Purpose: Mount Sinai St. Luke’s Hospital located in NYC, received a DSRIP (Delivery System Reform Incentive Program) grant to improve population health in the Medicaid population. Divisions of Endocrine and General Medicine collaborated to improve care for high-risk patients with T2DM in three urban primary care practices by implementing PM to reduce percentage (%) of patients with HbA1c >9.

Methods: A team of six CDEs was formed; two CDEs were embedded in the practices and each CDE was assigned to a PCP(s). Teams received quarterly reports of patients (HbA1c >9) and met monthly to discuss care management (PM). Eligibility criteria: HbA1c >9 taken within 12 months. Patients were excluded if receiving care by a CDE/endocrinologist. We calculated % of patients who reached HbA1c <9 using the first HbA1c from time of PM until their last repeated HbA1c over one year. We also evaluated % of patients who reached HbA1c <9 based on visits with: PCP only, CDE-PCP, CDE-endocrine or endocrine only. Lastly, we calculated % of patients seen by a CDE who attained HbA1c <9 with or without PM.

Results: A total of 549 patients were identified; 257 patients were eligible and received PM where 34% (n=87) improved, achieving HbA1c <9. Out of the 87 patients, 10.5%, 12.5%, 8.2% and 2.7% showed improvement, based on visits with: PCP only, CDE-PCP, CDE-endocrine or endocrine only, respectively. A total of 292 patients did not receive PM; 153 patients were eligible where 44% (n=67) improved, achieving HbA1c<9. Overall improvement in HBA1c <9 was found in 45% of patients seen by a CDE vs. in 35% of those not seen by a CDE, regardless of PM or endocrine involvement.

Conclusion: While use of PM for patients with T2DM identified as high-risk (HbA1c >9) was not impactful, visits with CDEs had the greatest impact on improving HbA1c to <9, regardless whether the patient was part of PM or not. We therefore recommend all patients with T2DM identified as high-risk (HbA1c >9) receive CDE support services.

Disclosure

D. Wittman: None. S.N. Casely-Hayford: None. E. Young: None. J. Albu: None.

© 2019 by the American Diabetes Association.
2019
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