Overview

People’s Community Clinic (PCC) created an interdisciplinary approach to overcome barriers to diabetes self-management by integrating nurses and health educators specialized in diabetes education into routine clinical care.

Organization Name

People’s Community Clinic

Organization Type

• FQHC

National/Policy Context

• Nationally, there is a growing trend towards nurse-led care in the primary care setting and for patients with complex medical needs, including patients with diabetes.

Local/Organizational Context

• At People’s Community Clinic (PCC), nurses were assigned a specific panel of patients to allow for their management a specific group of patients.
• Having an assigned panel of patients would allow the nurse to establish rapport, better assist with tackling barriers to care, and increase the nurse’s ability to provide telephonic follow-up in a timely and more organized fashion.
• Providing care in this way has been shown to improve health outcomes and is most effective with individuals who have uncontrolled diabetes.

Patient Population Served and Payor Information

• PCC serves all patients regardless of their type or lack of funding.
• 74% of the patient population lives at or below the federal poverty line, and only 2% of patients live at >200% of the federal poverty line.

Leadership

• This project was led by the Manager of the Chronic Disease Management Program, Chief Medical Officer, Associate Chief Medical Officer/Director of Adult Medicine, and Director of Health Promotion.

Funding

N/A

Research + Planning

• The team spent about 4 months planning the intervention. This involved meeting a few times per month over that period. In between the meetings, staff worked on completing action items assigned during the meeting.

Tools or Products Developed

• Patient roadmap to care: this is an interactive document that walks patients through the 6-month program. Patients can fill out the roadmap with dates and times of meetings as they progress through the program

Training

• There was no specific training required for this program.

Tech Involved

• NextGen
• i2i Tracks Software

Team Members Involved

• Certified Diabetes Educator
• Chronic Disease Health Educator
• RNs

Workflow Steps

• A patient presents to clinic for an office visit with PCP.
• The provider determines that the patient fits inclusion criteria for nurse panel at the office visit or nurse determines that patient fits inclusion criteria for nurse panel as revealed in a report run in i2i Tracks software, a population health management tool.
• The nurse meets with the patient at the office visit to discuss interest in participating in panel. If patient agrees to participate, they sign a consent form.
• Nurse schedules the patient to return for an individual appointment within 1-2 weeks. For the next 6 months, the patient attends nurse visits at clinic and receives phone calls, as outlined in the patient roadmap.

Budget Details

• Cost of i2i Track software

Where We Are

• This intervention is currently ongoing.

Future Outcomes

• Quantitative outcomes
  • Completion of labs and screenings: measurement of the rate of  receiving requisite labs and screenings per national guidelines (i.e. Hgb A1c, CMP, lipids, urine microalbumine/creatinine ration, TSH, foot exam, dilated eye exam, etc.)
  • HbA1c levels: the aim is improvement of HbA1c to < 8% for all patients
  • Class participation: the rate of patient participation in group cooking and diabetes education classes
  • Clinical interventions and outcomes: the intervention allows for tracking of clinical interventions and clinical outcomes for this group.
• Qualitative outcomes
  • Patients’ quality of life
  • Patients’ eating habits
  • Patients’ self-care skills
  • Patient-provider relationship
  • Patients’ understanding of medical care
  • Patients’ utilization of available resources

Benefits

• This project set parameters around timely in-person and telephone follow-up with nurses, allowing for a clear workflow that the patient and providers followed.
• The project is thought to be increasing participation in group cooking and diabetes education classes, and it has allowed for greater ability to track clinical outcomes and clinical interventions

Unique Challenges

• It was difficult to allow the nurse sufficient time to follow-up with patient over the phone because the team was short staffed. Having a protected time within their day to make follow-up phone calls made this easier.
• It was difficult to get providers on board with the new nursing role since they had grown accustomed to having the nurse available for nursing and even for non-nursing tasks
• This intervention required training other nurses in the clinic on basic Diabetes management education so that they could address the needs of patients not enrolled in panels, which was time-consuming.

Sources

Written with significant input from Elizabeth Washington

Chambliss, M.L., Lineberry, S.N., Evans, W.M., & Bibeau, D.L. (2014). Adding Health Education Specialists to Your Practice. Family Practice Management, 21(2):10-15.

Davidson, M.B, Castellanos, M., Duran, P., & Karlan, V. (2006). Effective Diabetes Care by a Registered Nurse Following Treatment Algorithms in a Minority Population. The American Journal of Managed Care, 12(4):226-232.

Davidson, M.B., Blanco-Castellanos, M., & Duran, P. (2010). Integrating Nurse-Directed Diabetes Management Into a Primary Care Setting. The American Journal of Managed Care, 16(9):652-656.

Funk, K. A., & Davis, M. (2015). Enhancing the Role of the Nurse in Primary Care: The RN “Co-Visit” Model. Journal of General Internal Medicine, 30(12), 1871–1873. http://doi.org/10.1007/s11606-015-3456-6