An Interdisciplinary Team Approach to Managing Diabetes in a Patient-Centered Medical Home

Background: Our private practice Patient-Centered Medical Home (PCMH) clinic proposed a pilot team-based program where patients would be seen between physician visits by an interdisciplinary team comprised of our CDE, Clinical Pharmacist, and Care Manager with the goal of helping to improve glycemic goals.

Methods: Patients age 18 or older with an A1c greater than 8.0 were identified through registry review and invited to participate. Team providers were under the supervision of the project lead physician. Number of visits was individualized for each patient. Visits centered on diabetes education, goal setting, and motivational interviewing. The project was pre-defined to have been successful if 15% of patients achieved improved control.

Results: A recruitment goal of 100 was targeted and 107 patients were identified and enrolled. One hundred and six patients completed the pilot program. Average A1c at the beginning of the study was 9.1%. A1c decreased to 8.2% at the end of pilot, a 0.9% decrease. A1c ranged from 8.0 to 14.5% at pilot initiation. At the end of the pilot A1c ranged from 5.1 to 10.8%. This represents a change of -7.4 to +1.8%. Seventy patients (65%) achieved improved A1c. Forty four (41%) patients achieved an A1c less than 8.0%. An additional 26 (24%) patients had improvement in A1c. Patients had an additional 7 visits on average. Average blood pressures declined by 2.7 mmHg systolic and 0.11 mmHg diastolic. Microalbumin to creatinine ratio testing increased to 95% compliance, an increase of 20%. Appropriate statin use was unchanged at 79% of patients.

Conclusions: The majority of pilot enrollees improved their diabetic control over the course of the pilot program. The pre-specified level for success was exceeded. This project demonstrates the ability of a private practice with limited resources to seek creative solutions and partnerships to improve patient care of challenging and complex patients.