Embedding Diabetes Expertise within Primary Care

Efficient delivery of care within the primary care setting is critical to address the needs of the vast majority of individuals living with diabetes. And yet, as diabetes care has become more complex, primary care providers often find themselves insufficiently prepared and capacity for referral to subspecialty care is lacking. We have designed and implemented a novel program within primary care practices in a large healthcare system. Practices were engaged in a model whereby an interprofessional diabetes team was embedded for 6 months. The team was composed of an endocrinologist, CNS, PharmD and RD. The practices were oriented to the program and questions and concerns addressed. All diabetes metrics were pended as a part of the rooming process. Patient-centered care was delivered in one-on-one visits with the entire team as well as in shared medical appointments. Providers and staff were provided didactic and experiential instruction in practical strategies to diabetes care to ensure that diabetes self-management training (DSMT) was available within the practice once the 6 month program was completed.

Results: 157 patients with type 2 diabetes participated in the initial program. Age (58.4±11.8 years), gender (82F/75M), and HbA1c (9.8±2.0%) characterized the selected population. 40 individuals did not return for a second visit so data were analyzed for those completing at least 2 visits. Over the course of the program, HbA1c fell from 10.3±0.02 to 8.2±0.01%*; adherence to diabetes metrics increased for foot exams (31.2 to 98.1% *), microalbumin (61.1 to 87.2%*) and eye exams (25.5 to 47.1%*, * p<0.01 all comparisons) . All patients were returned to their primary care provider for long term care after completion of the program or once target HbA1c (<7.0%) had been achieved.

Conclusion: Embedding an interprofessional diabetes team within a primary care setting 1) significantly improves HbA1c and overall diabetes care; 2) provides sustainable DSMT services for primary care providers; and 3) focuses greater attention on diabetes.