Half-day diabetes clinic with 1:1 time with pharmacist, physician and nurse. One-on-one diabetes nurse educator meets with patients twice in first month, …
Comparison of Four Diabetes Delivery System Design Innovations
| |Cluster visits for |Chronic Care Clinic|Case Management |Planned Visits |
| |Diabetes Care | | | |
|Brief program |A nurse-led monthly |Half-day diabetes |One-on-one diabetes|Each provider |
|description |group visit for |clinic with 1:1 |nurse educator |proactively calls |
| |adults focusing on |time with |meets with patients|in patients with |
| |self management of |pharmacist, |twice in first |diabetes for a |
| |diabetes Each |physician and |month, quarterly |longer visit 30-45|
| |visit takes about 2 |nurse Nurse or |thereafter |minutes to |
| |hours Program |social worker runs |Patients are |systematically |
| |lasted 6 months, |a self-management |called weekly if on|review diabetes |
| |groups consisted of |focused group visit|insulin, twice a |care priorities |
|
|10-18 patients |that all patients |month if on oral |Visits occur at |
| |Various team members|are invited to |agents Nurse uses|least yearly Team|
| |assisted in groups |attend Visits |protocols to adjust|members assist with|
| |at intervals Nurse|occur 3-4 times |therapy working |care and |
| |contacts some |yearly Eight |closely with |coordination of the|
| |patients via phone |patients are in |primary care |visit |
| |as needed Primary |each group |physician and | |
| |care provider | |specialty support | |
| |reviews cases | | | |
|Patients |Age 16-75 with HbA1c|Adults with |Adults with HbA1c |Anyone with |
| |85 or none for 1|diabetes on |7 |condition |
| |year |medication | | |
|Setting
|HMO Kaiser Northern|HMO Group Health |Prudential |HMO Group Health |
| |California |Cooperative of |Healthcare HMO |Cooperative of |
| | |Puget Sound |members |Puget Sound |
|Comments on | |1:1 component is |can be reimbursable|Works in fee for |
|setting | |billable in fee for|in fee for service |service or managed |
| | |service settings |settings |care |
|Goals |Improve care |Routine assessment,|Improve glucose |Provide planned |
| |delivery and |peer interaction, |control and |chronic illness |
| |efficiency, improve |planned care and |self-management is|care |
| |self-management and |follow-up |sometimes reserved | |
| |glycemic control | |for high risk | |
| | | |patients | |
|
|Cluster visits for |Chronic Care Clinic|Case Management |Planned Visits |
| |Diabetes Care | | | |
|Intervention: |Diabetes nurse |Primary Care |RN CDE |primary care |
|Staffing |educator |Provider |working with |provider team may |
| |in consultation or |RN |endocrinologist and|be MD with MA, RN |
| |by referral: |Pharmacist |primary MD | |
| |podiatrist |SW or RN for group | | |
| |pharmacist | | | |
| |psychologist | | | |
| |nutritionist | | | |
| |pharmacist | | | |
| |primary care | | | |
|
|provider | | | |
|Intervention: |Risk factor |Planned visit |Monitoring, meal |Focus on diabetes |
|Topics |reduction, |following |planning, exercise|priorities: |
| |self-management, |evidence-based |Utilized stepped |reducing risk of |
| |skills teaching |clinical priorities|care protocols for |heart attack and |
| |monitoring, insulin|for diabetes same|medication |stroke, kidney |
| |use |as planned visit, |adjustment done by |disease, neuropathy|
| |By patient request: |column 5 |case manager and |and retinopathy |
| |exercise, sexual |Group focused on |referral to |Attention to |
| |dysfunction, stress |self-management |diabetes program |self-management and|
| |management, |support and sharing|which included |glucose control |
| |emotional concerns |among peers |exercise, dietary | |
|
| | |and group | |
| | | |experiences | |
|Results |RCT: |RCT: |RCT: |observational: |
| |Decr HabA1c by 13|incr preventive |decrease in HbA1c |increased patient |
| | |services |17, improved |and provider |
| |improved |incr satisfaction |health status, no |satisfaction |
| |self-efficacy |with diabetes care |increase in office |increased registry |
| |incr self-care |incr primary care |visits, |use |
| |practices |visits but decr |hospitalizations or|improved screening |
| |impr satisfaction |specialty and ER |hypoglycemic |rates |
| |lower hospital and |visits |events |decreased costs |
| |outpatient |improved outcomes | | |
|
|utilization |with incr | | |
| | |attendance, incl | | |
| | |HbA1c | | |
| |Cluster visits for |Chronic Care Clinic|Case Management |Planned Visits |
| |Diabetes Care | | | |
|Citation |Sadur et al, |Wagner, et al |Aubert et al, |McCulloch et al, A|
| |Diabetes Care, |Diabetes Care 2001 |Nurse |population based |
| |2212:2011-2017, |Apr;244:695-700 |case-management to |approach to |
| |1999 | |improve glycemic |diabetes management|
| | | |control in diabetic|in a primary care |
| | | |patients in a |setting Effective |
| | | |health maintenance |Clinical Practice |
|
| | |organization Ann |1998;1:12-22 |
| | | |Inter Med 15 Oct | |
| | | |1998, 129:605-612 |McCulloch et al, |
| | | |Available on-line |Improvement in |
| | | |at |diabetes care using|
| | | |http://wwwacponlin|an integrated |
| | | |eorg/journals/anna|population-based |
| | | |ls/15oct98/nursecas|approach in a |
| | | |ehtm |primary care |
| | | | |setting Disease |
| | | | |Management |
| | | | |2000;32:75-82 |
|Guide
available? |No |Yes |unknown |No, although |
| | |contact Connie | |articles provide a |
| | |Davis at GHC | |very complete |
| | |206-287-2554 or | |description of |
| | |daviscl@ghcorg | |program |
|Additional |Unpublished data, |Widely used in |Now completing RCT |Widely applicable |
|Comments |please do not |Britain as a mini |in another setting| |
| |circulate Requires|clinic Requires |Requires a | |
| |a high-functioning |attention to |clinically | |
| |nurse and a |logistics and |sophisticated nurse| |
| |physician willing to|adaptable staff |with close ties to | |
| |share | |primary care | |
|
|responsibilities | | | |
