Background: Models that address the needs of patients with diabetes mellitus (DM) in primary care (PC) are needed, as health systems move to value-based care. To support DM patients at high risk, an insurer-based program that paired nurse practice care managers (PCM) with certified diabetes educators (CDE) was designed to improve outcomes for DM patients with complex needs.

Objective: To assess the durability of glycemic improvement after diabetes self-management education and support (DSMES) intervention within a model that relies on a PCM to identify, refer, and provide ongoing support to complex patients who received a CDE intervention in PC.

Methods: 2 CDEs, serving rural and urban areas, were introduced as team members into PC practices. CDEs provided DM training to PCMs who then proactively identified and referred patients under clear criteria (DM related ER visits, hospitalizations, HbA1c>9, reported barriers to care) for DSMES in collaboration with PC provider and PCM. Post CDE intervention, the PCM was available for follow-up and ongoing support. HbA1c was monitored every 3 months after intervention and compared to baseline value to assess durability of improvement in glycemic control.

Results: Of 222 patients referred, 1had 6 and 80 had 12-month data for analysis. Patients were 52% female; mean age 57 (SD 13.43). Mean HbA1c decreased from 9.6 to 8.4 over 6 months and 9.2 to 8.1 over 12 months (p<0.001). Improvement in glycemic control was maintained for at least 1 year after intervention. There was no significant change in BMI over this time.

Conclusions: A model where CDEs partner with PCMs, who identify, refer, and provide ongoing support to patients post-CDE delivered DSMES, is an effective and feasible intervention to improve and sustain DM outcomes in PC. This collaborative approach expands opportunities to meet complex needs of DM patients and can contribute to the ability of practices and health plans to provide an effective intervention with ongoing patient support.


M. Zupa: None. V.C. Arena: None. M.B. Thearle: None. P.A. Johnson: None. L.M. Siminerio: None.

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