AMGA and Pfizer Inc. present the Models of Excellence Collaborative on Patient Adherence and Health Literacy

Henry Ford Medical Group, Detroit, MI
Intensive Ambulatory Care in Diabetes

EXECUTIVE SUMMARY: Diabetes afflicts 6% of the American population and its prevalence is increasing. At current rates of growth the American diabetic population will reach 40 million (7.6%) by 2025 and will occupy 15 - 25% of the panel of the average adult primary care physician within the medical group (roughly 350 patients per physician) (appendix). The American healthcare system is not equipped to manage this epidemic and, given current constraints, additional government or private funding is unlikely. Thus, it is imperative that cost effective approaches be identified.

A disproportionate share of disease burden (and subsequent expense) is borne by type II diabetics who are “dangerously out of (glycemic) control” (DOC). This terminology is also applicable to blood pressure and lipid control. Improved control in each of these clinical parameters has been associated with reduction in the likelihood of future complications. Such outcomes have been accomplished through specialized programs (using a multidisciplinary chronic care model) designed to meet the needs of this subpopulation. However, it is unclear whether these interventions are justified on an economic basis and, if justified, the time required to reach the financial “break even” point is unknown.

In 2003, the medical group developed a comprehensive plan to improve diabetes care using the six aims of quality proposed by the Institute of Medicine (Safe, Effective, Efficient, Patient Centered, Timely, Equitable) (appendix). This proposed IAC pilot is one component of that plan and is intended to overcome the barriers faced by DOC patients via traditional medical care (physician office visit based care). This pilot provides intensive diabetes care in a flexible venue with the support of a multidisciplinary team. This pilot is built on an existing infrastructure and expands on previous programs that have demonstrated success both within and outside of the medical group.

The key features of the pilot are:

• Care provided by an expert nurse with delegated authority to adjust medical therapy and multidisciplinary support
• Enhancement of patient self management skills
• Focus on three clinical diabetes parameters (glycemic control, BP, lipids)
• An economic “return on investment” analysis

The primary objective of this pilot is to achieve rapid control of high leverage clinical parameters, to enhance self management skills of DOC patients and to prove the business case for this intervention. An additional objective is to expand knowledge of the risk factors which predispose patients to failure in traditional care models. This knowledge will be used to support continuous improvement in traditional venues of care.

1. Identify 3 adult primary care sites for the intervention and 3 demographically matched sites to serve as controls.
2. Identify and train a registered nurse (Diabetes Care Provider or DCP) with previous experience in diabetes care at each intervention site.
3. Assemble a multidisciplinary support team consisting of:
   1. DCP
   2. Dietician
   3. Endocrinologist
   4. Certified diabetes educator
   5. Behavioral services professional
   6. Primary care physician (s)
4. Intervention:
   1. A randomly selected cohort of 200 eligible DOC diabetic patients across the three intervention sites to receive the intervention. A control group of 200 DOC patients will be developed at matched sites (power calculations support sample size).
   2. Pre-test eligible patients to establish level of diabetes knowledge and identify risk factors for poor adherence (ADD, depression,literacy,social/personal issues, attitude, and readiness for change)
   3. Customized intensive sessions by the DCP (by phone, email or office visit) with each patient on a weekly basis until control is achieved. The DCP will focus on rapid adjustment of medication as well as enhancement of diabetes knowledge and self management skills.
   4. Medication management by the DCP will follow clinical guidelines for glycemic, lipid and blood pressure control (glycemic and lipid control guidelines in appendix) with oversight by the primary care physician and the multidisciplinary team.
   5. Regular team meetings to review protocols, risk factors, patient issues, and data.
   6. Post test to reassess risk factors and diabetes knowledge.
   7. Upon achievement of clinical endpoint targets or completion of program all patients will transition to a telephone case management program provided by the HMO.
   8. Primary care physicians will assume diabetes care upon program completion.
5. Eligibility Criteria:
   1. Established Type II Diabetes for at least 2 years (ICD9 code or DM medication usage)
   2. At least 1 visit to any PCP at the intervention site in the past 1 year
   3. HMO insurance assigned to medical group network
   4. Poor glycemic control: 2 or more A1C levels above 9.5 in past 2 years or 1 A1C reading above 11.0 in the past year. (note: recent data from the medical group diabetes registry demonstrates that inadequate BP and/or poor lipid control coexist in more than 80% of DOC diabetic patients)
6. Exclusion Criteria:
   1. Transient Diabetes (pregnancy, steroids)
   2. Hospice enrollment
7. Program completion criteria: must meet all criteria
   1. Achievement of glycemic control - A1C below 8% for 2 consecutive readings at least 1 month apart.
   2. Achievement of blood pressure control - BP < 130/80 (125/75 for patients with microalbuminuria)
   3. Achievement of LDL cholesterol control - LDL < 100
8. Maximum length of stay in program = 6 months

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