Using Care Coordination to Improve Health of "Messy" Diabetes Patients

The importance of care coordination and the role of diabetes educators in the primary care practice is a theme of the 2016 meeting of the American Association of Diabetes Educators, taking place in San Diego, California.

Care coordinators provide vital links to keep high-risk diabetes patients engaged, bringing both improved health outcomes and greater satisfaction for doctors, according to a nurse 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 will be covered throughout the 2016 meeting 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.

AADE began Friday in San Diego, California, and concludes Monday.

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 filing 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 chronic disease accounts for $3 of every $4 spent on healthcare.

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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 given 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 where a patient has received education, educators can move on too complex matters in diabetes self-management education. This 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 model (PCMH), 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. The find out if patients followed through on referrals, 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.

Results. In Minnesota, diabetes care quality measurement centers on the “D5,” which are targets for blood pressure (140/90), cholesterol, A1C, 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 (T2D), met all 5 targets. That percentage jumped to 28.5% achieving A1C of <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 <8%, and by 2010, 47.5% of clinic’s patients had met the D5 with this standard. Care coordinators, through a patient-centered home model (PCMH) arrived in 2013, and within 2 years 56.2% of the clinic’s patients met D5 goals.

Melancon said 2 key tools that 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 where 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.”