Results from a Population Health Strategy for Diabetes in a Large Health Care System

Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. Awareness of population health management is increasing but the concept is not clearly defined or understood. Nevertheless, the overarching goal is to keep the patient population as healthy as achievable. Since diabetes is a chronic and progressive illness, population health management strategies hold promise and can be measured using health outcomes, disease burden or metabolic status. University of Washington Medicine, a large healthcare system in the greater Seattle area comprised of academic and community-based primary care clinics, recently initiated a diabetes population health (DPH) program. The is a centralized outlier management and surveillance system where a specialized team (endocrinologist and certified diabetes educator) remotely supports care teams (primary care providers, nurses) in diabetes management. In this pilot initiative, focus was on the highest risk patients with type 2 diabetes such as individuals who had chronically elevated A1C >9% over the past 12 months. The DPH team identified these individuals from an internal database, conducted chart reviews to identify potential areas for improvement, reached out to clinical care teams and offered individualized patient management strategies for the identified patients. Care of all identified patients remained with primary care teams. In 6 months there was a 1.4% point reduction in A1C (10.8% to 9.4%, n=34, p<0.01) primarily through the team’s work with care management nurses who in turn conducted outreach to patients to enable engagement, offered diabetes self-management support and improved care coordination. Thus, the number of individuals with diabetes and elevated A1C at any given period in the past 8 months was decreased by 60%. These early results suggest that an active diabetes surveillance program has the potential to improve health outcomes in diabetes.