1. John Peter Smith FMRP, Fort Worth, Texas
Diabetes Case Management Program Elizabeth Carter MD, Anita Webb PhD, Richard Young MD
John Peter Smith FMRP, Fort Worth, Texas
Background
Methods
FY 2008 patients: 858
A1C average at admission: 9.2
Current average A1C: 8.6
70% of patients have maintained or improved A1C
Eye Check up in past 12 months: 55% (473/858)
Foot exam in past 12 months: 56% (484/858)
80+% PCP compliance with the defined clinical protocol
84% of providers attended the educational round tables
Results
A successful 2007 program at three community health centers provided the template & evaluation data.
Plan of Expansion Across Network:
Eight community health centers participated
Group visits
Team care
Teach patient assessment and management skills.
Physician guidelines, protocols and tools
Monthly IT reports with latest A1c, LDL cholesterol, eye exam, foot exam, and immunization status
Patient incentives:
*Reduced copays
*DIABINGO
*Pharmacy vouchers
A reliable medical home is critical for patients with chronic medical problems such as diabetes.
In an effort to ensure this home, our large healthcare network targeted diabetes management as a 2008 critical success factor for quality improvement.
Case management and disease management:
Have proven effective for improving glycemic control, and
Have shown promise for improving patient care and outcomes.
*Expand the program to the entire network.
*Include RN case managers and a case clerk
for every large center.
*Evaluate the protocol for adjusting medications
by a certified diabetic educator.
*Expand the employee life style improvement program.
*Develop community partners throughout the county.
Recommendations
Research Question
Can improvements in access and health services lead to improved health outcomes for diabetes?
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