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Diabetes Management via Team-Based Approach with Pharmacist & Dietitian Support @ Brigham & Women’s Hospital - South Huntington

Keywords: Diabetes, Teams, Pharmacist, Dietitian


Brigham & Women’s Advanced Primary Care Associates - South Huntington implemented a team-based approach to treating patients with uncontrolled diabetes, incorporating routine visits and phone calls with a pharmacist and dietitian alongside medical providers, in order to address pharmacologic and lifestyle factors more comprehensively.


Stuart Pollack, MD, Mara Sansevero, Kaitlin O’Rourke


Anabel Starosta


Brigham & Women's Hospital Advanced Primary Care Associates - South Huntington, Jamaica Plain, MA

Organizational Context

  • Brigham & Women’s Advanced Primary Care Associates - South Huntington is a Patient Centered Medical Home
    • It is an affiliate of Brigham and Women’s Hospital, an academic medical center
  • The clinic was founded in 2011 with the goal of implementing team-based care 

Population Served

  • The clinic sees many complex patients with uncontrolled diabetes
  • Referral base is mostly BWH inpatients with co-morbid psychiatric disorders

Payer Case Mix:

  • 20% safety net – Medicaid, dual Medicare/Medicaid eligibility, Neighborhood Health Plan
  • 20% Medicare
  • 50% commercial Massachusetts payers – i.e. Blue Cross Blue Shield Massachusetts, Harvard Pilgrim
  • 10% national commercial payers

Project Leadership

  • This project was led by Dr. Stuart Pollack who is the Medical Director and an attending physician at the clinic. 
  • The program is centered around a team consisting of medical providers, a pharmacist and a dietitian. 
  • The project is implemented by providers (MDs and PAs) who refer patients to pharmacist Kaitlin O’Rourke and dietitian Mara Sansevero. 

Project Tools & Components

Project Research & Planning

  • The clinic conducted a formal analysis, consisting of research and discussion, to determine which types of non-physician providers could best deliver care across the spectrum of primary care; decided on pharmacist and nutritionist based on cost and perceived benefits. 
  • The pharmacist and dietitian involved were specifically hired with diabetes management in mind, with the clinic expecting about 50% of their time to be spent on diabetes. 
    • Due to persistent patient need, they spend about 80% of their time on uncontrolled diabetes. 
  • This is not an official program, but rather a team-based approach to diabetes care in which patients with uncontrolled diabetes see and communicate routinely with a dietitian and/or pharmacist.
  • Medical providers monitor patients' HbA1Cs and a Population Health Manager monitors clinic-wide HbA1Cs monthly to identify higher risk patients.
    • There are no explicit guidelines for which patients are at high risk and should see team members besides an MD/PA, but patients who are deemed rising risk or high risk are referred to dietitian and/or pharmacist.
  • Once patients also begin seeing the pharmacist, the pharmacist monitors HbA1Cs and can prescribe medication according to Massachusetts Chronic Disease State Management Programs without physician approval. 

Project Training

  • The pharmacist and dietician follow Continuing Medical Education guidelines for diabetes management.
  • Providers, including attending physicians, residents and physician’s assistants, meet with the dietitian and pharmacist to learn about new medications and attend patient glucometer teachings as needed. 
  • No clinic-specific training, but cultural competence and “soft skills” were prioritized in hiring decisions.


  • Epic
  • Partners Patient Gateway (Institution-specific Patient Portal)

Team Members

  • Physicians
  • Physician's Assistants
  • Pharmacists
  • Dietitians

Daily Workflow

  1. Physicians first establish care with patient, and introduce dietitian and/or pharmacist to patient during visit after it is determined that patient could use additional care to help control diabetes. 
    • There are no explicit guidelines for which patients are at high risk and should see team members besides an MD/PA, but patients who are deemed rising risk or high risk are referred to dietitian and/or pharmacist
  2. Dietitian and/or pharmacist typically divide patients based on patient needs: 
    • The pharmacist sees patients who need help titrating insulin or learning to use glucometers 
    • The dietitian sees patients who need help with lifestyle modifications
    • Sometimes patients are assigned based on availability or prior relationships, and some patients may see both the dietitian and pharmacist alongside physician
  3. Patients see medical provider or dietitian/pharmacist based on scheduling availability, with no clear order of whom the patient sees first. 
  4. In between visits, high-risk patients receive intensive outreach consisting of 1 phone call/week from the pharmacist. More stable patients receive 1 phone call/month from the pharmacist. Communication also occurs through the Patient Gateway.
  5. The dietitian usually communicates with the patients once per month or less frequently, since dietary changes take longer.  
  6. When patients are seeing both pharmacist and dietitian and require a high level of care, dietitian and pharmacist may schedule appointments on different days so that the patient is seen more frequently. 


  • Pharmacist and dietician salaries were taken into account when the clinic was deciding which types of providers to hire.
    • In Massachusetts, RNs are as expensive as pharmacists, leading clinic to hire a pharmacist.
  • Dietitians are significantly less expensive, which enabled clinic to achieve a balanced budget upon hiring a dietitian. 
    • In other parts of the country, where RNs are less expensive, clinic would have preferred to hire RNs instead of nutritionists since they are able to titrate insulin. 

Current Status

  • This intervention is currently ongoing as of August 2018.
    • In prior months, a shared medical appointment pilot was conducted in which a provider met quarterly with 5-10 patients.
    • Brigham & Women's Hospital Primary Care is planning to scale pharmacy involvement across primary care, but scaling is currently delayed by complications in how pharmacists who are not affiliated with pharmacies can bill insurance. 
    • The future phase of this pilot will consist of a shared appointment with 5-10 patients led by the dietitian and pharmacist and no medical provider. These appointments will be more informational. 


  • The main benefit of this program was increased patient access to providers. 
    • Patients are able to communicate with the dietitian and pharmacist more frequently than they are able to with physicians, and the pharmacist and dietitian can spend more time focusing on pharmacologic and lifestyle factors, respectively, than a physician alone can.  
    • Dietitian and pharmacist call patients weekly or monthly as needed, increasing the frequency of outreach. They can see patients on the same day or stagger appointments so patients requiring more intensive care can see a provider more frequently. 
  • There is no copay for meeting with the dietitian and pharmacist, reducing cost barriers for patients. 
  • Having both a dietitian and pharmacist meeting with patients, rather than just one or the other, allows the team to provide care in a less time-constrained way.  
  • Patients are able to receive their glucometer and be trained in using it the same day. 
  • This model also has been felt to improve the quality of care these patients receive 
  • Teams are better able to devise solutions than individuals alone, and can contribute different models of care. 
  • Physicians and PAs consult the pharmacist for medication suggestions and guidelines, increasing treatment options for uncontrolled diabetes. 


  • For each individual patient, ability to reach HbA1C, lipid, and blood pressure goals are being tracked.


  • This is not an official program of the clinic with rigid guidelines, which enables the team to have flexibility and treat patients on a case-by-case basis. 
    • However, this also adds ambiguity to which patients are considered medium risk or high risk, and when patients should be contacted more intensively. 
  • Time constraints require only patients with the most uncontrolled diabetes to be seen. As a result, many patients with diabetes do not see the dietitian or pharmacist
  • Because this is a team-based model, communication and interpersonal challenges arise.

Relevant Quality Metrics

Coming soon!

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