Background: Health systems are implementing value-based care models focused on quality. Organized care teams set the foundation for successful models with processes that address patient outreach and engagement. The purpose of this study was to evaluate the impact of “Glucose to Goal (G2G),” a diabetes educator (DE) driven, population-based intervention on glycemic improvement in reaching quality metrics for diabetes mellitus (DM) care.

Methods: A large primary care (PC) network established pod-style patient-centered medical homes (PCMHs) clustered by grouping multiple PC practices together based on patient panel size, hospital affiliation, and geographic proximity, and incorporating expanded care teams (DE, behavioral health, social worker, wellness guide, nurse care manager). Specific to DM, PCMHs adopted the G2G intervention whereby DEs used population health reports to proactively identify patients with HbA1c levels above target (>7%). G2G was assessed in 5 pods by comparing HbA1c values for only those patients with DM with pre/post results who participated over a three-month period (n=284) to those who did not (n=265).

Results: A total of 80% of patients receiving G2G improved their HbA1c levels with 46.8% reducing HbA1c by 1% and 24% reducing HbA1c by 2%. Comparatively, 31.3% of patients not receiving G2G improved their HbA1c with only 6.4% reducing HbA1c by 1% and only 1.5% reducing HbA1c by 2% or more. This translated into more than 1.5% difference in mean HbA1c change between groups, with patients receiving DE experiencing a mean reduction in HbA1c of 1.35% (8.61 to 7.26%) compared to increase of 0.35% (7.96 to 8.30%) for those not participating in DE (p<0.0001).

Conclusions: Study findings demonstrate the relevance of DE services in value-based PC models. As healthcare systems shift focus from volume to value, effective approaches to manage diabetes and improve patient outcomes take on new meaning.


J.L. Koshinsky: None.J. Krall: None.K. Ruppert: None.J. Kanter: None.F.X. Solano: None.L.M. Siminerio: None.

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