteristics

Charact erist ics # of part icipant s* %

• f Tot al*

Gender Female 45 33.3 Male 90 66.7 Race/ Ethnicity** Whit e 67 49.6 Black 35 25.9 American Indian 24 17.8 Hispanic 13 9.6 Chronic Conditions** Art hrit is 10 7.4 Breat hing 17 12.6 Cancer 6 4.4 Depression 41 30.4 Diabet es 10 7.4 Heart Disease 4 3.0 Hypert ension 26 19.3 S t roke 2 1.5 Ot her Chronic Condit ions 14 10.4 *Missing dat a are not report ed here.

** The t ot al is great er t han number of respondents because t hey were asked t o “ Mark all t hat apply.”

• The survey is comprised of 36 items:
• Health status (9 items)
• Healt h behaviors (10 it ems)
• Healt h care ut ilizat ion (1 it em)
• Out look on life (8 it ems)
• Social behavior (1 it em)
• Habit s of healt hy eat ing (5 it ems)
• Posit ive & negat ive feelings/ mood (1 it em) -not covered in t his present at ion
• Part icipat ion in any ot her workshop (1 it em) -not covered in t his present at ion
• S

hared the surveys with the ODOC Health Education Programs Director and “ peer educators” to check the sensibility of the wording and length of the survey.

• An incentive was offered to those who responded to our surveys.
• The survey responses were entered into a database.
• We also received pre/ post ODOC administrative Data.
• The pre/ post data was analyzed using various tests:
• Paired t-test, Related S

amples McNemar and Wilcoxon S igned Rank tests.

The Pre-Post Survey

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3/30/2017 5 Construction of Scales



Four scales have been created:



1) Health distress (4 items, Cronbach’s alpha=.74)

• assesses t he amount of t ime t he part icipant has been concerned about healt h (worried,

fearful) or had relat ed sympt oms (felt worn out , lack of energy)



2) Cognitive symptom management (6 items, Cronbach's Alpha= .72)

• When feeling miserable or in pain, frequency of using relaxat ion t echniques (e.g., feeling

dist ance from discomfort , t alking t o self in posit ive ways, pract ice progressive muscle relaxat ion, et c.) t aught in class.



3) Communication with physician (3 items, Cronbach's Alpha= .77)

• When visit ing a physician, frequency of preparing list of quest ions, asking quest ions about

t hings one doesn’ t know/ underst and, discussing personal problems related to illness



4) Being hopeful (7 items, Cronbach's Alpha= .75)

• This scale is used t o measure self-efficacy and goal-direct ed t hinking-t he it ems measure

degree of agreement on a series of st at ement s related to one’s view on life (e.g., having reasons t o be hopeful about t he fut ure, feeling prepared for t he fut ure, and meet ing t he goals a person set for self, et c.)

Findings 1) Health Status

Variable Mean Baseline Mean 6-W follow up Mean 6-M follow up P value* N* Improved/ worsened* St at istically significant ? * Disabilit y 1.64 1.66 1.69 0.74 129 Improved N Healt h Dist ress (scale) 2.95 2.82 2.66 0.00 135 Improved Y** Pain 2.25 2.15 2.15 0.28 135 Improved N Short ness of breath 1.87 1.90 1.80 0.34 135 Improved N St ress 2.99 3.01 3.05 0.46 135 Worsened N Self-rated healt h 3.09 3.29 3.27 0.09 116 Improved Y*** Weight (ODOC Admin dat a) 191.00 187.20

• 0.08

115 Improved N Blood pressure (ODOC Admin dat a) 102.20 102.50

• 0.86

115 Worsened N *The data are based on the comparison of the baseline & 6-month follow-up surveys except for the last two items that 6-week follow-up admin data are used. **Statistical significance level: 0.01 ***Statistical significance level: 0.1

Health Distress Scale (4 items): Assesses the amount of time the participant has been concerned about health (worried, fearful) or had related symptoms (felt worn out, lack of energy) Self-rated health (1 item): Respondents were asked to rate their health on a scale of 1=Poor to 5= Excellent.

Findings 2) Health behaviors

Variable Mean Baseline Mean 6-W follow up Mean 6-M follow up P value* N* Improved/ worsened* St at istically significant ? * Exercise 3.14 3.74 3.32 0.26 108 Improved N Cognit ive Sympt om Management (scale) 2.46 2.63 2.50 0.63 133 Improved N Communicat ion wit h physician (scale) 2.72 3.06 2.99 0.04 133 Improved Y**

*The data are based on the comparison of the baseline & 6-month follow-up surveys.

**Statistical significance level: 0.05

Communication with physician scale (3 items): When visiting a physician, frequency of preparing a list of questions, asking questions about things one doesn’t know/understand, discussing personal problems related to illness.

Findings 3) Health Care Utilization

*The data on number of medications are based on the comparison of the baseline & 6-month follow-up surveys. **Statistical significance level: 0.01

Variable Mean Baseline Mean 6-W follow up Mean 6-M follow up P value* N* Improved/ worsened* S t at ist ically significant ? * # of prescript ions 3.62 3.06

• 0.00

115 Improved Y** # of visit s t o medical facilit y 2.24 1.14

• 0.00

115 Improved Y** # of medicat ions 1.63 1.41 1.82 0.13 127 Worsened N

Number of prescriptions (1 item) Number of visits to medical facility (1 item): The values are based on the baseline and 6-week follow-up data from the ODOC Administrative data (monthly averages). These two indicators showed reduction in health care utilization and both were statistically significant.

0.5 1 1.5 2 2.5 3 3.5 4 # of Prescript ions # of visits t o medical facility 3.62 2.24 3.06 1.14 Mean (Baseline) Mean (6-Week Follow Up)

Findings 4) Outlook on Life

*The data are based on the comparison of the baseline & 6-month follow-up surveys.

**Statistical significance level: 0.01

Being Hopeful (7 items): This scale is used to measure self-efficacy and goal-directed thinking. The items measure degree of agreement on a series of statements related to one’s view on life (e.g., having reasons to be hopeful about the future, feeling prepared for the future, and meeting the goals a person set for self, etc.)

Variable Mean Baseline Mean 6-W follow up Mean 6-M follow up P value* N* Improved/ worsened* St at ist ically significant ? * Being hopeful (scale) 3.56 3.81 3.79 0.00 134 Improved Y** Subj ect ive happiness 3.61 3.96 3.86 0.00 125 Improved Y**

3.4 3.45 3.5 3.55 3.6 3.65 3.7 3.75 3.8 3.85 3.9 Being hopeful (scale) Subj ect ive happiness 3.56 3.79 3.61 3.86 Mean (Baseline) Mean (6-Month Follow Up)

Subjective Happiness (1 item): Respondents are asked to rate themselves, compared to other people around them, how happy they feel they are- on a scale of 1 being “Not a happy person” to 5 being “A happy person.”

Findings 5) Social Behavior

*The data on social tolerance are based on the comparison of the baseline & 6-month follow-up surveys.

**Statistical significance level: 0.01

Variable Mean Baseline Mean 6-W follow up Mean 6-M follow up P value* N* Improved/ worsened* St at istically significant ? * Institutional misconduct 0.05 0.01

• 0.00

115 Improved Y** Social t olerance 3.78 4.22 3.81 0.71 131 Improved N

Institutional Misconduct (1 item): The values are based on the baseline and 6-week follow-up data from the ODOC Administrative data. Average number of disciplinary actions fell over the course of this 6- week workshop.

0.00 0.01 0.02 0.03 0.04 0.05

Mean (Baseline) Mean (6-wk follow up)

0.05 0.01

Institutional Misconduct

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Findings 6) Habits of Healthy Eating

Diet and healthy eating habit (5 single items):

Average number of servings of vegetables per day increased over t ime and average number of cigaret t es was cut by almost a half.

Variable Mean Mean Mean P value* N* Improved/ worsened* St at istically significant ? * Baseline 6-W follow up 6-M follow up # of servings of sweet s per day 2.18 2.12 2.22 0.73 132 Worsened N # of servings of veget ables per day 2.16 2.19 2.32 0.01 132 Improved Y** # of servings of caffeine per day 2.28 2.16 2.35 0.30 129 Worsened N # of cigaret tes per day 3.50 3.35 1.92 0.00 131 Improved Y** # of cups of wat er per day 3.39 3.47 3.37 0.84 131 Worsened N

*The data are based on the comparison of the baseline & 6-month follow-up surveys. **Statistical significance level: 0.01

0.5 1 1.5 2 2.5 3 3.5 # of servings of vegetables per day # of cigarett es per day 2.16 3.50 2.32 1.92 Mean (Baseline) Mean (6-Month Follow Up)

Conclusions & Next Steps

 The results indicate that there are more benefits to the participants

than were originally intended.

 These programs are incredible ways to minimize the cost of

improving people’s lives.

 We should try to identify and remove any barriers and encourage

participation in other health programs.

 Next steps:

• Discuss the findings with the instructors and see if the weak points could

be improved and also the possibility of providing review sessions for the inmates to sustain the positive impact the program had on the participants

• Compare the impacts on the ODOC participants with those on the

community workshop participants and test whether the results are different

• Test whether the results hold between sub-groups

THANK YOU!

A special THANKS t o t he following OKDHS st aff who have great ly helped wit h t his st udy:

Candace S mit h, Research Assist ance Tosha Robinson, Research Assist ance And t o ODOC Management : Dr. S pect or, Dr. S ut miller and his st aff OS DH st aff: David Lee (CDS MP Mast er Trainer) & Marisa New Who managed t he dat a collect ion process And t o Dr. Mahmood S handiz who assist ed wit h t he IRB approval process

Questions or Comments?

Contact information:

Zach Root, Grant Developer Aging S ervices Division Oklahoma Department of Human S ervices (405) 522-3121 Zachary.Root@

• kdhs.org
• Dr. Zohre S

alehezadeh Office of Planning, Research and S tatistics Oklahoma Department of Human S ervices (405) 521-4498 Zohre.S alehezadeh@

• kdhs.org