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Learning outcome: Outline the steps involved in developing a user-friendly diabetes risk report by collaborating with different stakeholders in the healthcare system for improving diabetes management.
Our health system is an integrated healthcare delivery system and our ambulatory care division is comprised of more than 65 physician practices. Our healthcare system is focused on population health management and diabetes has been identified as one of the most common and expensive chronic diseases in ambulatory care practices.1 Effective diabetes management is time-consuming for providers, and diabetes education cannot be covered in a single follow-up visit. The population health team explored ways to support the providers and clinical staff to be more proactive in identifying and managing high-risk diabetes patients (A1c>9) by utilizing data tools available in EMR. In reviewing existing reports in EMR, no report would identify high-risk diabetes patients. The population health team met with IT to develop a new report. The objective was to combine clinical and behavioral data points to identify patients with a high risk for hospitalization and diabetes-related complications and to develop individualized health goals. Together the population health team and IT agreed on three data points to be included in the report: clinical-focused, compliance-focused and risk-focused. The team added clinical indicators of diabetes (i.e. A1C, BMI, and BP), visit history to identify the visit pattern with a focus on canceled and no-show appointments, and the composite risk score developed by EMR to identify patients with high risk for hospitalization. It has been found that if a patient with diabetes is a no-show to primary care appointments there is an association with increased risk for hospital admissions.2 This report is currently being used in primary care practices to identify high-risk diabetes patients, close gaps in care, and provide education. The report is now being used by the population health team’s newest initiative, health coaches. Health coaches are medical assistants (MAs) and licensed practical nurses (LPNs) who undergo training on various topics concentrated on driving better outcomes in population health. The report was made available to health coaches who team up with providers and identify high-risk diabetes patients. The health coaches use the report to identify patients, do pre-visit planning, close gaps, and support patients to create goals. The health coaches reinforce the patient’s health goals during the visit and follow up with patients later to review the progress of their goals and document and communicate with the healthcare team. Documentation and patient outcomes are displayed in a dashboard where clinical leaders can see the impact the health coaches have on patients with chronic diseases. The report created helped the team to utilize data effectively and efficiently in the population health framework and develop a tool that is accessible to providers and clinical team members, including RNs, LPNs, and medical assistants. The clinical teams have recognized the power of data to manage chronic disease in a population-based approach.