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CP37 - Diabetes Care Program: A Nurse-Led, Team-Based Approach to Chronic Disease Management

‐ Aug 18, 2021 11:36pm

CP37 - Diabetes Care Program: A Nurse-Led, Team-Based Approach to Chronic Disease Management

Poster Type: Innovation

Category: Quality of Care and Quality Improvement

Issue or Challenge: Diabetes is a complex chronic illness that has significant medical, social, and financial impacts when the disease is not controlled. The percentage of poorly controlled diabetic patients at Community Health Care (CHC), a Federally Qualified Health Center, in April 2019 was 32%. This percentage included patients whose Hemoglobin A1c (HgbA1c) was greater than 9% or untested. Each patient with a poorly controlled A1c is at risk for serious complications. The problem needed to be addressed in an innovative way to improve patient outcomes, reduce total cost of care for these patients, and improve both the patient and provider experience.

Description of Innovation: The creation of the Diabetes Care Program (DCP) was an exciting initiative to improve patient engagement, disease management, and clinical outcomes for patients with uncontrolled diabetes. The development of a formalized DCP shifted diabetes management from a primarily individual provider and patient model, with limited provider access and time, to a team-based model led by nurses with a focus on patient education and engagement. The new care model consists of a nurse visit with the patient immediately before the provider visit and routine follow-up phone calls with the nurse and patient. The nurse uses motivational interviewing and patient education to engage patient in disease self-management with consideration of social determinants of health. Another component of the project was establishment of workflows to outreach to patients that needed diabetes care but had not had a diabetes visit in the last year or were overdue for follow-up based on their last visit. Clinical workflows include specific patient outreach and point of care diabetes management, regardless of initial reason for visit. These workflows help ensure patients’ chronic disease needs are consistently considered, evaluated, and managed.

Impact or Result: The impact of the DCP was significant. Our baseline data revealed that 32% of diabetic patients had an uncontrolled or untested Hgb A1c. After 9 months of program utilization, the uncontrolled percentage decreased to 25.9%. There were 345 patients enrolled in the DCP and 83% percent of those patients showed improvement in their A1c scores during their enrollment in the program. Furthermore, 57% of those patients ended with a level less than 9%. The average A1c decreased from 11.5% to 8.9% in the enrolled patients. Additionally, the clinical care teams enjoyed this work which may have contributed to improvement in overall staff satisfaction survey results.

Replicating this Innovation: The DCP is a program that has an ability to easily be replicated at other organizations providing care to patients with diabetes. We were able to use existing staffing models with an RN on every care team to shift the schedules to accommodate the new workflows and RN patient support. The RN staff enjoyed this level of patient interaction. Additionally, the development of outreach and mechanisms to evaluate diabetes in patients regardless of the initial reason for the visit provided an opportunity to better manage chronic disease and provided an opportunity to truly function as a Patient Centered Medical Home.


Theresa Jennings, DNP, ARNP, FNP-c, Family Nurse Practitioner, Clinical Assistant Professor, Community Health Care, Inc; University of Iowa College of Nursing

Rebecca Hayes, MD, MEHP, CMO - Pediatric and Internal Medicine Physician, Community Health Care