Original Research

Diabetes Patient-Centered Medical Home Approach

Fed Pract. 2014 December;31(12):16-22

References

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Multidisciplinary Approach

The multidisciplinary team formed at the trial T2DM clinic consisted of a medical doctor, family NP, pharmacist, RN, licensed vocational nurse, and registered dietician. The team members were each encouraged to obtain Certified Diabetes Educator (CDE) certification. For the first 6 months of developing the clinic, staff scheduled weekly team-building meetings to encourage esprit de corps. The weekly meetings were also used to discuss difficult patient cases. The RN case manager provided the patients with individualized plans to help them meet specified goals and provided easy accessibility for patient questions and concerns. The pharmacist was integral in helping patients understand the role of their medication and was also certified to make medication adjustments related to diabetes.

A recent Institute of Medicine (IOM) report encouraged the expansion of roles for nurse practitioners (NPs) in coordination and primary care delivery.²⁶ The IOM collaborative statement is based on numerous studies showing that NPs provided equivalent quality of care compared with that of primary care physicians in routine chronic disease management.²⁶ Nurse case managers functioned as an integral part of the intensive therapy involved in the landmark Diabetes Control and Complication Trial.²⁷

The intended policy analysis and outcome evaluation was confined to data collected from a disease-specific (T2DM) clinic with a PCMH approach developed April 2011 at WBAMC. Data were obtained from the WBAMC database designed to track the HEDIS measures.

Enrollees of the clinic were restricted to patients diagnosed with T2DM who were TRICARE beneficiaries. Males and females, aged > 20 years with an established A_1c > 6.5% comprised the patient population of the clinic. Individuals who were managed by WBAMC or were TRICARE standard beneficiaries were excluded from the study. Because patients with T1DM have a different pathology than those with T2DM, they were referred to endocrinology. Patients with gestational diabetes were referred to obstetrics for management.

Data Collection

Existing data in the Armed Forces Health Longitudinal Technology Application (AHLTA) EMR were used for this analysis. Data were accessed by a Common Access Card (CAC card) enhanced security system accessed only through secure CAC applications.

Diabetic outcomes of glycemic control as measured by the A_1c value were examined prior to clinic enrollment (time 1: PCM care delivery) and subsequently (time 2: PCMH care delivery) at the health care provider’s discretion. The second time varied between 2 and 6 months, depending on (1) provider need to determine quickly (2 months) whether a downward trend was occurring because of multiple comorbidities; (2) provider discretion to wait an additional 3 months (A_1c turnover x 2 = 6 months), while medication adjustments are being made; and (3) according to feasibility of follow-up based on patient’s scheduling. Low-density lipoprotein cholesterol (LDL-C) was also examined at both PCM care delivery and PCMH care delivery.

The endpoints of a reduction in A_1c by 1% and an LDL-C that is ≤ 100 mg/dL determined improved diabetes outcomes. Existing data (eg, glycemic control [A_1c], lipid control [LDL-C]), from April 1, 2011, to December 31, 2011, were logged in a clinic database. These data served to demonstrate the effectiveness of the T2DM PCMH approach to clinic management. The PCMH principles that were examined included the standard operating procedure for the T2DM-PCMH clinic: frequent appointments > 2 in a 3-month period), a multidisciplinary team, and intensive, repeated education.

Data analysis was conducted with descriptive statistics (frequencies, means, SDs) and t test analysis to determine relationships between variables of A_1c, LDL-C, and frequency of visits. Improved diabetic outcomes, as previously defined, inferred that developing principles of a T2DM-PCMH clinic based on the principles of a PCMH provided a solution to optimal T2DM management compared with routine primary care delivery, consisting of a TRICARE-assigned PCM.

Results

A total of 638 unique patients were seen at the T2DM-PCMH clinic. Of these, 237 patient records in the database met the inclusion criteria and were acceptable for analysis and evaluation. Patients were omitted for the following reasons: 255 patients did not meet protocol of a minimum 2 visits during the evaluation period, 77 patients were omitted due to no second A_1c available, 65 patients did not meet the clinic protocol of a A_1c of > 6.5%, and 4 were omitted because no A_1c was available for pre- or postanalysis. Data analysis and evaluation of the remaining 237 acceptable patients demonstrated that a T2DM-PCMH approach provided improved diabetic care compared with routine, PCM management.

Patients enrolled at the WBAMC T2DM clinic demonstrated clinically significant improvement (P < .001), and 80.5% achieved > 1% improvement in glycemic control. The greatest number of visits of 26 visits, an outlier not typical of the frequency of patient visits, was attributed to brittle T2DM requiring more frequent monitoring. Most patients had 3 T2DM-PCMH clinic appointments (2 were the minimum visits described in clinic protocol).