Effective Chronic Care Management Strategies in Diabetes

How diabetes can serve as a template for chronic care management strategies

With the transition from a fee-for-service to a quality and value-based reimbursement system, diabetes is taking center stage as the quintessential chronic disease state. Diabetes can be used as the template to develop effective chronic care management strategies through the implementation of systems and processes to help patients, providers and integrated health systems succeed in this new environment.

In the era of value-based care, providers need to follow a four-pronged approach to achieve the outcomes and quality care that patients with diabetes deserve.

  1. Outpatient care models must be developed that helps to make primary care providers successful.
  2. Specialty care must be strengthened to assist with the care of difficult to manage individuals.
  3. Inpatient management strategies that achieve the glycemic control necessary to limit the excess morbidity and mortality related to poor glycemic control.
  4. Transitions of care between these different areas; primary care, specialty care, and hospital care must be bolstered.

The most essential aspect to the success of this four-pronged approach is to provide caregivers, providers, and patients with diabetes the proper self-management education, making certified diabetes educators the keystone of this care model.

Outpatient Diabetes Care

Primary care providers must be armed with the resources, both electronic and human, to successfully manage a large population of people with diabetes and foster effective population health management. Unfortunately, historically providers have been poorly trained in managing a population of patients.

However, population health management is the key to success as we move forward into this new reimbursement model. Providers must be able to identify, engage, and communicate successfully with patients who are struggling with their diabetes care. Without the proper technology in place the identification of these patients, which is essential, is nearly impossible. Electronic Health Records (EHR) must have population health functionality to allow data mining and thus the identification of those patients who are:

  • Missing appointments
  • Not achieving A1c, blood pressure, or lipid targets
  • Frequently visiting the emergency room
  • Requiring recurrent hospitalizations
  • Not refilling their medications
  • Missing their specialty appointments with the eye doctor, the podiatrist, etc.

Therefore, without a robust EHR with a population health management overlay in place managing chronically ill patients, like those with diabetes, will not be successful. Human resources must also be in place to engage these patients once they are identified and care teams need to be established to provide this care. Care teams should include:

  • Care coordinators
  • Nurse educators
  • Dietitians
  • Clinical pharmacists
  • Providers
  • The patient

Struggling patients require frequent communications as their care teams work to keep these individuals out of the hospital and emergency rooms, improve their treatment goals, and enhance their long-term outcomes. To be effective, patients need to be engaged in the manner in which they prefer through text message, e-mail, phone calls, telehealth visits, or mail. Technology must be used in the movement forward in population health management as patients are accustomed to receiving information on their own terms.  Investment in the electronic and human resources is essential in making this care model successful.

Specialty Diabetes Care

The paucity of specialty care in many regions makes it challenging to have difficult patients seen in a timely manner. Therefore, it is essential that alternatives, such as telemedicine, be developed to work with primary care providers and diabetes care teams. It is also imperative that primary care providers receive the necessary continuing medical education regarding diabetes care.

Inpatient Glycemic Control

As part of this holistic approach to care it is also essential to improve glycemic control of hospitalized patients to shorten length of stay, prevent readmissions, reduce morbidity and mortality, avoid postoperative surgical infections, and reduce the need for post-hospital skilled nursing care. This is best accomplished though a multidisciplinary team-based approach with nursing education and engagement along with the development of basal bolus insulin order sets and the use of dosing decision support tools as well as Glycemic Management Systems.

Transitions of Care

Efficient systems must be developed to assist with the transition of patients between all these different facets of care in a timely and seamless manner. Technology can be leveraged along with the care coordinators and diabetes educators to smooth out the process. Improved communication between providers is also essential to ensuring an accurate transition.

Diabetes Education

Diabetes self-management education is essential for all patients with diabetes and is truly the cornerstone of diabetes management. People with diabetes have a multitude of things to manage on a daily basis including:

  • Proper use of a glucose meter
  • Medication adherence
  • Proper use of injectables
  • Decision-making in regards to food intake and exercise
  • Proper treatment of acute complications of diabetes including hyper and hypoglycemia
  • The daily struggle of balancing all of this along with work, school, family, and friends

Proper education for people with diabetes needs to occur in all of the above areas including the outpatient arena. When patients transition out of the hospital, they may be going home on a different medication regimen, therefore increasing the need for education and practice during the transition of care. Therefore, certified diabetes educators are the most essential part of this chronic care model.

People with diabetes, as with all patients, deserve the best possible care and this new model of healthcare provides the opportunity to improve their care as the focus moves from fee-for-service to outcomes and quality.

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