Team-based approach helps patients better control type 2 diabetes

Tanya Albert Henry , Contributing News Writer

Nearly one in four patients who walks through the door of a suburban Chicago community-based health clinic has type 2 diabetes and the clinic’s team-based approach in managing the condition—from pre-visit laboratory testing to the daily huddle—has gone a long way in effectively managing these complex patients, including helping to control A1C levels.

An AMA STEPS Forward™ module explains how team-based approaches like this can help physicians better manage patients with type 2 diabetes, including improving patients’ glycemic control and preventing complications from the disease. The module outlines six steps practices can take to implement a team-based approach and provides answers to common questions physicians may have about helping patients manage their condition.

This kind of team-based approach has been used at Oak Forest Health Center where patients receive treatment regardless of their ability to pay for care. The practice leaders streamline care before patients even enter the exam room. For example, with more than 15,000 primary care visits annually, the practice began encouraging patients to visit the laboratory for tests before seeing their physician.

A team member even performs reminder calls for patients who have pending lab orders, such as A1C, lipid and urine protein. Meanwhile, in the clinic, medical assistants (MAs) are getting ready by printing the patient schedule for each team a day or two before patients arrive. The MA also notes the A1C value for each patient on the summary sheet.

On the day a patient is scheduled to come into the clinic, the medical team huddles with the schedule and summary sheet to share information and set expectations for each visit. When the patients check in, they receive a self-management goal survey to fill out. Once in the exam room, MAs will administer Ambulatory Health Risk Screen tests to the patient.

With all this work completed before the patient and physician meet, the doctor can easily discuss test results, home blood-glucose test logs and self-management goals, such as weight loss, decreasing A1C, making lifestyle changes and taking medication regularly. The results are recorded in the electronic health care records, allowing physicians to celebrate patients’ successes and encourage improvements where needed.

And if an Oak Forest Health Center patient is diagnosed with type 2 diabetes, systems are in place so they are referred for education about the condition and receive care management visits with a registered nurse. Patients also are connected to social services they may need to help with needs beyond clinical care, such as vouchers for fresh fruits and vegetables for patients who have food insufficiency.

This teamwork and planning ahead has allowed the clinic to better care for diabetes patients, especially when it comes to helping those who have trouble controlling their blood sugar levels, said Ezike Chukwuemeka, MD, an internist at Oak Forest Health Center.

“One case in particular that comes to my mind involves a woman with chronically uncontrolled diabetes who was complaining of having ‘shakes’ when her blood sugar reaches 200 mg/dL. Through CM visits and diabetes education, we were able to successfully bring her diabetes under control and her A1C under 7 percent,” Dr. Chukwuemeka said. “We would not have been successful without a team effort.”

The AMA STEPS Forward module offers six steps to help practices develop an efficient team-based approach like this one to manage diabetes.

Engage your team. Include front desk staff, medical assistants and other care providers in meetings so everyone is on the same page and understands the importance of improving how type 2 diabetes is managed in the practice.

Evaluate the impact of poor glycemic control among patients in your practice. Analyze practice data to determine how many patients have poor glycemic control and then ask each team member to identify the negative consequences of poor glycemic control—such as delays in the schedule because of prolonged visits. Physicians should also ask team members to identify the benefits of improving control.

Choose one aspect of diabetes care to address first. So the team doesn’t become overwhelmed, identify one area for each team member to focus on in caring for patients with diabetes. For example, screen for depression, medication adherence or help patients understand their numbers.

Pilot an intervention with your team. Once the team has chosen something to focus on, create a Plan-Do-Study-Act cycle to perform small tests on specific changes for quality improvement purposes. Post a tick chart on the wall where staff can see the progress. For example, one project goal may be increasing the percentage of patients referred for diabetes education. To meet that goal, create a standing order for diabetes education referral.

Optimize medications. Some patients may be on antidepressants, sulfonylureas or steroids that cause weight gain. Look at their medication lists and see if there may be substitutes.

Engage patients in their treatment plan. Patients are more likely to stick to the plan if they helped design it. Have shared decision-making conversations, ask patients to repeat back what you’ve discussed, ask “what questions do you have for me” and provide education tools for patients and their families to review at home.

The free module may be completed for continuing medical education credit. The AMA’s STEPS Forward collection features 50 practice-improvement modules. Several come thanks to a grant from, and in collaboration with, the Transforming Clinical Practices Initiative (TCPI).

Several modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve large-scale health transformation through TCPI’s Practice Transformation Networks. The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support by way of STEPS Forward resources to enrolled practices. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules.

In October, the AMA announced a multistate effort aimed at reducing the incidence of type 2 diabetes nationwide. Building off of its initial work in California, Michigan and South Carolina, the AMA is launching similar statewide efforts in eight additional states. The Association will work with state medical societies in Maine, Maryland, Mississippi, New York, Ohio, Oregon, Pennsylvania and Rhode Island to further develop models to prevent new cases of the disease. Learn more about Prevent Diabetes STAT™, a national collaboration between the AMA and the Centers for Disease Control and Prevention launched in 2015.