Search

The purpose of this quality improvement project was to implement and evaluate a care delivery model integrating the registered nurse care coordinator (RNCC) into a family practice that is certified as a patient-centered medical home (PCMH) by the National Committee for Quality Assurance. The initial target population was the 937 patients with diabetes in the family practice. A pre-post design was used to assess changes in patients' diabetic quality indicators after integrating the role of RNCC using existing staff. This 6-month project compared the following diabetic quality indicators: blood pressure <140/90 mm Hg, hemoglobin A1c ≤7, low-density lipoprotein cholesterol <100 mg/dL, documentation of smoking cessation counseling, and aspirin prescription if existing vascular disease. Yearly documentation of microalbuminurea level, and filament foot and retinal examination was assessed. Patient and health care team satisfaction also was measured. Care coordination interventions included: telehealth, group visits, standardized individual patient education, as well as creative uses of the electronic medical record for workflow changes, daily huddles, and monthly meetings. The results were positive, statistically significant differences in the pre and post scores for A1c ( P=.001, n=790), foot exam ( P=.001, n=850), and microalbumin ( P=.01, n=850). Post intervention, patient and health care team satisfaction with the RNCC role was high (mean scores ≥3 on a 5-point Likert scale). Integrating the RNCC within a multidisciplinary team in the PCMH had a significant positive impact on diabetic quality indicators. Patient and health care team satisfaction with the RNCC role was high. ( Population Health Management 2015;18:330-336) [ABSTRACT FROM AUTHOR]

Racial and income disparities persist in diabetes management in America. One third of African and Hispanic Americans with diabetes receive the recommended diabetes services (hemoglobin A1c [A1c] testing, retinal and foot examinations) shown to reduce diabetes complications and mortality, compared to half of whites with diabetes. National data for Asian Americans are limited, but studies suggest that those with language and cultural barriers have difficulty accessing health services. A diabetic registry has been shown to improve process and clinical outcomes in a population with diabetes. This study examined whether a community center that serves primarily low-income Asian American immigrants in Santa Clara County, California, could improve diabetes care and outcomes by implementing a diabetic registry. The registry was built using the Access 2007 software program. A total of 580 patients with diabetes were identified by reviewing charts, the appointment database, and reimbursement records from Medicaid, Medicare, and private insurance companies. Utilizing the registry, medical assistants contacted patients for follow-up appointments, and medical providers checked and tracked the patients' A1c results. Among the 431 patients who returned for treatment, the mean A1c was reduced from 7.27% to 6.97% over 8 months ( P<0.001). Although 10.8% of the patients changed from controlled to uncontrolled diabetes post intervention, 32.6% of patients with uncontrolled diabetes converted to controlled diabetes ( P<0.001). The diabetes control rate improved from 47% to 59% at the end of the study. This study demonstrated that a diabetic registry is an effective tool to manage an underserved population with diabetes, thereby reducing disparities in diabetes management. ( Population Health Management 2012;15:220-229) [ABSTRACT FROM AUTHOR]