Case Management: Disease Management of Diabetes in Indian (South Asian Hindu) Americans
Agnieszka Harasim, Irene Oh
New York City College of Technology/CUNY
Nursing Case Management
NUR 4030-E730
Professor Rosalyn Forbes
May 6, 2014

Case Management: Disease Management of Diabetes in Indian (South Asian Hindu) Americans

Concept
Disease management is a part of case management that focuses on patients and their progress with a particular disease, such as with diabetes. Disease management is defined as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (Finkelman, 2011, p. 170). It is of interest because diabetes is very prevalent in the U.S. because of many dietary and lifestyle changes that immigrants may come across that is different than their home country. This is true, in particular, with South Asian Indians. With diet changes such as eating fast food rather than a home cooked meal, there may be more incidences of diabetes patients and the need for disease case management for this population.
Disease management (DM) is a “service strategy or method used by third party payers to control costs and improve care. DM focuses on the whole patient who has a specific disease or illness, typically a chronic, long-term illness” (Finkelman, 2011, p. 169).
“Because culture can have a strong influence on dietary preferences and meal preparation practices, culturally competent care has special relevance for the care of the patient with diabetes. This is especially pertinent when considering the prevalence of diabetes in certain cultural groups… The increased prevalence can be attributed to genetic disposition, environmental factors, and dietary choices” (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007, p. 1271).

Cultural Competence
Purnell (2009) describes the difference between cultural awareness, cultural sensitivity, and cultural competence. He says that cultural awareness is having an appreciation for external things, such as the arts, or physical characteristics. Cultural sensitivity might have to do with interpersonal things, such as being aware of what not to say to offend someone. And cultural competency is being aware of and increasing one’s cultural diversity, which can help the health care provider give better care. This includes being aware of your own existence and not letting it have an influence on others of different backgrounds, being understanding of the patient’s culture and what health care might mean to them. They keep away from judging, are respectful of cultural differences, are open, comfortable, and adaptable to cultural encounters, and will educate themselves in cultural competence.
India is a triangular-shaped peninsula in the south of Asia’s mainland, inhabited by more than a billion people. About 70% of the working population is involved in agriculture. They live in small villages and have small farms, with old cultivation techniques based on human or animal power. The farmers are usually only barely able to provide for their own families. They might produce traditional crops such as rice, wheat, peanuts, or corn. If producing cash crops, they might produce sugarcane, tea, tobacco, or cotton. Because of a lack of water, only about half the land is suitable for crops.
More than 80% of Indians follow Hinduism, but other religions might include Islam, Christianity, or Sikhism. “Hinduism is a culture as much as it is a religion, and the balance of balance of culture and religion forms the social structure of the Hindu society” (Giger & Davidhizar, 2008, p. 539). Indians also follow the caste system, and believe in reincarnation. There is an official prohibition of the slaughtering of cattle in the constitution. The number of livestock is one of the highest in the world, yet most of them are malnourished and diseased. They revere life, especially in regard to the cow, which is a symbol of fertility. “Although rivers, trees, and other forms of life are also regarded as sacred, the cow is considered the holiest life form” (Giger & Davidhizar, 2008, p. 540). Because of their reverence for living animals, many Indians are vegetarians.
There are also urban areas that are heavily industrialized and overpopulated. Thousands die yearly from malnutrition and disease in the slums of large cities such as Calcutta and Mumbai. Some of the diseases are bacterial diarrhea, hepatitis, typhoid fever, dengue fever, malaria, and HIV or AIDS. (Giger & Davidhizar, 2008)
“The relationship between the people’s beliefs concerning the causes of illness and attempts to seek relief if learned from local folk practioners. Illness and its treatment are perceived as biological as well as social phenomena… Adequate knowledge of these beliefs can assist nurses in the formulation of nursing diagnosis and nursing interventions and guard against undue conflicts with the practice of folk medicine” (Giger & Davidhizar, 2008, p. 540).
Indians immigrated to the United States mostly from the urban cities. There were a couple of immigration waves. The first began in the early 20th century through the mid-1920’s. Racial discrimination and lack of being able to gain economic advancement made it hard for the early Indians to sustain themselves and their culture. The next wave started after 1965 and still continues. Many are highly educated, and come to the U.S. for job opportunities and a higher standard of living. There are 1,600,000 Asian Indians in the U.S. (Purnell, 2009)

Common Health Concerns in Asian Indian living in United States
Studies have shown that regardless of the lifestyle or associated risk factors, Indian Americans have been highly susceptible to the diseases such as diabetes, coronary artery disease (CAD), and hypertension. According to Mayo Clinic, Asian Indians have the highest prevalence for developing type 2 diabetes, which is currently estimated at 32 million, and is expected to increase in the next 30 years. It appears that it’s due to genetic resistance to insulin (IR) or pancreatic beta-cell dysfunction. Asian Indians could be predisposed a higher risk for developing type 2 diabetes. Busko (2013) said that “poor beta-cell function is extensive in Asian Indians and therefore could be correlated to dysglycemia which consequently had greater influence on insulin resistance in assessed individuals.
Research observed that not only sedentary lifestyle, but also race puts some people at risk of being more vulnerable for developing type 2 diabetes. In 2008, Mayo Clinic researchers conducted a study that included Asian Indians with diabetes, non-diabetic American Indians, and northeastern American European with type 2 diabetes. The participants were fed the same diet, they were of similar age, and they were given the same amount of physical activities. The research found that the Asian Indians a “had greater degree of insulin resistance than American Europeans, even though the study subjects were not obese” (Mayo Clinic, 2008). Bakker & Sleddering (2013) found that type 2 diabetes (T2DM) is extremely high among native and migrating Asian Indians despite their age and body mass index (BMI). Diabetes is the common denominator accountable for risk factors in developing coronary artery disease, cerebrovascular accident, diabetic nephropathy, and chronic kidney disease among Asian Indians.
In India, high–risk health behaviors and various life styles are contributing factors to significant health problems. In particular, cigarette smoking and alcohol consumption could be accountable for heart, lung, and liver problems. Although this ethic group abstains from these habits for religious reasons, according to the American Cancer Society, in India, one in forty women is diagnosed with breast cancer. Whereas in the United States, one out of eight Asian Indian women will develop this type of cancer. Some types of cancer are genetic, environmental or influenced by certain lifestyle. It is observed that cancer of the cheek, nose and mouth are common because of ‘pan’ and tobacco chewing. According to National Cancer Institute, in the United States, Asian Indians are among those with lower incidence rates and death, along with Guamanian men and women.
In addition, general health issues and health considerations include cardiovascular disease and hypertension. These diseases have the highest incidence in elderly people. Vulnerable groups such as seniors, children adolescents and women require individually tailored approach, derived from different needs.
Depression and isolation are the most common problem among older generation, for the following reasons: they resent immigration, unemployment, or retirement. Depression and isolation are considered a shameful problem. Therefore, it is often underreported. It is a cultural belief that serious mental health issues could be expressed, but depression tends to be hard to acknowledge.
According to Asian Indian Community Group Reports (2007), women are not aware of regular lifesaving screenings such as mammography, Pap smears, or even regular doctor’s visits. Moreover, the lack of health insurance seems to be the biggest obstacle in access to health care. Many people have no access to health care because of their immigration status, lack of transportation, or simply just a language barrier.
India is a country with a mosaic range of culture, ethnicity, religions, and languages. Therefore some of the cultural aspects of the disease and primary healthcare could be seen as peculiar or superstitious. In India, most of the individuals believe that body, mind and soul are the real entry to the disease (Giger & Davidhizer , 2008). Indians also believe that people who acquire contagious form of the disease such us tuberculosis or cholera receive some kind of punishment for their sins (karma), which they committed in the past.
Although Asian Indians rely on natural ways of treatment such as herbs, and the natural environmental promotion of spiritual well being in the form of meditation, the majority of the Indian community accepts Western medical practices in the U.S. The families are very protective about their members, thus prior to any visit with a doctor, they consult their choices with relatives or educated family members. Ginger & Davidhizer (2008) said that Asian Indians who immigrate to America have a tendency to self-medicate with medication that they obtain from relatives or close friends. In India, older people utilize a home remedy medical system called Ayurveda, which is based on lifelong knowledge of health-improving properties of natural herbs and spices. Some of the popular remedies include turmeric as an antiseptic or anti-inflammatory, and ginger to alleviate stomachache.
Purnell (2009) expressed that Hindus generally adapted well, as recipients of American health care. Nowadays, there are no known medical restrictions or policies that prohibit blood transfusions or organ transplants for Asian Indians living in America.
Generally, physicians are viewed as authoritative sources of knowledge that can bring help and cures for diseases, so they are highly respected. Purnell (2009) highlighted that any mental disorder is perceived as God’s will, thus seeking professional medical help is highly unlikely.

Case Management: Overview of Disease Management
Disease management in diverse care settings
Diabetes is a disease that continually increases in numbers among the entire population, including children. Therefore, this disease requires meticulous case management design recommendations for people with diabetes, pre-diabetes, or those at risk for diabetes. According to Case Management Society of America (CMSA), “case management of diabetes includes: assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes (2011).
Assessment
In order to accurately develop management of care for any client, the case manager needs to focus on adequate assessment of the outcome that delivers high quality health care, and simultaneously reduce the cost of care. The initial assessment provides the nurse case manager with subjective and objective data that could help to identify nursing diagnosis, scan for risk factors and identify outcomes. Therefore, before planning and implantation, the nurse case manager must identify the client’s important health information and functional health patterns.
Planning
Nursing management care plans include overall goals for patients with diabetes mellitus. First of all, we want the patient to be actively participating in the diabetes regimen. Clients who have the opportunity to explore their options by being involved in his/her own treatment could realize and start motivating themselves to change specific behaviors. Secondly, this planning must include short-term goals and long-term goals that can be achievable. A short-term goal could be to plan for less hyperglycemic or hypoglycemic episodes by controlling diet and frequently checking the blood glucose levels. A long-term management goal could be to almost eliminate hyperglycemic or hypoglycemic emergency, and keep the blood glucose level normal or close to normal range. Finally, we want to prevent or minimize diabetes complications by slight behavior modifications that lead to lifestyle changes and proper health maintenance.
Service planning and resource allocation
According to Case Management Society of America (2011),“the consistency of one provider helps to establish a trusting relationship and minimize repetitions” (p.16). Therefore, a trustworthy relationship between the potential client and case manager should be developed, with a mutual agreement and a comfortable patient-nurse verbal contract. CMSA (2011) recommends implementing case management in conjunction to multi-component interventions. These include:
• patient self- care education
• home visit
• telephone outreach
• telemedicine
• support groups/talking circles
• group education
• work site visits
• letters
• encouragement cards
• client reminders

Establishing goals
Initially, the case manager must encourage the client by convincing and motivating him/her for possible behavioral changes that could lead to beneficial and long lasting positive outcomes. The following CMSA goal-setting guidelines goals should be:
• short-term
• small steps
• SMART (specific, measurable, attainable, realistic, time-bound)
Prioritizing needs and goals
Prioritizing is very important component as a nurse case manager establishes goals and patient’s personal needs. First, physical needs must be accomplished and then CM can address any psychosocial needs. Acute situations involving the patient’s safety must be resolved immediately.
Negotiation between patient and case manager should involve a series of convincing arguments until the client agrees to accept a design plan of action, and verbalizes motivation and willingness.
Evaluation and follow-up is very important for many reasons. Such as identifying if the plan of care in case management was successful or not, and to recognize possible errors, and develop an area for improvement.

Age related needs
Elderly people could have impaired or inadequate perception for pain therefore CM needs to observe for non-verbal signs and symptoms. To care for elderly CM has to check for background effectively especially in culturally diverse country as the United States. Sometimes, older immigrants do not know English therefore interpreter must be provided to them.
Vulnerable population
Diabetes does not discriminate, any age any nation is not immune from it. However there are some ethnic groups which are more vulnerable than other this includes Native American, Hispanic, African American, Asian American, Pacific Islander, obese and babies who were born overweight (Lewis et. al 2007).

Process of disease management in managed care settings,
Overview of outcomes management

The Disease Management Association of America (DMAA) is also known as the Care Continuum Alliance. “Its primary goal is population health improvement through health and wellness promotion, disease management, and care coordination. DMAA promotes the role of population health improvement in raising the quality of care, improving health outcomes, and reducing preventable health care costs for individuals with chronic conditions and those at risk for developing chronic conditions” (Powell & Tahan, 2010, p. 328). In addition, the “goals are to improve patient outcomes, encourage self-management and patient-centered care, reduce costs, support preventative care, and increase patient adherence to recommended medical care.” It will also include, “prevention, early detection/diagnosis, treatment, and management” (Finkelman, 2011, p. 170).
“Usually, the role of the physician is to continue to provide appropriate interventions for the patient; however, other health care professionals, often nurses or case managers, provide education that focuses on prevention and health maintenance based on the disease and the individual needs of the patient. The major goal is to prepare the patient to understand the disease and increase the patient’s self-management of the disease” (Finkelman, 2011, p. 170).
“In disease management case management models, case managers apply evidence-based guidelines or protocols. These protocols are nationally recognized standards of care that that describe the necessary care and treatments (diagnostic and therapeutic interventions) for patients with a specific chronic health condition such as heart failure or end-stage renal disease and based on the severity of illness. These protocols also include the expected outcomes of care that are easily measured and tracked over time. Case managers assess patient and classify them, based on specific criteria, into low-, moderate-, or high-risk groups. Then they manage the care of the patients, applying treatments and interventions indicated by their risk group. Treatments include medications, lifestyle changes, and health education. Such models of care have proven effective in preventing the need for emergency department visits or acute care hospital stays” (Powell & Tahan, 2010, p. 14).
Many immigrants have low income and cannot afford supplies to test and maintain their blood sugar levels. Luckily, “effective July 1998, Medicare coverage for glucose monitors and testing strips expanded. All diabetics now qualify for glucose monitoring devices, strips, lancet devices, lancets, glucose control solutions for checking the accuracy of the test strips, and monitors. This applies, regardless of insulin intake, if a Medicare patient’s diabetes would be better controlled through testing blood sugar. However, a 20% coinsurance applies on all diabetes supplies. The patient should ask his or her physician to write a prescription, which should state how often the blood sugar should be tested; this will indicate how many test strips will be dispensed. Medicare covers the quantity of test strips ordered” (Powell & Tahan, 2010, p. 192).

Case study for management/outcomes of the management program
A two-year study was done on diabetes patients in regard to case management. Though the patients were Hispanic, being culturally sensitive to the needs of diverse populations could give vital information to benefit others:
Evidence exists that optimum glucose control is important to prevent diabetes complications and improve overall health. The primary goal of the DYNAMIC study is to evaluate the effectiveness of an enhanced nurse case management intervention to improve clinical and psychological outcomes in patients with diabetes in primary care setting, thus determining the impact and sustainability of the intervention on glycemic and lipid control over two years. The intervention is designed to incorporate aspects of the chronic care model with the addition of self-management support through MI and education. In addition, extensive nurse training and increased attention to clinical care guidelines for PCPs will improve outcomes. The study will also evaluate cost-effectiveness of the intervention and feasibility of incorporating the strategy into the primary care setting. The DYNAMIC intervention addresses important questions regarding the use of nurse case managers in overall diabetes care, the role of health care providers to initiate or intensify therapy when indicated, and the psychosocial effects of diabetes on emotional distress, quality of life, and self-care behaviors. Interventions sensitive to the needs of Hispanic individuals, who have a higher incidence of problems with diabetes, are critical in order to improve diabetes outcomes for this population. If proven beneficial, NCM could be integrated in practices worldwide with a substantial impact on improving costs, outcomes, and the lives of those with diabetes. The intervention could also be adapted to other chronic illnesses and conditions through other randomized, controlled interventions. (Stuckey et al., 2009)

Conclusion
In summary, we would like to note that disease control and management could be accomplished by the health promotion and consistency in disease management. By embracing these two processes, there is a greater increase on the control of health improvement and sustain maintenance, especially in Asian Indians with diabetes. Research based on evidence-based practice concluded that healthy life styles with bases on regular physical activities are the key to a better quality of life and prolonged longevity. What establishes our accomplishment is personal transformation as nurses, with well-managed care and is knowledge-based and culturally competent. If we want to understand our patients, and be efficient and effective in disease case management, we need to not only utilize the nursing process, but also step in the cultural shoes of our patients, and become part of a team with them.

References
American Association of Diabetes Educators. (2012). Diabetes Inpatient Management. The Diabetes Educator, 38(142).
American Cancer Society. (n.d.). Breast cancer fact sheet. Retrieved from aancart.org
American Psychological Association (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.
Asian American Health Initiative. (2007). Asian Indian community needs summary report. Retrieved from aahiinfo.org
Bakker, L. E., Sleddering, M. A., Schooner, J. W., Meinders, A. E., & Jazet, I. M. (2013, October 1). Pathogenesis of type 2 diabetes in South Asians. European Journal of Endocrinology, 169(5).
Busko, M. (2013). Beta-cell dysfunction may drive diabetes in Asian Indians. Retrieved from medscape.com
Egede, L. E., Strom, J. L., Fernandes, J., Knapp, R. G., & Rojugbokan, A. (2011). Effectiveness of technology-assisted case management in low-income adults with Type 2 diabetes (TACMDM):study protocol for a randomized controlled trial. Trials, 12(231).
Finkelman, A. W. (2011). Case management for nurses. Saddle River, NJ: Pearson Education.
Giger, J. N., & Davidhizar, R. E. (2008). Transcultural nursing: Assessment and intervention (5th ed.). St. Louis, MO: Mosby Elsevier.
Indian health diabetes best practice. (2011). Diabetes/Pre-Diabetes Case Management.
Ishani, A., & Greer, N. (2010). Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes. Diabetes Care, 37(5).
Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P. G., & Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (7th ed., Vols. 1-2). St. Louis, MO: Mosby Elsevier.
Mayo Clinic. (2008). Why is there such a high incidence of diabetes among Asian Indians? Retrieved from sciencedaily.com
National Cancer Institute. (2014). Cancer incidence and mortality patterns among specific Asian and Pacific Islander population in the U.S. Retrieved from seer.cancer.gov
Polit, D. F., & Beck, C. T. (2014). Essentials of nursing research: Appraising evidence for nursing practice (8th ed.). Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins.
Powell, S. K., & Tahan, H. A. (2010). Case management: A practical guide for education and practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins.
Purnell, L. D. (2009). Guide to culturally competent health care (2nd ed.). Philadelphia, PA: F.A. Davis.
Shrivastava, S. R., Shrivastava, P. S., & Ramasamy, J. (2013). Role of self-care in management of diabetes mellitus. Journal of Diabetes & Metabolic Disorders, 12(14).
Stellefson, M., Dipnarine, K., & Stopka, C. (2013, February 21). The chronic care model and diabetes management in US primary care settings: A systematic review. Preventing Chronic Disease, 10.
Stuckey, H. L., Dellasega, C., Graber, N. J., Mauger, D. T., Lendel, I., & Gabbay, R. A. (2009, July). Diabetes nurse case management and motivational interviewing for change (DYNAMIC): Study design and baseline characteristics in the Chronic Care Model for Type 2 Diabetes. Contemporary Clinical Trials, 30(4), 366–374.
Versnel, N., Welschen, L. M., Baan, C. A., Nijpels, G., & Schellevis, F. G. (2011). The effectiveness of case management for comorbid diabetes type 2 patients; the CasCo study. Design of a randomized controlled trial. BMC Family Practice, 12(68), 1-9.