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Diabetes and the Patient-Centered Medical Home

Evidence-Based Diabetes ManagementMarch/April
Volume 19
Issue SP2

There have been efforts to overhaul the healthcare system for decades. At more than 7% of the GDP,1 healthcare is big business. And, while healthcare spending has increased, diabetes is on the rise. With nearly 26 million people with diabetes and another 79 million with pre-diabetes, literally 1 in 3 people are impacted by the disease with an economic impact of approximately $174 billion in 2007.2 All the while, people got fatter and more sedentary, and heart centers and dialysis centers have gone up like shopping malls. Clearly, something needed to be done differently.

In the 2001 Institute of Medicine report, entitled Envisioning a National Healthcare Quality Report,3 a new phrase was coined—patient-centeredness. A collaboration among clinicians, patients, and their families (when appropriate) that takes into account the desires, needs, and preferences of the patient, in addition to providing patients with the knowledge and support they need to participate in their own care and make decisions about their care. The report emphasized meeting the patient’s changing needs over the life cycle—needs about staying healthy, getting better, living with illness or disability, or coping with the end of life.4


Enter the patient-centered medical home (PCMH). In a PCMH, each participant has a care coordinator and a team that takes collective responsibility for providing and/or arranging for the patient’s individual healthcare needs. Episodic care is replaced by coordinated care and a long-term healing relationship with a high level of accessibility. Communication among the patient, their family, clinicians, staff, and care providers such as a home care nurse, pharmacist, or mental health provider is timely and efficient. The latest information technology is used to prescribe, communicate, track test results, obtain clinical support information, and monitor performance ().5

The idea is to reduce total cost of care by emphasizing prevention, improved practice efficiencies, reduced unnecessary testing and referrals, and reduced preventable emergency department (ED) visits and hospital admissions. Care teams are mobilized to better manage complex patients using the right provider at the right time in the right way with everyone working at the top of their licensure.

The idea is to reduce total cost of care by emphasizing prevention, improved practice efficiencies, reduced unnecessary testing and referrals, and reduced preventable emergency department (ED) visits and hospital admissions. Care teams are mobilized to better manage complex patients using the right provider at the right time in the right way with everyone working at the top of their licensure.

Table 1

Efforts related to the implementation of the PCMH have been done all across the country in large and small settings since the ’90s.6 Yet, there is still a lot to learn about how to evaluate them. Improvements in diabetes care in glycated hemoglobin (A1C), blood pressure (BP), and low-density lipoprotein (LDL) or bundled scores have been reported (). Additionally, there has been documentation of improved patient/staff satisfaction and patient selfmanagement.6,7

Out of these national projects grew other state efforts. In Minnesota, the redevelopment of the PCMH is part of the health reform legislation passed in 2008. As of the writing of this article, there are 214 PCMHs in Minnesota, most of which are in the Minneapolis-St. Paul metropolitan area, and most are parts of large integrated health networks.8

In 2010, to provide some support for smaller clinics to become certified, the Minnesota Department of Health posted a request for proposal for The Safety Net Primary Care Transformation Grant to provide expert support and facilitation for safety net clinics toward the implementation of the PCMH. Four sites were selected to participate and the author served as the consultant to provide the expert support to these 4 sites.

All of the 4 sites served the safety net population of their respective areas. Each had started toward becoming a PCMH, but there is still work to do. The process began with a gap analysis as the first step, allowing them to develop individualized work plans specific to their respective sites.

Three of 4 sites identified people with diabetes as their initial target population and the fourth site identified high utilizers, many of whom also have diabetes. Diabetes is a high-cost, high-risk, multi-factorial chronic condition, which requires a care team, and the PCMH is well suited to meet the needs of those patients who have the disease. The diabetes educator is often the designated care coordinator, and other members of the care team will participate in carrying out the care plan as appropriate.

Care Planning and Care Coordination

The care plan is established collaboratively with the patient, with goals appropriate for their needs at the time, and will change as needs change. Everyone on the team has access to the latest care plan and can update it based on their respective interaction with the patient. Once goals are reached, ongoing support is provided to maintain the progress and to prevent relapse. Additionally, the care coordinator connects the patient to community resources, such as diabetes support groups, online resources, or a walking group.

This ongoing tracking and monitoring is an essential component of the PCMH. Each PCMH as a registry or a list of all their participants in the PCMH generated from the electronic health records that can be stratified based on a predetermined set of parameters. For someone with diabetes, those parameters are most often A1C, LDL, BP, and/or body mass index, and may also include the date of the last clinic visit, date of last laboratory tests, date of last eye examination, smoking status, comorbidities, and any other relevant data points. This information is reviewed by the care coordinator along with the primary care physician (PCP) and the care team to determine the current status of the patient, update the care plan as needed, and track tests, referrals, and any transitions of care. This is often referred to as “working the list.” If gaps in care are noted, the care coordinator will contact the patient to schedule an appointment with the appropriate care provider or make certain the patient follows up on a recommendation, such as visiting their eye doctor.

The complexity of care coordination increases as patient needs increase and always takes into consideration the “whole patient,” addressing all preventive services and other health issues. This is the core of the PCMH.

Standardization of Work Flow

A key success factor is standardization of the clinic work flow. When a visit to the PCP is scheduled, the “pre-visit planning” begins. The care coordinator encourages the patient to come in a few days ahead of time for any laboratory tests that are due, and any other known issues that can be addressed ahead of time will be taken care of at that time. This will ensure that the PCP has the information needed to have a more meaningful conversation with the patient about their current status and any changes that will need to be made in their care plan. All too often, laboratory tests are done at the time of the visit and results are not available until days later, losing the opportunity for those teachable moments.

On the day of the visit, there is a similar set of tasks set in motion, often referred to as “during visit” care. Having a standardized process ensures that critical things are not missed. Once the clinic visit is done, an “after visit summary” may be given to the patient that reiterates any agreed-upon goals and recommendations.

After the visit, the care coordinator will follow up on any issues brought up during the visit. This is often referred to as ongoing support or “between visit” care. For example, if there have been any changes in medication, the care coordinator/diabetes educator will continue to work with the patient to monitor blood glucose values and adjust medications according to a set of protocols.

Health Information Sharing and Quality Improvement

All of this is dependent upon a process whereby the health information follows the patient as they move through the system and is accessible to every care team member, including the patient. Although the PCP and the care coordinator are ultimately responsible for the overall care plan, different care team members may add to the plan. For example, a registered dietician uses the overall care plan as a base for an individualized meal plan created in collaboration with the patient. This meal plan is then added to the care plan so that all team members are aware of it.

Or consider this. If a participant in a PCMH enters an ED, imagine the PCMH and name of his care coordinator are in his record. The ED staff will care for him as appropriate, but they would also contact his care coordinator who would then follow up with him to ensure that he gets what he needs to ensure that any future preventable ED visits are avoided. If a patient is not part of a PCMH, with availability of his health information and in collaboration with the patient, the ED staff could connect him with a PCP before he leaves. The result is a reduction in total cost of care.

Table 2

Sound impossible? All 3 of the care systems that experienced improvements in diabetes care using care coordination and care planning along with payment incentives for doing the work also experienced cost savings through significant reduction in ED visits and inpatient admissions ().6,7

While using the health information on an individual basis helps track progress of a specific patient, population level data should be routinely reviewed to determine progress across the entire population. Diligence about using population-level data is critical in driving improvements in care. Examples of such population-level measures are A1C rate and levels, BP, LDL rates and levels, and patient satisfaction. The utilization rates of the ED, hospital admissions, and readmissions will be needed to determine any change in total cost of care.

Lessons Learned and Managing Change

However, none of this comes easily and without a lot of work. Things will happen. No matter how hard you try, there will be other things that will compete for time, and extenuating circumstances, such as budget constraints and staff turnover, that may cause a shift in corporate priorities. Time will always be an issue, especially when you want involvement of providers. Leadership support for the time to do the work is essential. And, it is critical to review the aim regularly to determine whether to stay the course. If leadership support wanes, it will be extremely difficult for the team to succeed.

But, even with leadership support and the time to do the work, there will still be some resistance to change. When given a choice, we all tend to fall back on what’s familiar. The first step in the process of changing behavior is to “unfreeze” the existing situation. However, our openness to change is also affected by environmental influences, personal factors, and attributes of the behavior itself. Some say change is cyclical, taking relapses into account.9 The team leader will need to assist the group through these relapses by facilitating a discussion about what they learned and what they could or would do differently. Thus, focusing on the change agent and the importance of this role cannot be underestimated.10 Finding the right team leader and champion will be critical to your success.

And, having the confidence to make the change and operate in a new way is also an issue. Clearly, with changes in roles and responsibilities, many individuals at these sites needed to learn new skills. Often, the change looks good on paper, and makes rational sense, but the team does not have the skills to implement it. The team may get so excited about a change that they bypass the necessary training and preparation, finding themselves facing either resistance or little enthusiasm.11 To avoid this potential problem, it is important to include those members of your team impacted in the change right from the start, so everyone has ownership in the process and the solution.

So Where Are They Now?

Two of the Minnesota sites are certified as PCMHs. One was given a variance on their care planning, which meant they needed to provide staff training, collaborative goal setting, and care planning. One site was busy opening a new clinic site and there was a strategic decision to delay PCMH certification until they were able to imbed the principles into all 4 of their clinics. They hope to submit their application within the year.

The fourth site is reexamining its vision without moving to certification as a PCMH at this point in time. Changes in strategic direction and loss of some key individuals caused it to halt the process toward certification for now. However, both of these sites did improve on all the processes considered core to becoming a PCMH.


Should you choose to adopt the PCMH, you need to recognize that there will be early adopters and there will be skeptics and it will most likely require a culture change for your organization. Starting small with a targeted population, such as diabetes, is helpful in allowing everyone an opportunity to test this change before implementing it with all patients.

You will likely struggle with IT and you can expect confusion as to how the PCMH and care coordination fit with the day-to-day work flow. And, everyone will struggle with staff turnover at some point. This will make it especially necessary to maintain organizational memory of the process.

In summary, the core concepts of the PCMH have demonstrated results. However, to get there, leadership support for not only the concept but also for the work is essential. Although the application and certification are important, the real results come from embedding the principles in your standard operating procedures. The PCMH becomes the way you do your work. Author Affiliation: From Halleland Habicht Consulting, LLC, Minneapolis, MN.

Funding Source: None.

Author Disclosure: The author reports serving as a consultant for Lifescan and Novo Nordisk, employment with Halleland Habicht Consulting, LLC, receiving lecture fees from BD, Lifescan,and Novo Nordisk, and attending the American Association of Diabetes Educators and American Diabetes Association meetings.

Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Address correspondence to: Teresa L Pearson, MS, RN, CDE, FAADE, Halleland Habicht Consulting, LLC, 33 South Sixth Street, Minneapolis, MN 55402. E-mail: tpearson9@comcast.net.References

1. US Government Spending website. www.usgovernmentspending.com. Accessed December 2, 2012.

2. Centers for Disease Control and Prevention website. 2011 National Diabetes Fact Sheet. www.cdc.gov/diabetes/pubs/factsheet11.htm. Accessed December 2, 2012.

3. Hurtado MP, Swift EK, Corrigan JM. Envisioning the National Health Care Quality Report. http://books.nap.edu/catalog/10073.html. Accessed December 2, 2012.

4. Foundation for Accountability. Reporting Quality Information to Consumers. Portland, OR: FACCT; 1997.

5. NCQA website. www.ncqa.org. Accessed December 2, 2012.

6. Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes. Diabetes Care. 2011;34:1047-1053.

7. Grumbach K, Bodenheimer T, Grundy P. The outcomes of implementing patient-centered medical home interventions: a review of the evidence on quality, access and costs from recent prospective evaluation studies. http://www.pcpcc.net/files/evidenceWEB%20FINAL%2010.16.09_1.pdf. Accessed December 2, 2012.

8. Minnesota Department of Health website. Health Care Homes (aka Medical Homes). http://www.health.state.mn.us/healthreform/homes/index.html. Accessed December 2,2012.

9. Lippitt R, Watson J, Westley B. The Dynamics of Planned Change. New York, NY: Harcourt, Brace and World; 1958.

10. Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice. 1982;19(3):276-288.

11. Robbins S. Organizational Behavior. 10th ed. Upper Saddle River, NJ: Prentice Hall; 2002.

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