Better Together: Diabetes Care Model

At Michigan Medicine, experts see thousands of patients a year for a variety of ailments. A high percentage of those patients have chronic conditions that benefit from consistent monitoring.

To improve how the organization manages such patients, a new care management model was recently deployed at two ambulatory clinics for people with diabetes.

It’s called the Diabetes Care Model, which aims to target diabetic patients with an elevated HgbA1c. And it does so by faculty and staff in a number of different roles coming together to improve the lives of those they serve.

The Diabetes Care Model group at West Ann Arbor-Parkland Plaza

How it works

Bi-weekly, a report is run in MiChart to find patients who have high A1c levels (hemoglobin that indicates whether or not a patient has diabetes), but whose most recent blood test is older than 90 days. Additionally, MiChart scans the system to see if those patients have an upcoming appointment with a primary care physician or endocrinologist.

“If the patient has an A1c great than 8 and has no appointment scheduled in the next 60 days, we reach out to the patient in an attempt to re-engage them in their care,” said Jan Doolittle, senior nursing director for primary care at Michigan Medicine. “Research shows diabetic patients have higher rates of readmission to the hospital and/or utilize more services due to health complications. This is a perfect population for the care managers to engage with.”

Once the list of patients is formulated, a multidisciplinary team reviews it. This team includes a care navigator — who is a registered nurse, a panel manager clinician and a pharmacist.

“Following these meetings, outreach to the patient will occur and a face-to-face meeting will be scheduled with the care navigator or pharmacist to enroll the patient in the program,” Doolittle said. “Patients may be referred to others, such as a registered dietitian or social worker, if clinically indicated.”

During the enrollment phase, individualized care plans are developed with the patient, who will also identify self-management goals. Care gaps are reviewed, a needs assessment is completed and barriers to care are addressed. Team members also provide patients with resources and recommendations — such as diabetes education classes — to get them on a healthy track and help them achieve their goals.

The nurse care navigator or pharmacist will follow the patient over the phone or with face-to-face visits until their next scheduled visit with the care manager three months after the first visit. The patient will return to see a primary care physician at the six-month mark, when their progress will be assessed and their goals reviewed and reinforced. Patients are discharged from the program once they have achieved their A1C goal.

Members of the Diabetes Care Model team at the Briarwood Medical Group

A successful strategy

To date, this care plan has been instituted in the primary care clinics at West Ann Arbor-Parkland Plaza and with the Briarwood Medical Group. That includes more than 100 patients as of February.

More clinics are scheduled to get on board soon, with Livonia likely adopting the model next month.

“We’re finding enough success that we know this can work across the organization,” Doolittle said. “Our patients say that this program helps keep them stay on track, and when you look at the data, the typical patient enrolled in the program has thus far seen their A1c drop between 0.4 and 1.1 percent. That’s a big step forward.”

Caring ‘for the whole patient’

So why has the program been successful?

“The main reason is because we’ve given our care teams autonomy to make the necessary decisions to manage patients and their chronic disease using a patient-centered approach,” Doolittle said.

For instance, if a patient is meeting with a pharmacist and psychosocial concerns are identified, the pharmacist is empowered to refer and engage a social worker in the plan of care.

Similarly, if a care navigator sees that a patient’s most pressing issues include their eating habits, they may call in a registered dietitian to help formulate a plan.

“Previously, those types of services were only offered if a patient had a physician referral,” Doolittle said. “Utilizing protocols and standing orders has provided the team with the autonomy required to care for the whole patient.”

Building camaraderie 

It’s not just the patients who are benefiting from the new care plan — faculty and staff do as well.

“Everyone’s voice is being heard and we know that our employees feel a lot more engaged when they are involved in care planning as a team,” Doolittle said. “Not only that, but everyone is learning how valuable each team member’s role is. There used to be some ambiguity there.”

In the end, it’s a model that is working for primary care sites across Michigan Medicine — and it may work in other areas as well.

“When you take a team-based approach to helping patients overcome barriers, it’s more likely that you will find success,” Doolittle said. “That’s why we’re proud of this model and hope that it continues to help our patients and employees in the years ahead.”