Improving Diabetes Care Across the Spectrum

07 Aug 2013
Keeping diabetes under control requires a multi-pronged approach. Aligning Forces South Central Pennsylvania (SCPA) has made notable strides in improving diabetes care by focusing on care both in and outside of the doctors’ office. Primary care practices in SCPA have reduced the number of patients with unmanageable blood sugar levels by 10 percent since 2009. And, in 2011, more people with diabetes in the region saw improvements in their cholesterol levels. Thirty percent of practices achieved either a 10 percent improvement in LDL cholesterol control or a HEDIS 90th percentile of 60.3 percent.
AF4Q SCPA Project Director Christine Amy attributes this improvement to three AF4Q programs: the Patient-Centered Medical Home (PCMH) Collaborative, the Patient Partners program, and the I Can! Challenge.
The PCMH Collaborative began with a focus of helping practices improve their diabetes measures. “Across the board, improvements were made with their processes as well as tests provided to patients with diabetes. We saw an increase in the number of monofilament tests given as well as improvements with blood pressure and A1c levels for diabetic patients,” said Stacy Ropp, practice support specialist for WellSpan Medical Group.
Without monofilament tests, providers wouldn’t know if diabetic patients are losing sensation in their feet, and a loss of sensation can lead to amputation. Other practices improved their coordination of care for diabetic patients in need of retinal exams. A retinal exam usually is completed by an ophthalmologist outside of the primary care practice. Practices changed their tracking systems to make sure they received the test results. In addition, practice staffers were educated about the importance of retinal exams.
PCMH Collaborative graduates participate in the Enduring Learning Forum (ELF) on their route to achieving PCMH certification. Members of the ELF group will continue to work toward improving diabetes outcome composite scores. 
In addition to practice-level improvements, the Patient Partners program has integrated patient voices into each practice to ensure that the perspective of those receiving care is considered throughout the improvement process—and reflected in changes. “The goal is to look at our system from the patient perspective and to make the primary care physician experience better. By working as a collaborative community, we can determine what will make the biggest impact on a patient’s life,” said Amy. One of the successful outcomes of Patient Partners is the creation of a “brown bag medication review,” in which the patient brings all of his or her medications to a meeting with a provider for review. Patients take this opportunity to clarify dosage and purpose of each medication.
Outside of practices, AF4Q SCPA enables patients to do their part and make healthy choices. The I Can! Challenge encourages patients with chronic diseases like diabetes to adopt healthier lifestyles. A Patient Partner participant from Stony Brook Family Medicine recently shared his success story—since joining the I Can! Challenge, he cut his insulin use in half and no longer needs to take blood pressure medicine.