Filling Gaps in Diabetes Care With the Retail Clinic

Growth in retail health clinics reveals unmet medical needs for Americans who lack insurance, who cannot leave work, or who have disconnected with the health system. This growing sector of the health system is diagnosing and treating diabetes cases that would otherwise be missed.

The nation’s challenge with diabetes goes beyond the needs of the 22.3 million Americans who have been diagnosed with the disease. Achieving population health means reaching the estimated 8 million who are undiagnosed, and the 86 million more who have prediabetes before they progress.

The question is, how to find them? Type 2 diabetes has no symptoms in the early going, so its discovery likely happens when patients seek care for something else—a sinus infection, an ear ache, even a flu shot.

That’s where the retail clinic is filling a void. For patients without insurance, who cannot take time off work, or who lack a family doctor, clinics in grocery stores or a local pharmacy are offering care that would otherwise not be given, according to speakers at the opening session of Patient-Centered Diabetes Care, presented by The American Journal of Managed Care Thursday in Teaneck, New Jersey.

Eileen Myers, MPH, RDN, and Cathleen McKnight, DNP, on behalf of The Little Clinic in Kroger Stores, and Kristene Diggins, DNP, of CVS Health’s Minute Clinic, presented examples of how the retail model meets the needs of persons with diabetes, by being available whey patients are and by building trust—through customer service and cost transparency.

“If we look at all of the retail clinics, you will see the mission of access and affordability,” Myers said. Over the past decade, the retail clinic foot print has grown; The Little Clinic now operates 194 locations in 10 states and Minute Clinic is in 49 states. Speakers for both clinics say they are determined to not be fragmented from the rest of healthcare--quite the opposite. They nuture referral relationships for complex cases and are developing electronic health records to track the many patients they see.

The convenience of the retail setting makes it ideal for the constant follow-up that diabetes care demands. The Little Clinic’s pairing with a grocery chain lets the person with diabetes to enjoy an ongoing relationship with a dietitian.

After an initial assessment, Myers said, “It’s not just an interaction during a patient visit, but a friendly ‘hello’ when people come in to do their grocery shopping each week.”

Myers said The Little Clinic provides 4 foundations of diabetes care: weight management, tobacco cessation, nutrition, and immunizations. But speakers from both clinics said their emerging niche is finding those cases of diabetes that have been missed by others—sometimes for years. “A person who comes through with a third positive UTI (urinary tract infection) probably has more going on,” Myers said.

Diggins shared the story of her clinic’s duty to screen commercial truck drivers for their license renewals. One provider found a driver with a glycated hemoglobin (A1C) of 12%. That level was so high that he had to be sidelined until he could work with a primary care physician to bring it under control.

How do patients get to this point? McKnight explained how the diabetes patient who visits the retail clinic is one who has often disconnected from the healthcare system.

“Of those patients who come into the clinics, 56% don’t have a primary care doctor,” she said. “If we follow up with them, they haven’t been to a primary care practice in a year, and are no longer considered patients in that practice.”

Diggins said Minute Clinic’s location within CVS offers the opportunity to create a collaborative model with the pharmacist, and to deploy techniques of motivational interviewing to counsel patients on drug therapy.

“Forty percent of chronic disease medications are never refilled,” she said. “That doesn’t surprise me.” If diabetes doesn’t present any symptoms and patients don’t understand what the medication does, “It’s just deducting from my grocery bill.”

She reviewed a process called the “5 A’s”, from the Agency for Healthcare Research and Quality, which call for engaging the patient and preventing clinical inertia: assessing how much the patient knows about diabetes, advising them and developing a partnership, agreeing to set goals, assisting the patient in developing a long-term plan (including identifying barriers), and arranging for follow-up.

Education about why medication is needed must always be paired with lifestyle lessons. “The best outcomes are when we continue to look at behavioral modification,” Diggins said.

Building trust with patients, and educating them about the consequences of failing to care for themselves is crucial, she said, and the retail setting offers of window of opportunity to engage those who the healthcare system has thus far failed to reach.

“The old expression, ‘just tell me what to do doc,’ gets us in trouble with this disease,” Diggins said. It becomes easy to be complacent because the causes of diabetes are all around us.

“Diabetes,” she said, “is almost part of being an American.”

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