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.
People’s Community Clinic
- 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.
- 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.
- 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.
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
- There was no specific training required for this program.
- i2i Tracks Software
Team Members Involved
- Certified Diabetes Educator
- Chronic Disease Health Educator
- 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.
- Cost of i2i Track software
Where We Are
- This intervention is currently ongoing.
- 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
- 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
- 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.
Written with significant input from Elizabeth Washington
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