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Developing a Successful Diabetes Center of Excellence

UMass DCOE co-director David Harlan proposed this framework in The Journal of Clinical Endocrinology & Metabolism

Date Posted: Wednesday, March 14, 2018

The Diabetes Epidemic

Nearly 30 million Americans have diabetes, which accounts for 12% of all deaths in this country.  Diabetes-related health complications contribute are extremely costly in both lives and dollars.  Annual health care costs associated to diabetes are estimated at $245 billion.  We must improve access to care and how it’s delivered.

Defining a Diabetes Center of Excellence

Diabetes research centers are well defined by the National Institutes of Health (NIH), but there is no clear definition for clinical Diabetes Centers of Excellence (DCOE).  We propose a framework to guide DCOE development to improve the patient care experience (both quality and satisfaction), reduce health care costs and improve the health of the overall population.

With value-based purchasing and reimbursement replacing fee for service, it’s important to implement new financial systems for compensating diabetes care that may not be provided by fiscally constrained private and academic medical centers.

Infrastructure of a Diabetes Center of Excellence

The definition of a DCOE implies the presence of an appropriate infrastructure to qualify for designation as a “center.”  Adequate staffing is an essential component to provide diabetes self-management education to new and existing patients.  The following must also be part of the basic DCOE model.

  • Education people how to inject medications and utilize diabetes management technologies such as meters, insulin pumps and continuous glucose monitors
  • Downloading and analyzing blood glucose data during the patient’s clinic appointment as well as between visits in order to modify the care plan as needed
  • Discuss diet, exercise, and medication use in relation to people’s individual lifestyle
  • Reply to phone calls, e-mails and texts in a timely manner
  • Offer behavioral health and social support, including identification and access to community resources
  • Provide professional education to the health care team within the center as well as out in the community
  • Educate family members
  • Coordinate care with the other health professionals that treat the patient
  • Sort out insurance issues for medication pre-authorizations according to tiers of coverage.

Six Pillars of a Successful Diabetes Center of Excellence

The following six core elements provide a realistic yet efficient approach to standards of care for large patient populations. This model can serve as a template and comparator for existing and emerging DCOEs in an effort to standardize and create excellent diabetes care.

1. Non-exclusive focus on high-risk individuals and an open-door policy

Given the ongoing diabetes epidemic, the number of patients who qualify for care will often exceed capacity because of the national shortage of endocrinologists. There are less than 6500 practicing endocrinologists in the United States, many of whom do not see patients with diabetes.  

Two potential, preferably complementary pathways can address this problem.

  • Systematic triage by a nurse experienced in diabetes care can help ensure access for those who would most benefit from receiving care in a DCOE. This includes all patients with type 1 diabetes (T1D) and others with poor glycemic control (blood sugar), impaired hypoglycemia awareness, multiple complications, post-transplant diabetes, and atypical forms of diabetes.  This approach allows a focus on population management and risk stratification before referral.
  • At the same time, wherever possible an “open door” policy will ensure that patients in need of care are not turned away. To accomplish this, nurse practitioners, physician assistants, certified diabetes educators and registered dieticians can be educated and trained to assume a larger collaborative role in the management of patients seeking care at the DCOE.

2. Communication across the medical community to guide care

Standardized and clear communication and coordination of patient care is another crucial element of the delivery of effective and comprehensive care for patients seen in a DCOE across the spectrum of disease. Coordinating care through patient-centered medical homes (PCMHs) starts with care contracts that outline expectations, roles, and responsibilities at the time of referral from primary care.

Pre-consultation exchanges

Address questions that may not require an in-person visit, such as the need for minor medication adjustments.  Addressing these questions in a timely manner removes the need for an extensive in-person visit to the DCOE and allows ongoing management by primary care providers (PCPs).  It also reduces waiting times for new patient appointments for those identified as being at highest need.

Consultations and shared management

Some patients need a certain number of in-person visits to a DCOE that address the initiation of injectable therapy, insulin pump therapy, or use of continuous glucose monitoring. These patients can often return to their PCP with recommendations for ongoing management once these issues have been addressed. Whenever possible, the patient continues to see the PCP for day-to-day management while maintaining access to the DCOE.

Management by the DCOE can involve shared diabetes management using electronic medical record correspondence between providers across the spectrum of care, including periods of transition such as from hospital to home.

3. Comprehensive Care

An integrated referral network ensures that diabetes care is provided efficiently and effectively by the DCOE. Given that the majority of patients will be referred to DCOE by their PCPs, open and ongoing communication ensures that proper feedback is available to all providers involved in the many aspects of diabetes care. One potentially effective strategy is to schedule monthly collaborative sessions between endocrinologists and collaborating providers where patients who pose specific or more challenging management issues can be discussed.

Availability of the numerous diabetes-related specialties needed for comprehensive diabetes care engages patients and providers alike in establishing screening or early detection and management of diabetes-related complications. This step can be accomplished by co-locating specialties that serve as a one-stop shop for patient convenience or by coordinating appointments with collaborating providers on the same day.

4. Learning health care system & ongoing focus on quality improvement

An integral focus of the DCOE is engagement in clinical research to develop pharmacologic and public health interventions for diabetes. DCOE can use the learning health care system model that links individual and population information in a centralized comprehensive database or registry that allows assessment of relevant clinical process and outcome data and costs. These registries are optimally designed to meet minimum standards to ensure robust access for researchers and other specialists who can assist the center in extracting meaningful clinical metrics and epidemiologic data. Deidentified patient data would allow comparisons of outcomes between DCOEs, fostering research and quality improvement strategies that can extend beyond the United States to international groups.

The DCOE must serve as a beacon of ongoing quality improvement initiatives that help ensure that the most robust and up-to-date care is being provided in an environment that incorporates new information and technologies into clinical practice. The DCOE ideally will implement such programs as the iterative plan-do-check-act process for long-term projects, Kaizen events for short-duration improvement projects, and Lean Six Sigma (a method that relies on a collaborative team effort to improve performance by systematically removing waste and reducing variation). If interventions are evaluated systematically within a learning health network, effective approaches can be rapidly spread across the health system and beyond through a consortium of DCOEs.

5. Outcome assessment

To maintain a DCOE, there must be an ongoing effort to preserve high-quality care by producing verifiable results for review and comment by third parties, such as funding organizations or insurance agencies, as well as by patients. The current metrics, such as goal-directed measures of hemoglobin A1c, lipid parameters, and blood pressure, are important but of limited value. Other metrics, such as delay in progression of complications, frequency and severity of hypoglycemia, improvement in cardiovascular morbidity and mortality, and overall longevity and quality of life, are likely to be more important than laboratory measures alone.

6: Education and dissemination

Dissemination of findings and best practices by the DCOE favorably influences other institutions involved in diabetes care. Local, regional, and national conferences, grand rounds, and small group sessions can promote best practices within and outside an institution. Short “expert courses” that provide expertise on crucial elements of diabetes management can help in disseminating expert diabetes care beyond the confines of a DCOE. Outside of formal training programs, DCOEs have the opportunity to work with “itinerant endocrinologist” programs in which specialists from the center visit or establish close relationships with PCPs at the same or other institutions to share expertise and develop mutually beneficial relationships.

Conclusion

DCOEs are an important component of the evolving models of health care delivery that provide cost-conscious, integrated, patient-centered care to patients with diabetes. Optimizing clinical outcomes while assessing cost, efficiency, and redundancy will result in cost-effective and accessible care.

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