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