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Using Care Coordination to Improve Patients' Engagement and Health

Evidence-Based Diabetes ManagementDecember 2016
Volume 22
Issue SP15

AADE16 Conference Coverage

Care coordinators provide vital links to keep high-risk patients with diabetes engaged, bringing both improved health outcomes and greater satisfaction for doctors, according to a nurse and a researcher who have seen coordination work.

Maggie Powers, PhD, RD, CDE, and Toni Melancon, RN, shared how care coordinators have raised the bar for quality care in the Park Nicollet Health System, which operates a 426-bed hospital and provides diabetes education at 10 locations in Minnesota’s Twin Cities region. Their talk, “Diabetes Educators and Care Coordinators Create a New Paradigm for Primary Care,” addressed a theme that was covered throughout AADE16, the 2016 annual conference of the American Association of Diabetes Educators (AADE): an aging population with more chronic disease is overtaxing the nation’s primary care physicians (PCPs), who need support from certified diabetes educators (CDEs), social workers, dietitians, and other health team members.

Powers and Melancon showed how the care coordinator, who is often a nurse but may be a social worker, can make things better for both patients and physicians by filling in the care gaps and preventing overuse of drugs and services. Melancon, who is the manager for Clinical Care Coordination, Health Support, said care coordinators are key for those patients with limited education and huge needs. “We work with the messy patients, the ones who are struggling,” she said. These patients consume more than their share of services and are one reason that 86% of healthcare costs are consumed by people with 1 or more chronic diseases.1

Powers, who is a clinician and research scientist at the International Diabetes Center (IDC) at Park Nicollet, said the center’s presence gives the health system tools for success: IDC develops consistent messaging and materials used in all regional centers, as well as clinical guidelines and targets. This ensures the same quality standards for 600 diabetes education visits a month. “It is very important that we have consistent messages,” Powers said, whether the person touching the patient is a nurse, dietitian, or a physician. Patients cannot be given different targets for glycated hemoglobin (A1C) from different caregivers, for example. If a patient’s care needs deviate from guidelines, Powers said, everything is recorded in the electronic health record (EHR) so all who touch the patient are aware. Using the EHR works against clinical inertia. When care team members can see which topics have been covered in a patient’s education, they can ensure that diabetes educators address more complex issues in self-management. Diabetes self-management training is one area where CDEs can bill; care coordination itself is still often not reimbursed, although its value shows up in shared savings from Park Nicollett’s accountable care organization.

What Care Coordinators Do

Coordinators in the Park Nicollett system work within a patient-centered medical home (PCMH) model, which Melancon said not only achieves the goals of the Triple Aim—improved health, improved patient satisfaction, and lower costs—but also redefines roles, unburdening PCPs from some tasks and providing support so that patients make progress. “There is an additional benefit, which includes the satisfaction of the primary care provider,” Melancon said.Care coordinators perform many tasks, she said. They ensure that specialists and the PCP communicate, they find out if patients followed through on referrals, and they manage transitions of care and assist with advanced care planning. Within a PCMH model, they help ensure that all members of the care team are collaborating and working at the top of their license. They encourage patients to be active participants in their own care, and they work with families to support patient goals.

Not every care coordination model is the same, Melancon said. “I don’t believe there is a ‘right’ way to do it,” she said.


In Minnesota, diabetes care quality measurement centers on the “D5,” which are targets for blood pressure (140/90 mm Hg), cholesterol (statin use as recommended), A1C (less than 8%), being tobacco-free, and taking aspirin when recommended.

Powers shared data that tracked progress on the D5 from a clinic in a lower-income area: in 2006, only 10.6% of those with type 2 diabetes met all 5 targets. That percentage jumped to 28.5% achieving A1C of less than 7% in 2010, the year after IDC began providing on-site educator and nutritionist support.

Starting in 2009, Minnesota also began tracking the share of patients with A1C less than 8%, and by 2010, 47.5% of the clinic’s patients had met the D5 with this standard. Care coordinators, through a PCMH model, arrived in 2013, and within 2 years, 56.2% of the clinic’s patients met D5 goals.

According to Melancon, 2 key tools make the PCMH model work: use of data and constant follow-up. Data registries that pull from the EHR help spot problems, and care coordinators benefit from a weekly conference call during which they take turns presenting the hardest cases. “Transparency in sharing quality measures provides accountability,” she said, since physicians are inclined to see how they compare to their peers. She presented 2 cases that revealed how good care coordinators are relentless in keeping after patients, even when they don’t take phone calls or follow instructions.

“A lot of this is just bringing people back for appointments,” Melancon said. “It’s making sure that patients understand when they are supposed to come back.” Reference

Chronic disease overview. Centers for Disease Control and Prevention website. http://www.cdc.gov/chronicdisease/ overview/. Updated February 23, 2016. Accessed October 2, 2016.

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