Care of diabetes in this country is far from optimal. Statistics suggest that only about half of all Americans with diabetes have their disease under control, and the situation threatens to become more desperate if the incidence of diabetes continues to increase as expected. However, studies show some nontraditional models of care delivery make quality improvement of clinical, as well as process, measures possible—even in some of the toughest populations.
One critical message from such studies is that diabetic patients require much more time with the clinician than the typical office visit allows.
However, some innovators get around this issue by training nonphysician specialists (e.g., nurses or pharmacists) to take charge of diabetes care, especially for those patients who struggle with the disease.
How to pay for such nontraditional models in the current system of reimbursement remains a stumbling block to large-scale implementation, but data suggest that under the right circumstances, diabetes clinics managed by both nurses and pharmacists offer several advantages.
Approach slashes utilization
Mayer Davidson, MD, director of the Clinical Center of Research Excellence at Charles Drew University in Los Angeles and a professor of medicine at the University of California, Los Angeles, recently reported on the results of a nurse-directed diabetes program he developed and implemented at a public health clinic in Los Angeles.1 In that model, the Diabetes Managed Care Program (DMCP), Davidson trained a registered nurse to follow patients according to detailed treatment algorithms derived from evidence-based guidelines.
“She would see the patients in a special clinic, follow them on the phone, and schedule visits with them,” says Davidson, explaining that the nurse was charged with keeping close tabs on glucose levels, lipids, blood pressure readings, foot screenings, referrals for eye exams, and all of the other key aspects of diabetes care. “She made sure they got the kind of treatment that you can do if you have the time and the expertise to do it.”
Further, under the supervision of Davidson, the nurse was also able to direct treatment, including changes in medication.
“All of the things you should do, she made sure got done,” says Davidson. “I was available by phone [for consultation] at all times, but I would also meet with her once a week and sign the charts.”
To assess the program’s effect on utilization, investigators compared the emergency department (ED) and hospital utilization for 331 patients during the program’s intervention year and the year prior to implementation.
What they found was a 51% reduction in utilization during the intervention year, and dramatically reduced expenses.
Hospital and ED charges dropped from more than $129,000 in the year prior to the intervention to just $24,630 during the intervention year.1
Clinical measures also improved, according to Davidson. “When [the nurse] started with the patients, their average HbA1c was 8.6, which is about average for the country,” he says. “And she got [these readings] down to about 7.”
Time is critical
A number of factors contributed to the success of the program, according to Davidson. He emphasizes that the nurse was highly skilled and well-acquainted with the types of cultural issues that can affect compliance.
“She is Hispanic, and 75% of our people were Hispanic, so she was able to achieve a rapport with them that a [non-Hispanic] physician, frankly, can’t do,” says Davidson.
Additionally, the ability to make timely treatment decisions was critical as well, he notes.
Perhaps most important, however, was the amount of time the nurse was able to devote to making sure that all of the recommended care tasks related to diabetes care were looked after. “When a patient comes to see a doctor, he [or she] has all these other concerns, and the doctor has limited time,” says Davidson. “Here, we have a situation [in which] this specially trained provider can spend time with the patient, only focusing on diabetes and what needs to be done.”
Another critical factor is accessibility, says Maria Castellanos, RN, the nurse who primarily delivered the patient care as part of Davidson’s study and continues to work within the DMCP model to deliver care to diabetes patients at county clinic sites. “These are people who make the minimum wage, so if you are going to ask them to take a half-day off—which is typical of many clinics—then we are going to have a problem,” she says. To get around this obstacle, appointments are scheduled in the early morning hours, as well as in the evenings and on weekends.
Further, when appointments are broken—a common occurrence in this population—an administrator makes every effort to reschedule the appointment before the end of the day. “These are low-income people. That is why we give them options,” Castellanos says.
Model is versatile
In fact, although he hasn’t always had the funding to collect data, Davidson has replicated the model in many other settings and socioeconomic groups. The challenges presented can differ, but the model adapts easily to different circumstances, he says. “In [the study population] the nurse was able to follow 150–175 patients [at a time],” says Davidson. “In a middle-class setting, a nurse can follow up to 250 patients, because many of the [required care tasks] can be done over the phone or via fax machines.”
However, the intervention needs to be ongoing to remain effective, Davidson says. Studies have shown that patients sent back into usual care typically regress to where they were before the intervention within six months. Consequently, Davidson suggests that the best way to implement the model is not in a specialty clinic, but to have the trained nurse on site, within a regular adult clinic, so that he or she can see diabetic patients on an ongoing basis.
Davidson has been running a DMCP program based in a hospital setting for at least eight years, but financial pressures have thus far gotten in the way of his efforts to replicate the model on a much larger scale. “You don’t get paid to take care of patients by phoning them or faxing things to them, and we don’t get reimbursed for [nurse visits] with patients, so in private practice, people have not wanted to do this,” he says. “I would have thought that health plans would want to do this, but their argument is that patients aren’t around long enough for them to reap the benefit, and therefore they have been resistant, although they are getting a little better.”
Life challenges take a toll
Linda Jaber, PharmD, an associate professor at Wayne State University in Detroit, has also had success working one on one with disadvantaged diabetic patients. She has accomplished this by working with a group of internal medicine physicians who refer some of their more complicated diabetic patients. The patients need to meet certain criteria to be referred to the Pharmacist Managed Diabetes Clinic (PMC), says Jaber. “They may have uncontrolled diabetes or noncompliance issues, or they may be on multiple medications and in need of a simplified drug regimen,” she says, adding that she rarely works with newly diagnosed patients or patients who are managing their disease reasonably well.
Once a patient is referred, Jaber typically meets with him or her as often as weekly or biweekly for three to five months—whatever is required to get the disease under control.
The model is similar to the DMCP in that it includes a hefty dose of patient education, close monitoring of all of the key parameters involved with diabetes care, and adjustments in medications as needed.
In addition, Jaber uses written patient contracts to get patients to agree to work toward goals that they have established together.
“I tell patients that all I am going to do is give them advice and guidance . . . but they will be doing all of the work,” says Jaber. “Then I prioritize things based on [my initial] session with them.”
For example, if a patient has never learned how to prevent or deal with impending hypoglycemia, that is likely to be high on the priority list of things to review.
“Education is the key because they can prevent it; they can treat it,” says Jaber. “It becomes not as scary when you talk about it.” Other matters that Jaber frequently addresses early on are myths about diabetes and barriers to proper management of the disease.
“Compliance is a huge issue with this population, but in many cases you can identify the source of the problem,” says Jaber, noting that financial problems may prevent patients from obtaining needed medications, or they may be afraid of insulin because they lack understanding of their disease. “It is not that they do not care. They do care, but you have to help them sort things through,” she says.
PMC boosts care and outcomes
Studies have demonstrated that care through the PMC improves glycemic control as well as adherence to diabetes care guidelines.2 However, although some physicians are enthusiastic about the approach, this support is not universal, Jaber says. “When I did my first study [of the approach], it was obvious to me that the success of the program came because of my expertise on the use of medications—my aggressive approach to using combinations of medications rather than one,” she says.
However, some of the physicians involved with that effort were uncomfortable with her involvement in the medication management aspect.
“They had no problem with me sitting down and providing education to patients, but once I stepped into the medication area, they were nervous because they felt I had stepped outside my area,” Jaber says.
However, many physicians are supportive of the approach and appreciative of her knowledge and experience with pharmaceuticals, she adds. As with the DMCP model, a critical element in the success of her model is time, Jaber says. In both cases, the patient’s initial visit with a clinician lasts for an hour or more, and physicians rarely have that kind of time to devote to a single patient.
She says the extra time would benefit patients with prediabetes, as well—perhaps enabling them to prevent development of the disease in the first place. Consequently, as she is only available to work in the clinic one day per week, Jaber is trying to obtain funding for another pharmacist to work there during the rest of the week. “There is so much we can do prior to a patient having diabetes,” she says. “And I could do much more of that if I had someone else to rely on.”
1. Davidson M, Ansari A, Karlan V. “Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population.” Diabetes Care 2007; 30:224-227.
2. Nowak S, Singh R, Clarke A, et al. “Metabolic Control and Adherence to American Diabetes Association Practice Guidelines in a Pharmacist-Managed Diabetes Clinic.” Diabetes Care 2002; 25:1479.