Patient care partners, innovative weight management tactics, patient registries and even telepsychiatry are part of the team approach to diabetes management at Hudson River HealthCare (HRHC) Diabetes Collaborative. The New York-based network of FQHCs finds that tiered care management generates the best outcomes for its patients with diabetes, explains Kathy Brieger, RD, CDE, HRHC’s chief operations officer, prior to her presentation on Diabetes Management in the Medical Home.
HIN: The Hudson River HealthCare (HRHC) Diabetes Coalition uses a patient-centered team approach to manage diabetes in its more than 3400 adult patients with the disease. HIN recently did a survey to find out about disease-focused programs in particular, those that manage diabetes. Our respondents told us that weight management is the most challenging aspect of this disease. Would you concur? If so, how does HRHC address weight management in its population?
(Kathy Brieger): I would agree with this. Weight management is one of the most challenging focuses of this condition. In order to meet this challenge, we’ve had to look at programs from a variety of aspects. We started walking clubs in some communities to encourage physical activity. There’s also a Taking off Pounds Sensibly group, which is a Weight Watchers format but at a lower cost for patients who may be at a low income. We’ve done programs on mindful eating and general ways of looking at portions. We’ve also done a lot of work related to children and preventions. I think this is a big target. We focus on prevention and giving people the options of attending a variety of program formats for weight loss.
HIN: Over the last 12-18 months we’ve seen that case managers are increasingly employed on site, in primary care practices, to assist with the management of chronic illness. Are there any case managers in the HRHC mix?
(Kathy Brieger): This is a key question to diabetes management. We’ve found that a team-based approach to care is really the most effective. We have several team members who help to case-manage the patients. And that includes everyone from a dietician to people called patient care partners. Patient care partners may not have a clinical license, but are trained in motivational interviewing and help to serve as a bridge between the clinical team and the patient. We also have sophisticated, high-level RN care managers who work in a targeted way with patients who have diabetes. Those are usually the patients who have comorbidities and who may have poor control over their diabetes. At Hudson River HealthCare, we look at a team-based approach using different levels of care to get the best outcomes. We find that that really is the most effective.
HIN: The more sophisticated care managers are for the sicker patients with comorbidities. How do you assign patients to the other two levels of management?
(Kathy Brieger): We have some reporting systems because we do have an electronic health record; we use eClinical Works® (ECW). We have different cutoffs for the care manager. We’ve run the registries. For people who have hemoglobin A1Cs of over 8 or 9, the care manager reviews them and she’ll pull off people who may have some of those indicators. Also, the medical providers will tell us, “This person may not have a hemoglobin A1C of over 8 or 9, but they’ve been in and out of the hospital several times.”
Right now, we’re also working with hospitals to get us hospital discharge summaries so we can see if those people who may have some unstable situations that we’re not aware of can be pulled in. For every single person who has diabetes, their care is also managed by the patient care partners. We taught them how to use the registries, how to call people in for group classes and how to send letters out for our programs. These levels are done in a three-tiered approach using the care team so that the patient care partner who is assigned to the care team, the nurse who is assigned to the care team and the provider assigned to the care team would together be able to route or send people to the right place. The bulk of our patients are able to do the low-level patient care part. It’s just the top 15 percent that are having some issues.
HIN: It sounds like registries are important to the program.
(Kathy Brieger): Yes, they are. Over 10 years ago, we started with the Patient Electronic Care System (PECS) as part of the federal government’s move to get a population health underway, but it was a limited standalone registry. And then about three years ago when we became fully electronic, we were able to get our registries and our reports done on all patients with all conditions, and that is valuable. We’ve done a lot of work on training our staff on how to use registries; it’s not so helpful just to have registries; you have to know how to use them.
We’ve tried to use registries as a teaching tool for everyone from even clinical assistants in training all the way up to the providers. They know how they can use it to have more effective team-based care, more effective disease-based focus, and even prevention of things like, “When did you get your mammogram done last?”
HIN: And finally, are there any applications in telehealth, telemedicine or remote monitoring that you are using successfully in the management of diabetes?
(Kathy Brieger): Yes. We’re involved with telemedicine, focusing on telepsychiatry at one site. We have purchased equipment and are right now getting it cabled for six different locations, so that we’ll be able to expand our services in the telemedicine area. We do have some sites that are located in remote areas. We are unable to get some specialists that may help in the management of diabetes. We think telemedicine will be a great resource in improving some access to services that may not be available in some of those remote areas. Even though we’re in New York, people think we have all types of access to specialists, but there are areas where they do not exist, even in New York. We’re looking forward to having that happen.
