Aligning diabetes care with components of the Chronic Care Model (CCM) facilitates productive interactions between a proactive care team and an informed, activated patient, allows the care plan to be individualized, and can improve care and outcomes. The Patient Assessment of Chronic Illness Care (PACIC) survey assesses patient experience with CCM-based healthcare delivery components. In the Division of Diabetes and Endocrinology at Scripps Health, a large integrated health system in San Diego, CA, patients with T1DM have access to an interdisciplinary team of clinicians who provide care, education, and ongoing support. Guided by the CCM, an interactive care delivery system involving the endocrinologist, PCP, diabetes educator, RD, behavioral specialist and the patient was implemented to facilitate proactive and productive care but some interactions remained isolated. Between June and August 2017, the PACIC survey was administered by research assistants to N=47 adults with T1DM who have received care in the Division for at least 6 months. Overall, patients reported high satisfaction with care (M=4.77 out of 5; SD=0.56). Results also indicated high ratings for specific CCM elements, including Patient Activation, Delivery System Design/Decision Support, and Self-Management Support (M=4.29-4.55). Lower ratings were observed for Follow-Up/Coordination (M=3.81; SD=1.01), suggesting a need for enhanced post-visit contact with patients, referrals to community programs, dietitians, and counselors, and discussion of specialist appointments. In line with the Institute for Healthcare Improvement’s Triple Aim focused on improving the health of populations through optimization of health system performance, an RN with specialized experience in T1DM was added to the team as the Diabetes Care Manager to assist with follow-up and care coordination. The PACIC will be re-administered after 6 months to determine the impact on patient perceptions of follow-up/coordination between visits.


R. Morrisey: None. E. Kaczmar: None. A. Tsimikas: None. F.M. Arnold: None. T. Clark: None. J. McCallum: None. A.L. Fortmann: None.

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