The community: partnerships with community programs to support patients’ needs.
Health system design: creation of a culture, organization, and mechanisms that promote safe, high-quality care.
Self-management support: recognizing the central role of the patient in managing his or her own care.
Delivery system design: focus on teamwork; proactive vs reactive health care management; follow-up beyond the office visit; case management for more complex patients; recognition of cultural variations.
Decision support: use of evidence-based treatment, with clinician access to ongoing education.
Clinical information systems: data available to monitor progress at the individual patient level and the service level.
In this supplement, several models for the treatment and management of diabetes patients are discussed as alternatives to conventional management in the PCP’s office. Christina R. Bratcher, MD, FACE, and Elizabeth Bello, RD, LD, CDE, describe a centralized multidisciplinary team approach that integrates the skills of practitioners from different disciplines, all practicing under one roof: generalist and specialist physicians, registered nurses and nurse practitioners, physician assistants, certified diabetes educators, dietitians, and, possibly, pharmacists. Patients receive all of their diabetes care in an integrated fashion and in a single stop: medical care, individualized diabetes education, nutrition, exercise and lifestyle coaching, and counseling and monitoring of drug effects. Integration of care is facilitated by the use of electronic medical records. Evidence suggests that this approach results in improved patient outcomes and reduced overall costs. However, the main issue of concern with the model is the negotiation of coverage, which leaves the patient responsible for some noncovered services. The expenses could be substantial and the patient might have to decide which services to receive.
Sweta Chawla, PharmD, MS, CDE, describes a nontraditional model of diabetes care delivered by pharmacists, called medication therapy management (MTM). Pharmacists are playing an increasing role in diabetes management and their rapid growth as a sector of qualified health professionals makes them an important asset that should complement primary diabetes care. The pharmacist can help improve outcomes by preventing medication-related morbidity and mortality and providing patient education. However, it is of concern that a physician referral is not needed for MTM services and that the pharmacist can take over patient care and even override the physician’s recommendations, as suggested in the case presented by Dr. Chawla. The role of pharmacist-delivered MTM in the overall scheme of diabetes management is clear: it can help optimize diabetes drug therapy, reducing risks and possibly also improving patient compliance via educational interventions. However, pharmacist-delivered MTM should definitely be part of an integrated and coordinated multidisciplinary team, whether centralized or not.
The boutique medicine model, developed in the 1990s, has provided physicians hampered by the constraints of managed care with an alternative approach to increasing the amount of time spent with each patient and improving their quality of care. In this model, the practice enrolls fewer patients and each patient pays a monthly or annual fee to have improved access to services. In return, the patient receives extended visits with a comprehensive plan of care that includes not only medical assessment, but also individualized education and close follow-up. In the practice described by Jeffrey P. Schyberg, MD, the physician has time to undertake multiple aspects of diabetes care, including extensive diabetes education. This approach might deny patients the opportunity to utilize valuable available resources and skills from other health care providers that are important for the integral management of diabetes. The business model is attractive; however, the services are not available to most patients. Boutique medicine has raised mixed reactions, but is currently considered part of physicians’ free market opportunities by the American Medical Association.
In the final section, K.C. Arnold, NP, CDE (ANP, BCADM), describes a nontraditional/noncentralized model of diabetes care led by other health care providers—in this case, nurse practitioners (NPs). Advanced-practice nurses are increasingly delivering primary care to fill gaps left by the physician shortage. The American Nurses Credentialing Center has partnered with organizations, including the American Association of Diabetes Educators and the American Diabetes Association, to establish credentialing that allows NPs to fill more specialized diabetes management roles. These roles can be accomplished within physician-led practices, but also in independently run clinics, with or without physician involvement, depending on state laws. The article presents evidence that NP-provided primary care can be comparable to physician care for multiple health outcomes, and it emphasizes the nurturing nature of the patient-provider relationship within this model. The limitations for the NP-led practice described in this article seem to be similar to the ones encountered by traditional physician-led models, with cost and reimbursement issues and a high patient volume requiring follow-up visits to be spaced every 3 months. Nurse-led practices have the additional challenges of legal restrictions and physician resistance.