Transforming Population Health for Diabetes and Kidney Disease via Systems of Excellence

Am J Manag Care. 2025;31(Spec. No. 10):SP724

Health care leaders and physicians from University Hospitals convened at an Institute for Value-Based Medicine^® (IVBM) event held in Cleveland, Ohio, on October 23, 2025, to discuss advancements in value-based care and population health with an emphasis on diseases including diabetes and chronic kidney disease (CKD). Speakers shared strategies to reduce the length of stay for postoperative hospitalizations and how fee-for-service resources and value-based care can work together to improve patient outcomes and overall care.

University Hospitals, which hosted the event in collaboration with The American Journal of Managed Care^®, created 5 systems of excellence (SOEs) that reshape the way providers care for patients with CKD, diabetes, chronic obstructive pulmonary disease (COPD), heart failure, and hypertension. Two of the 5 systems of excellence (diabetes and CKD) were highlighted during the panel by the each of the directors.

Addressing Value-Based Care in Patients With Diabetes

Diabetes is the seventh leading cause of death in the US,¹ and University Hospitals, located in Ohio, where diabetes diagnosis is among the highest in the country, treats thousands of patients with prediabetes and diabetes. However, despite advancements in medications and treatments for diabetes, panelist Betul Hatipoglu, MD, medical director of the Diabetes & Metabolic Care Center at University Hospitals Cleveland Medical Center, said diabetes management in patients is still poor.

Improving overall health in patients with diabetes is likely to reduce their risk of microvascular complications by 37%, Hatipoglu said. In addition to microvascular complications, diabetes is also associated with kidney failure, kidney hemodialysis with hypertension, blindness, and nontraumatic below-knee amputation, among other conditions, she described.

Hatipoglu attributed inadequate diabetes management to an endocrinologist shortage. She oversees diabetes care for a total caseload of 4000 patients, but she emphasized that there are 37 million people with diabetes and only 6500 adult endocrinologists in the US.

“[We’re] already trying to work into population health this diabetes system of excellence, to redesign how we take care of diabetes in the ambulatory space,” Hatipoglu said.

At University Hospitals, administrators and providers designed SOEs to utilize multispecialty collaboration to improve adequate follow-up and management of patients with diabetes and relieve physician burden due to drastic physician-to-patient ratios.

Patient care teams, which Hatipoglu described, can include diabetes educators, primary care physicians, nurses, certified diabetes care and education specialists, and PharmDs.

“Diabetes is a team [effort]. You cannot anymore, in this day and age, treat diabetes as a one-man show. It’s not going to work anymore,” Hatipoglu said. “The patient goes in and sees the [primary care] physician and is then taken care of by the other team members, step by step, depending on what they need, [whether it’s] their medications optimized or adjusted, their risk factors controlled, or their educational needs met.” 

The Missing Piece to Multispecialty Collaboration and Managing Chronic Disease

The University Hospitals SOEs aim to not only reduce admissions and readmissions of patients with chronic disease but also reduce the primary care physician (PCP) burden. Director of the CKD SOE Sarah Lang, MD, is a PCP who can attest firsthand to PCP burnout and the demanding burden on physicians in the specialty.

“A recent analysis said that in primary care—this is crazy—to effectively manage every metric and close every gap would require us to do 27 hours of work in a 24-hour day,” Lang said during her presentation.²

Lang further emphasized the PCP shortage compared with the number of patients with CKD. Approximately 1 in 7 adults has CKD in the US,³ and Lang said that 90% of them don’t know they have it. Yet, similar to the other SOEs, Lang said Medicare beneficiaries with CKD account for a quarter of Medicare spending alone, in addition to being a condition with the highest admission and readmission rates.

As part of the SOE multidisciplinary collaboration, pharmacists play a significant role in reducing physician burden and comanaging patient care. At University Hospitals, pharmacists can initiate, discontinue, adjust, and titrate medications; order laboratory tests; and prescribe medications under initial referral from the patient’s PCP.

“The goal is to provide continuity of care between the PCP, the pharmacist, and the specialty visits,” Lang said.

Pharmacists at University Hospitals are also able to meet with patients more frequently than PCPs do, significantly reducing gaps in patient care.

Reducing Hospitalization and Improving Quality Care

Another University Hospitals initiative targets postoperative outcomes and reducing the length of hospitalization. Heather McFarland, DO, is a critical care anesthesiologist and system chief of the Anesthesia Value Network at University Hospitals, where she manages the Enhanced Recovery After Surgery (ERAS) program. ERAS has 14 standardized guidelines, which include 111 service lines that have been adopted by 13 hospitals to date. With approximately 350 patients per month enrolled in the ERAS program, the mean occurrence of surgical site infections is less than 1%. Additionally, the 30-day readmission rate has not exceeded 20% in the last year and was lowest at 12% in December 2024.

Not only is the program improving patient outcomes but it is also saving hospitals millions of dollars by “decreasing variation and improving standardization.”

“We are following the new NPO [nothing by mouth] guidelines, and so it took that first really specific group of people to be champions with us, and then it was [those] data coming after it that helped convert a lot of the rest with them,” McFarland said during her presentation.

The ERAS program is also dependent on operating room staff and clinical care teams to be present and proactive during surgery and postoperative care, McFarland said. In order to encourage and reassure smaller roles in the operating room, McFarland said they hang affirmation banners on the wall to remind staff why they are there and that they are an integral part of the team.

“It helps you to think about what you’re doing when you come into that operating room space,” she said. “We always talk about fractal management as this management system that we use where people can really feel like they belong in part of this initiative.”

Additionally, Charles LoPresti, MD, system chief for hospital medicine at University Hospitals, discussed further the fine line in the length of hospitalization stays. He emphasized the concerns regarding quality with either too short or too long hospitalizations.

“From the time of admission to the time this patient is discharged, that is the sacred timeline when everything is functioning as it should, right?” LoPresti said during his presentation. “[But] something comes up, and now all of a sudden, we get thrown off of this timeline, and now our discharge exceeds what our ideal discharge time is.”

LoPresti categorized barriers to discharge into 3 buckets: germane, intrinsic, and extrinsic. Germane he defined as the optimal length of stay required to provide a patient with quality care. Intrinsic delays, he explained, are often extended stays due to variation in physician practice, whereas extrinsic delays occur because of something inefficient with the system (eg, poor care team communication, hospital staffing/scheduling, when resources/tests are available).

However, by utilizing electronic health records and adhering to clinical practice guidelines, LoPresti believes care teams can significantly shorten delays to discharge, thus reducing hospitalization stays.

“We just want to standardize the 85% we actually want to decrease. Take that off your plate, and then really focus on the 15% of patients that do need a very tailored approach to optimize postdischarge care,” he said. “Hospitalists will be more likely to discharge a patient sooner if they feel comfortable that the patient’s going to get seen in a timely fashion. Making sure that we leverage post–follow-up appointments and things like our ‘Healthy at Home’ virtual clinic has been a big plus for us at University Hospitals.”

However, extrinsic barriers, he said, are slightly harder to address, especially when it comes to communication. University Hospitals has implemented patient-centered rounds, which are scheduled meetings among physicians, bedside nurses, and patients to address timely concerns and procedures, ensuring everyone is on the same page.

Advancing Population Health and Value-Based Care: Insights From the Panel

The IVBM event concluded with a panel discussion featuring George Topalsky, MD, president of University Hospitals medical practices; Valerie Reese, MBA, vice president of population health at University Hospitals; and Jordan Winter, MD, director of surgical services at University Hospitals.

Panelists discussed University Hospitals’ ambitions to shift from reactive, sick-care models toward prevention and early intervention. They also discussed the conflict between the University Hospitals population health initiative and fee-for-service models.

“We are dependent, dare I say, addicted, to the demand for our services.... In fact, our compensation is directly tied to our individual productivity,” Winters said. “You get rewarded for unnecessary surgery; as long as you don’t get sued for it, you get rewarded for it. Until we figure out how to wean ourselves off this model and truly commit to change, there is going to be [mis]alignment.”

Panelists concluded the session, acknowledging the move toward multispecialty collaboration in primary care to further improve value-based care for patients. These transformations require substantial education, adaptability, and continuous alignment from physicians and administrators.

“We’ve made a lot of progress by focusing on outcomes and building a culture of collaboration—explaining the whys and the hows, solving problems together,” Topalsky said, concluding the panel. “It’s an ongoing journey, but as we continue to adapt, engage, and align around what truly matters, I’m confident we’ll keep moving forward.”

Author Information: Ms McCrear is an employee of MJH Life Sciences^®, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

1. Diabetes. CDC. September 17, 2025. Accessed November 11, 2025. https://www.cdc.gov/nchs/fastats/diabetes.htm

2. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the time needed to provide adult primary care. J Gen Intern Med. 2023;38(1):147-155. doi:10.1007/s11606-022-07707-x

3. Kidney disease statistics for the United States. National Institute of Diabetes and Digestive and Kidney Diseases. September 2024. Accessed November 6, 2025. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease