How a massive health system prioritizes chronic disease prevention

Sara Berg, MS , News Editor

With about 4.5 million patients with prediabetes and hypertension across 22 states and 94 hospitals, leaders at Trinity Health—a nonprofit health system based in Livonia, Michigan—saw the need for evidence-based care models to tap into right away.  

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That’s why, in 2018, the health system began working with the AMA to implement diabetes prevention program (DPP) lifestyle-change program referrals in five practice sites. Then in 2019, Trinity adopted the AMA’s M.A.P. BP Improvement Program as their systemwide quality effort on hypertension. 

The AMA has developed evidence-based tools and resources to support physicians and care teams in diagnosing and managing their patients’ high blood pressure. These resources are available to all physicians, care teams and health care organizations as part of Target: BP™, a national initiative co-led by the AMA and AHA. 

Additionally, the AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies.  

Trinity Health’s Kevin Taylor, MD, said stepping up engagement on diabetes prevention programs “really is a way of embracing our community, particularly our underserved community, and help them in a way that’s very meaningful and strategically going to have an impact.” He is an internist and the system’s senior medical director of population health. 

Standardization is crucial for delivering effective care across such a large footprint. Through the AMA’s M.A.P. BP Improvement Program, Trinity could use well-proven, standard models of care delivery that allowed physicians and their teams to easily implement. 

“The work the AMA is doing on hypertension and the DPP provides a population health template that we can endorse and spread across our many health care networks,” Dr. Taylor said in an interview during an education session at the 2019 AMA Annual Meeting. “Because these are well-proven models, and have the evidence to show that they work, we don’t have to develop new models of care for these patients.” 

Trinity Health first created a DPP pilot program identifying people with prediabetes at one of its sites, Mercy Medical Group in Chicago. To help, the AMA provided phone calls, education and taught teams how to retrieve data to identify patients.  

“I can truly say this is one of the first times we’ve ever been able to pull data out of our system for a community-focused program,” said Daniel Vicencio, MD, chief medical officer of quality at Mercy Medical Group. “People know that pulling data out of your system is tantamount to a minor miracle sometimes.” 

“We were able to pull data out of our systems and identify those patients, followed by getting the patients attuned in this particular call,” he added.  

Mercy identified a small group of African American patients over the age of 65 because preventing type 2 diabetes would help minimize other comorbidities. After a month and a half of this first cohort, 10 patients lost 20 pounds.  

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“Implementing a disease-management program that impacts a large percent of our primary care patients will be met with resistance. ... Not everyone is going to jump on board right away,” said Dr. Taylor. He added that there are always “early adopters, individuals who embrace the vision, and are able to implement the program in their practice. You want to identify these individuals early on and support them as champions for this work.” 

Administrative leaders also face barriers. For example, in one network there were five other initiatives that were identified as high priority by their quality-management team. The medical group leadership needed to prioritize their efforts and identified hypertension management as a top priority. This allowed the team to “figure out an implementation timeline that would work for them,” said Dr. Taylor.  

The AMA and Trinity Health are continuing to work together to reduce the prevalence of hypertension and type 2 diabetes.