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 initial 107 patients were identified and enrolled. One hundred and six patients completed year one, and 90 patients completed the second year. Nine patients were no longer followed through our clinic, and seven patients had died. Forty four (41%) patients achieved an A1c less than 8.0% at the end of the first year. At the end of year two, forty nine (54%) of the active patients achieved an A1c less than 8.0%. Starting in year 2, a second cohort of 46 patients with initial A1c greater than 8.0% were enrolled. The average A1c for this cohort was 9.39%. Thirty-nine patients continued to be actively followed at the end of year 2. The average A1c had dropped to 7.2% and 27 (69%) of this group had achieved an A1c less than 8.0%.

Conclusion: Most participants achieved diabetic control during Year 1 and maintained A1c at goal in Year 2 of the program. A greater percent of the second cohort was able to achieve A1c goal. This project demonstrates our interdisciplinary approach to help patients achieve and maintain glycemic control over a two-year period.


S.M. Lamie: Speaker’s Bureau; Self; Novo Nordisk Inc., Sanofi US. S.D. Rockafellow: None. D. Schepperly: None.

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