Overview:
Dr. John Berneike and his team at St. Mark’s Family Medicine implemented a pilot program to improve outcomes for diabetic patients using health IT tools and support provided by the local Regional Extension Center (REC), HealthInsight, in conjunction with staff assigned to the Beacon Community Program.
The Beacon Diabetes Self-Management Care Coordination Program at St. Mark’s used the practice’s electronic health record (EHR) to generate a report of all of their patients with diabetes to assess whether they were up-to-date on required lab, eye, and foot exams, and whether their measures were in control. Patients needing testing were identified and called in for appointments to see their providers.
Using EHR reports, staff identified 15 patients who were at high risk for significant medical problems; these patients were formally entered into the Medical-Assistant led Care Coordination Program. Using “motivational interviewing” techniques designed to facilitate behavior change, medical assistants assessed patients’ barriers to successful diabetes management, and then developed shared care plans with action goals. Medical assistants monitored patient progress with more frequent telephone contact and office visits.
Dr. Berneike and his team developed care coordination templates, “We have a form in our EHR that our care coordinators use to track the patient’s progress, document their outcomes and alert us when follow-up is needed,” said Dr. Berneike. With this data captured in the EHR, the entire care team is able to know each patient’s exact status at any time. All care team members track the patients’ own goals to ensure they provide the right support and encouragement.
In preparation for the program, Dr. Berneike and the lead registered nurse trained the medical assistants to provide this care coordination. HealthInsight’s Care Coordination training also teaches how to assess patients’ readiness to change health behaviors, as well as their confidence to do so. Staff members participate in role play to improve their understanding of how to elicit patients’ fears, problems, and challenges. Medical assistants also receive training to assess health literacy and provide appropriate diagnosis and treatment instructions.
Outcome:
The group of 15 high-risk diabetic patients in Salt Lake City, Utah, experienced significantly improved A1C blood sugar levels as a result of a comprehensive care coordination program. As a group, the 15 patients saw their mean A1C of 9 drop below 7 over a four-month period.
One of the many success stories was a patient named Sydney, whose ability to manage her diabetes was complicated by depression — a condition that the team uncovered by asking specific questions using the motivational interviewing protocol.
With the close coordination and support of the St. Mark’s team, Sydney successful lowered her A1C level from 16 to 7, lost 75 pounds, and went down four pants sizes.
Lessons Learned:
Dr. Berneike credits much of the program’s success to the assistance his team received from their local Regional Extension Center, HealthInsight. “I don’t think we could have done it without their help,” said Dr. Berneike.
Next-Steps/Future Vision:
Building on the success of the pilot, the St. Mark’s team has expanded the care coordination approach to patients with other chronic diseases.