Small Providers, Better Diabetes Care

07 May 2014
The citizens of Memphis, TN, suffer from Type II diabetes rates above the national average. The average rate of diabetes prevalence in the United States is 8.3 percent, and in Shelby County the average rate is 12 percent, according to the County Health Rankings. Diabetes and pre-diabetes contribute to the majority of premature deaths in Tennessee, according to a recent study from the University of Tennessee Health Science Center.
And at the front lines of care, primary care physicians in Memphis tackle treating patients with diabetes with the help of Project Better Care, a program from Common Table Health Alliance (CTHA), leader of Aligning Forces for Quality (AF4Q) in the region. The guiding principle of Project Better Care is that patients are best served by preventive care in primary care practices. Both quality of care and patient experience are maximized by comprehensive chronic care management, rather than reactive treatments and visits to the emergency room. Patients with diabetes are more likely to receive high-quality care if they have regular visits from a primary care provider with whom they have a strong, stable relationship.
In each of the five original Project Better Care practices, there were one to three providers, with a patient base ranging from 6,000 to 8,000. An average of 38 percent of patients were diabetic. Dr. Susan Nelson, medical director of CTHA, says that from a provider prospective, treating diabetes can be overwhelming. “Management of diabetes encompasses everything you eat, whether you sleep well, and with a diabetes diagnosis, now you have to deal with numbers and stick yourself. It’s overwhelming for patients, and it’s overwhelming to treat for doctors because time is always short,” she said.
Memphis has many small primary care providers, often with three or fewer physicians, rather than one or two dominant provider systems. To support these smaller practices, Project Better Care uses the Chronic Care Model to create readiness for becoming a patient-centered medical home (PCMH). Currently, Project Better Care encompasses 11 small primary care practices and has tracked data for approximately 800 patients with diabetes.
One new element developed recently under Project Better Care is the creation of a “portal,” or chronic disease registry, to help drive quality improvement efforts. The portal pulls information about diabetes care into an easily accessible online system from a provider’s electronic medical record system (EMR). The last primary care practice without an EMR is in the process of choosing one to implement.
Practices are now transitioning to make looking at their own quality data a regular part of their quality improvement strategy. The three different components of the portal help providers examine quality improvement. First, the circle dashboard gives a snapshot of where a practice is in terms of measures like body mass index captured, tobacco screening, and blood pressure less than 140/90. Providers can look at the whole practice or measures associated with individual clinicians. Trend data over time are also available. Finally, providers have the ability to compare their data to Healthcare Effectiveness Data and Information Set (HEDIS).
Katie Dyer, data analyst for CTHA, believes that transformation at the practice level is around the corner. “Once practices know how they are performing, they can begin to see how to improve chronic disease self-management and coordination of care,” said Dyer.
Dr. Nelson also sees the change that quality data are spurring. “Doctors are very competitive; they want their rates to improve. When you start making a point that every patient gets a foot exam, practices know it’s good for patients, and they can see their efforts aren’t wasted. When practices move the needle, they feel good. It takes work to do this kind of quality improvement, but the portal makes the practices focus,” said Nelson.
Representatives from the 11 Project Better Care practices convene quarterly for a learning collaborative. Said Dr. Nelson, “Providers are finding new ways to do old things at the learning collaboratives. There’s such energy and excitement in the room. They come away with tools to help patients.” For example, one practice developed a diabetes care flowchart and quickly shared it among PBC practices. “The small practices aren’t isolated any more, and it’s making a difference,” said Dr. Nelson.
The ultimate goal is to have practices in Project Better Care attain PCMH status. The patient-centered medical home emphasizes care coordination and communication. PCMHs can result in higher quality, lower costs, and improved patient experience of care. There are even more opportunities for expansion in the future. Said Renee’ Frazier, CEO of CTHA, “The goal is to expand in our market, or even statewide.”