Guest Blogger: Laurie Smith, LMSW, CDE MedNetOne
Happy Fall! We've just passed Halloween, Thanksgiving is
right around the corner, and the Christmas season is upon us. It is also National Diabetes Month, a time to
reflect on a disease that (by CDC estimates) is projected to affect one in
three U.S. adults by the year 2050.
While the American Diabetes
Association (ADA) estimates that nearly 26 million Americans are living with diabetes,
it also estimates that nearly 25% of those persons remain undiagnosed. The ADA also estimates that another 79
million people are now pre-diabetic. Therefore, the danger (and perhaps opportunity) of this disease lies at
the intersection of early detection and treatment.
The concept of a Patient-Centered
Medical Home (PCMH) provides an ideal framework in which to transform the way in which
providers and patients engage in the prevention and treatment of chronic
illnesses such as diabetes. Through this
physician-led team-based approach to healthcare, patients are now receiving
increased access to providers (RelayHealth online patient portal, extended
hours access, etc.) and their team. Evidence-based care (annual depression screenings, preventative testing,
etc.) is being delivered in more
coordinated and effective ways at reduced costs and information technology is
being used to better manage the health of PCMH patient populations.
Are you using Wellcentive to
alert you to place reminder calls to your diabetic population to obtain their
yearly foot exam? 6mth A1c? Other lab values? This is a tool available to us that can both
increase our HEDIS scores and improve patient health and outcomes, not to
mention patient satisfaction.
Another key feature of the
Patient-Centered Medical Home is the use of a Care Manager. A Care Manager can assist the PCMH team with
diabetes management in a number of ways: a coaching call between visits to address
potential barriers to adherence; further
disease education and/or clarification of PCP’s orders; goal-setting and problem-solving related to
diet and exercise; closer tracking of
referrals to specialty providers; brief
intervention for depression and/or anxiety; etc.
With the costs of treatment for
diabetes in the US estimated at $245 billion in 2012, one of the most important
strategies to combat this disease is prevention. The Patient-Centered Medical Home and use of
a Care Manager are essential tools in this approach. Through targeted population-based health
management, PCMH teams can utilize patient registries for early detection of
this disease through identifying patients exhibiting other risk factors (such
as family history, ethnicity, obesity, hypertension, hypercholesterolemia,
etc.) and screening them earlier and at regular interval. Beginning to identify and treat pre-diabetes
is key to reducing costs and improving overall treatment outcomes.
Finally, it is important to
remember that the most beneficial prevention and treatment for diabetes can be
seen through lifestyle change. Increasing our steps per day and reducing our portions are small steps
that each of us can make on a daily basis to prevent diabetes. Sharing knowledge and encouraging our
patients to set small, achievable goals can result in improved patient
satisfaction. Reaching out to families
and caregivers and getting involved in our community to promote healthy
lifestyle intervention sends a message to our patients that we are as committed
to combating this disease as they are.
For further information see the
links below:
· Visit the National Diabetes Education Program at
www.YourDiabetesInfo.org for more
information.
· Small
Steps. Big Rewards. Your GAME PLAN to Prevent Type 2 Diabetes helps people assess their risk for
developing type 2 diabetes and implement a program to prevent or delay the
onset of the disease. This resource includes an activity tracker and a fat and
calorie counter.
· Practice
Transformation for Physicians and Health Care Teams is designed for
health care professionals and administrators who want to change systems of
health care delivery around diabetes.
MedNetOne
– PCMH information: http://www3.mednetone.net/Providers/PCMHN.aspx
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