Diverse Population Requires Communication, Trust in Managing Diabetes

Friday, February 10th, 2012
This post was written by Cheryl Miller

Hudson River Healthcare’s (HRHC) successful strategy for diabetes management begins and ends with the patient, says its chief operations officer Katherine Brieger.

How a patient communicates with their health systems, their providers, their communities, and their families is integral towards their success in managing their diabetes, Brieger says in Healthcare Intelligence Network’s recent webinar, Patient Centered Medical Home: Diabetes Management. But what if the patient comes from a diverse population with challenging problems?

That’s the perspective behind Brieger’s honest, compassionate discussion about HRHC’s Diabetes Collaborative program, which has been in place for over 12 years, and combines attributes from both the Institute for Healthcare Improvement (IHI) and the Wagner Chronic Care Model, to manage diabetic care for more than 3,400 adult patients.

A large percentage of those patients are migrant farmworkers and homeless people, Brieger, also an RD and CDE, says. Care management does work, and getting patients involved in programs is key to their success, she says.

To do this, HRHC implements a patient-centered team approach to treatment, incorporating a full range of clinicians, MDs, (licensed and unlicensed, as in patient care coordinators) LPNs, and case managers to help patients manage their illnesses. Patients are stratified according to severity of health, and self management support and education, including community education days, group visits, and sessions with social/psychiatric workers, dentists, CDEs and RDs, are regularly scheduled to help evaluate and direct the patients.

Opening up access hours for patients, providing language interpretation, and teaching at low literacy levels are also keys to the program’s success, she continues.

Because weight loss is the most challenging aspect of diabetes management, HRHC offers innovative weight management programs like walking clubs, diet programs, mindful eating, and prevention services, Brieger continues.

Certified Diabetes Educators (CDE) are crucial to patient care, says Brieger, who is a CDE; as are case managers. And registries are an important element of the program; “It’s not enough to have a registry, but to know how to use it,” she says. Even telepsychiatry is used in remote areas lacking specialists, Brieger says, contrary to what people might think of New York’s densely populated area; “we have a lot of remote areas,” she says. Continuity and follow up are also key, medications are issued electronically; high risk patients are followed closely, and nurse care managers are implemented for the most complex patients.

To promote quality and continuity, site quality reports are sent out each month, and every nine months sites are visited by site teams.

Brieger shares other elements of the Diabetes Collaborative Program, including:

  • How to identify and assess patients for diabetes management, including an analysis of literacy and learning and social barriers that could impact outcomes for complex patients;
  • How to train staff and report quality data to drive further performance improvement;
  • How to assign measures for program evaluation and reimbursement, along with the results Hudson River has achieved.
  • But basically, it all begins and ends with the patient, Brieger concludes. Taking in the patient as a whole, and instilling a level of trust into the relationship, is what gets the best results.

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