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Shepherd’s Hope: Community ProjectBryce Catarelli, Robert Fore, Kristen Kessinger, Christina Morgan, Jessica Ogle, Sherline Pierre, Eria Quigley, and Jessica ZackelUniversity of Central FloridaCommunity IssueResearch has shown that obesity, hypertension, and diabetes are interrelated and result in lower quality of life for affected individuals (Banegas et al., 2007). It was identified that these were the three most prevalent conditions being treated in patients at Shepherd’s Hope in Longwood, Florida. Shepherd's Hope is a non-profit volunteer health care center focused on providing healthcare to individuals with an income at or below 200% of the poverty level, as well as individuals who are uninsured and not eligible for government assistance (Shepherd’s Hope, 2011). In an effort to deliver healthcare to a greater number of individuals, Shepherd's Hope relies on partnerships from the local community to support its various locations across central Florida. University of Central Florida (UCF) graduate nursing students have partnered with the Shepherd’s Hope Longwood location to develop and implement patient education to address diabetes, hypertension, and obesity. At this location, English, Spanish, and Creole are the most common languages. Patient education will be designed to elicit critical thinking, questioning, and consideration of changes to current health states and habits. Through live teaching sessions and written materials, the information will address general pathology, signs and symptoms, and lifestyle modifications aimed at empowering the patient and increasing self-efficacy in management of the condition. This will lead to increased quality of life. Literature ReviewDiabetes Mellitus Background. Diabetes affects over 25.8 million children and adults in the United States, with almost 1.9 million cases diagnosed annually (American Diabetes Association [ADA], 2013a). Diabetes is a chronic multifactorial metabolic disease involving abnormal glucose and insulin utilization. Complications include heart disease, stroke, hypertension, blindness, kidney failure, neuropathy, and potential amputation. It is estimated to cost over $245 billion dollars annually, with average medical costs over 2.3 times higher annually for those with diabetes compared to those without. Education plays a significant role in prevention and management of this chronic disease and can greatly impact improvement in quality of life.Interventions. According to the National Institute for Health and Care Excellence (NICE), there are no specific recommendations for education on type I or type II diabetes (NICE, 2008). It is recommended, however, that educational sessions should be provided within the community by appropriately trained multidisciplinary teams who promote active learning and participation by those with diabetes. It should be adapted to fit the population at hand and integrated into routine diabetic care. Individuals with diabetes who were educated on diabetic self-management in the form of presentations or active participation have demonstrated to retain more information for use later on (Gravely, Hensley, & Hagood-Thompson, 2011). Strategies for improving care include culturally sensitive communication styles that take into account literacy and numeracy, patient preferences, and cultural and financial barriers to care (ADA, 2013b). According to one literature review, education for diabetes mellitus should be presented in a patient-centered, dynamic, and holistic fashion that promotes self-management and behavioral changes (Kosti & Kanakari, 2012). One program, entitled “Do Well, Be Well with Diabetes”, allowed teams of healthcare professions to establish health coalitions at various community locations to deliver education and nutritional concepts to individuals in the community (Bielamowicz, Pope, & Rice, 2013). After pre- and post-test scores were analyzed, findings suggested improved knowledge base and self-reported behaviors. Lowered hemoglobin A1C and fasting glucose levels were also demonstrated. In one study using this program involving only 19 participants, a lifetime health care cost savings was estimated at over $683,900 for the group. In one low-income community in Louisiana, research assistants conducted a study in which brief 15-minute community clinic-based presentations were provided (Terry et al., 2012). Diabetes self-management guides, behavioral goals, and action plans were presented and reviewed. In follow-up calls, approximately 79% of 200 individuals recalled their action plan and 80% of those achieved their goal by four weeks. This resulted in increased physical activity, improved diet, and less visits to the provider for diabetes-related concerns over an extended period of time.Resources. Throughout the Orlando-area, there are many resources available to the public for diabetes education. Several organizations orchestrate the various meetings, including Defeat Diabetes Foundation, Inc, Florida Hospital Diabetes Institute, and American Diabetes Association. Classes can range from cooking instructions to medication management. The Florida Hospital Diabetes Institute also offers free classes and support group presented each month (Florida Hospital Diabetes Institute, 2013). ObesityBackground. Obesity is an epidemic within the United States and is classified as a body mass index greater than 30.?According to Healthy People 2020, approximately 1 in 3 adults suffer from obesity, while close to 1 in 6 children and adolescents are classified as obese (2013). Obesity is considered to be a major risk factor for development of high blood pressure and cholesterol, diabetes, heart disease, stroke, osteoarthritis, and several forms of cancers. This is particularly evident in the low-income population, where there is reduced access to grocery stores, more financial stress, and less opportunity for recreational activities (Armstrong, Wacker, Best, & Mcpherson, 2011).? By implementing educational programs that address increased physical activity and improved diets rich in fruits and vegetables, these risk factors can be greatly reduced.Interventions. Patient education centered on lifestyle modifications plays a significant role in the management and prevention of obesity. According to the Obesity Education Initiative, launched by the National Heart, Lung, and Blood Institute, education reduces the prevalence of obesity, inactivity, and associated comorbidities (2013). The main outcomes of the education initiative are to change patient’s dietary habits and increase physical activity levels to reduce the morbidity and mortality associated with obesity. To achieve these goals, using educational intervention, a myriad of different, multifactorial approaches should be utilized to target the population on a community level. A population approach, as well as a targeted approach of high-risk patients, is thought to address the problem effectively. The partnership of healthcare professionals within the community to provide education about obesity has been shown to increase physical activity and enhance nutritional practices (Center for Disease Control and Prevention [CDC], 2009). The different perspectives and expertise offered by healthcare professionals in the community benefit the patient by enhancing their engagement in the community and encouraging them to work towards a common goal. Activities and informational sources are distributed to educate regarding dietary habits and appropriate physical activity levels. High-risk targeted patients are educated a little differently utilizing current evidence-based standards. The intervention for this population is focused on strategies for weight loss, and then maintenance. Family-based initiatives are also highly recommended (Mayo Clinic, 2013).Resources. There are many resources available to the community to help curb obesity in both adults and children. These programs include the US Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), National School Lunch Program, and School Breakfast Program. For those older than 55, free exercise equipment and classes are offered at the Mayor William Beardall Senior Center in Orlando (City of Orlando, 2013). Various sports programs and classes are also offered to teenagers and adults at low costs through the Families, Parks, and Recreation program offered by the City of Longwood. Longwood also has a host of city parks with playgrounds and fields available to the public for free. For qualifying low-income families, programs such as Temporary Assistance to Needy Families (TANF), Medicaid, and the State Children’s Health Insurance Program (S-CHIP) may offer waivers or reduced-cost memberships to community facilities providing exercise rooms or classes (Armstrong, Best, & Mcpherson, 2011). These programs also may provide reduced cost or free access to nutritional counseling or physical therapy.??HypertensionBackground. Hypertension is a chronic condition affecting 31.9% of American adults (CDC, 2012). Within minority groups, undiagnosed and uncontrolled hypertension remains a problem. As of 2010, African Americans had the highest incidence of hypertension as a population at 40.4%. Screening is imperative in the detection of hypertension, as symptoms may not manifest until late in the disease process when complications have occurred (National Institutes of Health, 2013). Regular screening and education should occur for all adults to ensure prompt treatment and prevention of hypertension and related complications.Interventions. Patient education as an intervention in treating and preventing hypertension is a significant contributor to increased success in achieving blood pressure goals. One study researched the effectiveness of educational interventions on managing hypertension in patients (Magadza, Radloff, & Srinivas, 2009). The educational interventions included presentations, monthly meetings, and informational handouts. Researchers found that these factors significantly increased patients’ knowledge/health literacy levels of hypertension and increased overall compliance with treatment regimens. This lead to improved health outcomes.In applying education as an intervention to the community health setting, there are several important factors to include in the plan of care. Information sessions should be organized and modified to the appropriate health literacy levels (Glynn et al., 2010). Regular follow-up with primary care providers also reinforces teaching and addresses any additional questions. It is also important to include self-monitoring of blood pressure into the educational materials to enhance compliance with the treatment regimen in the home setting. Significant topics to address include the basic pathology and complications of the disease, prevention tips, the DASH diet, recommended physical activity, medication adherence, and signs of possible complications. Additionally, utilizing a variety of mediums to present educational material will contribute to greater understanding and compliance with the factors discussed. Resources. The Orlando area offers a myriad of resources for patients with hypertension. The Orlando Health Heart Institute offers screenings, diet management, smoking cessation, along with many other services in various clinics around the area (American Heart Association, 2013). Additionally, Orlando Health offers Hypertension Care Management (Orlando Health, 2013). This is a program for patients who have difficulty controlling their blood pressure and need additional education and assistance. They offer educational material, support groups, development of hypertension self-management skills, and lifestyle modifications. In addition to treatment regimens, these educational programs and community resources have shown to be a significant contributor to prevention of this chronic disease as well as the overall health of the community.Focused Community AssessmentAccording to the Seminole County Florida Government census (2013), the city of Longwood, Florida consisted of a population just fewer than 14,000 individuals in 2010, with roughly 85% of the population Caucasian, 15% Hispanic and 5% African American. Understanding the demographics of the Longwood region, where the Shepherd’s Hope clinic is located, is essential to planning and executing appropriate educational interventions. Considering the lack of insurance and financial restraints on these patients, it's important to look at how their economic status influences both their overall health and access to healthcare. In 2010, roughly 7% of the population in Longwood was living under the poverty line, with 5% of those being families of 4 or more persons. Considering that Shepherd’s Hope is a resource clinic that provides a variety of services for those that are uninsured and/or have low-income levels, the population at this facility may also reside within different cities of Seminole County other than Longwood. In 2010, the Seminole County population consisted of roughly 400,000 individuals (Florida Department of Health, 2012). Approximately 21% of children younger than five years of age and 7.3% of adults over the age of 65 were living below the poverty line in Seminole County. ???????????Income also played a role in the incidence of these diseases. The percentage of adults with an elevated BMI was highest in those adults who made less than $25,000 a year (Florida Department of Health, 2013a). These statistics were also more concerning for adults who lived in Seminole county compared to the state average. Similarly, when looking at the data for both diabetes and hypertension, it can be noted that there is a higher percentage of diagnosis in those who make less than $25,000 annually and a slight increase in incidence in Seminole County compared to the state average.Data from the Florida Department of Health indicates that Seminole County ranks slightly higher when compared to state average in relation to our target chronic disease such as diabetes, obesity, and hypertension (2013b). This indicates a serious need to target this population and promote awareness and prevention to help reach the goals of Healthy People 2020, as well as supporting the necessity for intervention in our target population.?For example, in Seminole county, 13.5% of adults are diagnosed with diabetes, compared to a state average of 10.5%. ?This high rate of diabetes is classified in quartile 4 by the Florida Department of Health, which indicates a? "least favorable situation" and ranks among the lower 25% of counties statewide. Seminole county also had a slightly higher death rate related to diabetes compared with the state. In regards to hypertension, 35.6% of adults in Seminole county have been diagnosed with hypertension, just above the state average of 34.3% (Florida Department of Health, 2013c). In addition, 38.4% adults are overweight and 26.4% are classified as being obese.??????????? When comparing data from 2002 through 2010, the incidence of these conditions is increasing, indicating a huge need for intervention to help deter these trends. These concerning statistics help support the need for interventions serving the low income and uninsured of Seminole County. They also point out an alarming discrepancy between disease incidence in those with lower incomes who have more barriers when it comes to accessing healthcare and receiving adequate diagnosis and treatment.?This also represents a "health disparity"?that adversely affects the health of this population. One of the goals of Healthy People 2020 as published by the U.S. Department of Health and Human Services is to " achieve health equity, eliminate disparities, and improve the health of all groups” (2010).?The goal of these interventions are aimed to benefit the target population when partnered with the Shepherd’s Hope to achieve the Healthy People 2020 goals of eliminating disparities and improving health for all. Factors Influencing the Community ? Over 43,000 people in Seminole County are living in poverty (U.S. Department of Commerce, 2013). Additionally, almost 20% of Seminole county residents are uninsured (Florida Department of Health, 2013d). In minorities and low-income populations the prevalence of having diabetes mellitus and hypertension, either concurrently or individually, is higher (Baumann, Chang, & Hoebeke, 2002). The rates of morbidity and mortality related to chronic conditions are also higher in these disadvantaged groups. Specific to Shepherd’s Hope, patient teaching regarding lifestyle modifications including diet, exercise, and weight management are integral parts of improving chronic disease outcomes. Increasing the focus of healthcare toward preventative care, especially in the Shepherd’s Hope patient population, will ultimately lead to decreases in preventable deaths from poor diet and physical inactivity.At Shepherd’s Hope, the problem lies in the short amount of time allotted to each visit and the complexity of chronic conditions being addressed. To avoid taking vital time out of the visit with the provider, patient education and teaching will be completed prior to the visit in the patient waiting area. ?Since all care is provided by volunteers, not all patients are guaranteed to be seen and it is suggested that patients arrive one hour before the health center opens. ?This provides ample time to offer patient teaching sessions focusing on hypertension, diabetes, and obesity to help patients make necessary changes toward a healthy lifestyle. Even if patients are unable to see a provider on a day they come to the clinic, they will have opportunities to gain vital education regarding chronic diseases and lifestyle modifications to improve their health.Barriers and Facilitators One identified barrier of patient education on common disease processes is limited patient contact. Shepherd’s Hope is a non-profit volunteer organization and due to this, hours of operation for the health clinic are limited to three hours in the evenings, Monday through Thursday (Shepherd’s Hope, 2011). These limited hours of operation create long lines, resulting in many people not receiving medical care or short visits that are not providing enough education on disease process and prevention. A second barrier for this project is the limited time for “live education” to take place. This project is set to take place over a specific time and upon completion at this time there is no one appointed to take over this style of education. Additionally, the low socioeconomic status of the patients being served can be seen as a financial barrier to implementing the lifestyle modifications addressed in patient education. The previous graduate nursing group working at Shepherd’s Hope also left inconsistent and poor education material that exceeded the health literacy level of the population served. This resulted in the need for this project to be constructed and designed from the ground up. Through a collaborative effort with Shepherd’s Hope, the most commonly seen disease processes have been identified as diabetes, hypertension, and obesity. Fortunately, these disease processes have a wealth of research material to draw from. In an effort to combat the limited patient contact, an interactive game will be developed based on the three most commonly seen problems. This interactive game will allow for education that the patient would otherwise spend standing in line waiting. Additionally, it will make the experience more enjoyable and the patient more likely to return for follow-up treatment. The large waiting room is also a facilitor, as it provides adequate room to educate those waiting and allows for one-on-one interactions. There is also helpful staff to accommodate the project. Another facilitator is the guarantee of having patients to educate, as there is always a large volume of patients present at the clinic during open hours. Project DesignThis project will be called “Living for Health.” It will be designed around three main pathologies: diabetes mellitus, hypertension and obesity. Each disease process will be addressed on a separate visit to Shepherd’s Hope in the form of interaction and education with patients in the waiting room. On each visit, the UCF students will engage patients in the waiting room with a trivia game focused on one of the three pathologies. Questions will be asked in an effort to educate patients and facilitate learning.? A poster will be presented that addresses basic information about diabetes, hypertension, or obesity. It will highlight the disease process and lifestyle modifications that patients can make to lower their risk factors. ?A one page concise handout will be provided to patients which reinforces the material provided on the poster and items discussed during the interactive trivia. This will allow patients to take the information home with them and easily access it.The global goal for the project will be to provide the patients at Shepherd’s Hope with the education and tools to increase awareness of their health, particularly diabetes, hypertension and obesity. The education provided will allow patients to learn about their health, ask questions and identify choices they can make which will positively impact their health.?Specific objectives for the “Living for Health” project are as follows: Patients at Shepherd’s Hope will engage in the interactive trivia by answering questions when asked by the UCF studentsEducational material in the form of three posters and handouts will be available for the patients at Shepherd’s Hope addressing diabetes mellitus, hypertension, and obesityPatients at Shepherd’s Hope will understand and be able to identify risk factors associated with diabetes mellitus, hypertension, and obesityPatients at Shepherd’s Hope will identify lifestyle modifications they can personally make to lower their health risksSpecific activities for the achievement of each objectiveInteractive trivia will be held in the waiting room of Shepherd’s Hope on three separate occasions. UCF students will ask patients questions regarding diabetes mellitus, hypertension, and obesity and elicit answers from patients.The UCF students will present three different posters on three different occasions in the waiting room of Shepherd’s Hope and will leave this material with the clinic at the completion of the project. Educational handouts that reinforce the content of the posters will be made and left with the clinic to distribute to patients.Patients will be asked and educated what places them at risk for diabetes mellitus, hypertension, or obesity during the interactive trivia.Patients will be asked to identify and explain lifestyle modifications that can be made to reduce the risks associated with diabetes mellitus, hypertension or obesity.The waiting room at the Shepherd’s Hope clinic will be utilized to meet the objectives of this project. Chairs and a small table will be used to present the posters and allow the UCF students to conduct the interactive trivia. A printing location will be utilized to print the content compiled by the students. Paper, ink and use of a computer and printer will be utilized to provide the patients at Shepherd’s Hope with handouts. Various educational resources will be used by the students to gather information on diabetes mellitus, hypertension, and obesity. These will include peer reviewed articles, databases and current recommendation guidelines tailored to an appropriate level of health care literacy for the community. Personal transportation by the students will be used to commute to and from the Shepherd’s Hope clinic.The budget for this project will be $40. There are eight group members and this will require each member to contribute $5 to the project. This will cover the cost of three posters, handouts and printing costs. Fuel or tolls for personal transportation will not be accounted for in the cost of this project.?The planning and preparation for this project will take place during March and April during the last half of the Adult 1 semester. Implementation of these interventions will take place during the summer of 2013 at the Longwood Shepherd’s Hope location. These interventions will be assessed for effectiveness as evidenced by increased patient knowledge and participation in their healthcare. ConclusionIn closing, Shepherd’s Hope provides an invaluable health care service to those in poverty in the Seminole County area. Their health care services are provided by volunteers and because of this, they have very limited resources. The goal of the Living for Health Project is to extend the healing services they provide by employing basic interactive games, posters, and handouts. By focusing on obesity, diabetes, and hypertension, the most common disease processes treated, we can efficiently educate a majority of patients. This education will empower the patients to make lifestyle changes to improve their condition, as well as make them better partners in health care. ReferencesADA. (2013a). Diabetes statistics. Retrieved from . (2013b). Standards of medical care in diabetes. Diabetes Care, 36(1), S11-66. doi: 10.2337/dc13-s011American Heart Association. (2013). Council for high-blood pressure research. Retrieved from , S. C., Wacker, J., Best, D., & Mcpherson, M. E. (2011). Fighting childhood obesity: Resources to help the community pediatrician curb this epidemic. Contemporary Pediatrics, 28(2), 40-51.Banegas JR, Lopez-Garc?a E, Graciani A, Guallar-Castillon P, Gutierrez-Fisac JL, Alonso J, & Rodr?guez-Artalejo F. (2007). Relationship between obesity, hypertension and diabetes, and health-related quality of life among the elderly. European Journal of Cardiovascular Prevention and Rehabilitation, 14, 456-462.Baumann, L. C., Chang, M., & Hoebeke, R. (2002). Clinical outcomes for low-income adults with hypertension and diabetes. Nursing research, 51(3), 191-198.Bielamowicz, M., Pope, P., & Rice, C. (2013). Sustaining a creative community-based diabetes education program: Motivating Texans with type 2 diabetes to do well with diabetes control. Diabetes Educator, 39(1), 119-127. doi: for Disease Control and Prevention. (2009). Recommended community strategies and measurements to prevent obesity in the United States. Retrieved from for Disease Control and Prevention. (2012). NCHS data brief: Hypertension among adults in the United States, 2009-2012. Retrieved from of Orlando. (2013) Athletics. Retrieved from? Department of Health. (2012). Seminole County environmental health profile. Retrieved from Department of Health. (2013a). Adults who have a healthy weight (BMI from 18.5 to 24.9). Retrieved from Department of Health. (2013b). County chronic disease profile. Retrieved from? Department of Health. (2013c). Adults with hypertension who engage in blood pressure control measures. Retrieved from Department of Health. (2013d). Florida charts: Adults with any type of health care insurance coverage. Retrieved from: Hospital Diabetes Institute. (2013). Free diabetes support group. Retrieved from , L. Murphy, A., Smith, S., Schroeder, K., & Fahey, T. (2010). Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev (3):CD005182. doi: 10.1002/14651858.CD005182.pub4.Gravely, S., Hensley, B., & Hagood-Thompson, C. (2011). Comparison of three types of diabetic foot ulcer education plans to determine patient recall of education. Journal of Vascular Nursing, 29(3), 113-119. doi: People. (2010). Disparities. Retrieved from People. (2013).?Nutrition, physical activity, and obesity.?Retrieved from , M., & Kanakari, M. (2012). Education and diabetes mellitus. Health Science Journal, 6(4), 654-662.Magadza, C., Radloff, S., & Srinivas, S. (2009). The effect of an educational intervention on patients' knowledge about hypertension, beliefs about medicines, and adherence. Res Social Adm Pharm (4):363-75. doi: 10.1016/j.sapharm.2009.01.004.Mayo Clinic. (2013). Obesity. Retrieved from: Heart, Lung, & Blood Institute. (2013). Obesity education initiative. Retrieved from: Institutes of Health. (2013). Hypertension. Retrieved from: . (2008). Guidance on the use of patient-education models for diabetes. Retrieved from Health (2013). Hypertension care management. Retrieved from ’s Hope. (2011). Our story. Retrieved from County Florida Government. (2013). Census 2010. Retrieved from C., D., Hilary K., S., Darren A., D., Daci J., P., Cristalyn, R., Donna, F., & Connie L., A. (2012). Diabetes implementation of a self-management program in resource poor and rural community clinics. 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