Diabetes costs an estimated $3 billion each year in Oregon due to higher health care costs and reduced productivity (Oregon Health Authority, 2015). A person with uncontrolled diabetes is at risk of serious health complications such as heart disease, kidney disease and limb amputations. Improving glycemic control has proven to help reduce readmissions and ED utilization rates. Evidence has shown that for every 1 point reduction in HbA1c, the risk of developing eye, kidney or nerve disease is reduced by 40 percent, while the risk of heart attack is reduced by 14 percent (HRSA, 2012). Yet, many patients fail to meet treatment goals for lowering HbA1c. Issues related to patient compliance and medication adherence are associated with adverse clinical outcomes for patients with diabetes. Furthermore, many older patients with diabetes face additional barriers to disease management, including cognitive dysfunction, depression, physical disabilities and polypharmacy. Clinic visits, even when a patient is compliant with provider recommendations, do not provide enough time to adequately address the many complicated issues related to diabetes management such as nutrition therapy, insulin management , behavioral health and health literacy needs.
"The Mobile Diabetic Clinic project helped us better understand barriers faced by some of our vulnerable patients in managing diabetes and other chronic conditions. Meeting with a patient in the home environment allowed us to gain better insight into a patient’s situation to help set realistic and attainable goals and to see if change was needed in a patient’s medications and care plan. Some patients were more comfortable meeting in the clinic or over the phone. This project allowed us the flexibility to match care to a patient’s individual needs to improve patient engagement." Rebecca Lundgren, RN
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- The St. Charles Mobile Care Clinic provided ongoing clinical support to help patients with diabetes gain self-management skills, identify barriers to care and make lifestyle modifications to improve health outcomes. The mobile clinic borrows concepts from outreach and telehealth programs that have proven successful in helping vulnerable patients become more engaged in their own care while also enabling providers to make timely adjustments to treatment plans.
- Key components of the mobile care clinic include: patient home visits with a Certified Diabetes Educator/ RN and Community Health Educator to assess patient and environment while providing needed care; weekly phone calls and/or electronic communications from a RN Care Coordinator to discuss progress and identify needs; education and care provided as needed by a Pharmacist, Dietitian, Community Health Educator and Behavioral Health specialist; regular reporting to the PCP of patient progress and changes in health status; utilizing Epic tools such as glucose flow sheets and My Chart to track patient progress (please see attached Visio diagram.) In addition, patients can borrow home blood pressure monitors and scales from the clinic for use while enrolled in the program.
- This project was implemented by St. Charles Health System, Inc.
- The St. Charles Mobile Care Clinic provided ongoing clinical support to help patients with diabetes gain self-management skills, identify barriers to care and make lifestyle modifications to improve health outcomes. The mobile clinic borrows concepts from outreach and telehealth programs that have proven successful in helping vulnerable patients become more engaged in their own care while also enabling providers to make timely adjustments to treatment plans.
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The project attempted to:- Lower the rate of patients with uncontrolled diabetes, measured as A1c greater than 9.0%, improving health outcomes and reducing costs.
- Improve patient engagement and self-management skills.
- Reduce emergency department utilization and hospital admissions/readmissions
- Improve the control of hypertension for participants in the program.
- Develop and refine processes and workflows to scale the program across the system.
- Find community partners to approve of survey and assist with collecting data.
- Evaluate data and begin expanding program outreach.
Provided 40 home visits and 25 in-clinic visits to 26 patients who were identified as having poor control of diabetes, with HbA1c greater than 9% and/or were identified by a provider as St. Charles Health System, Inc. 2016 - 2019 COHC Application - Standard Process needing extra outreach to identify barriers and improve engagement in care.
There was an overall positive change in A1C for patients who followed up with at least one HbA1c. The average change in A1C for 18 patients that we were able to follow through subsequent HbA1cs was -2.38% points, which is 0.38% above our goal of 2% average reduction points in A1C.
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- The project improved collaboration between St. Charles Medical Group and the St. Charles Diabetes and Nutrition Services, helping to understand resources that could be shared. The project also allowed for improved understanding for providing team-based care.
- Challenges encountered included staff turnover and staff being diverted to meet immediate needs in the health system. We were challenged to match the staff availability of the diabetes educator with the availability of the patient. Another challenge came from working with hard-to-reach patients who are more likely to no-show and cancel visits.
This project was important to help recognize and work to address gaps in the primary care clinics to be successful in developing innovative models in team-based care in the future.
Of the patients that received visits from the St. Charles Mobile Diabetic Clinic, there was an overall positive change in A1C for patients who followed up with at least one HbA1c.
Patients were introduced to a variety of resources through cross-system information sharing.
This project served adults and older adults with diabetes.