Program Developed to Help At-Risk Type 2 Diabetes Patients Receive Necessary Care
Date Posted: Tuesday, February 18, 2020
Key to a long and healthy life for people living with type 2 diabetes is maintaining blood glucose within a specified target range. Proper diabetes self-management results in healthy blood sugar levels, thus reducing the risk of developing serious complications from poorly-controlled diabetes. Testing blood glucose on a regular basis is extremely important. This includes throughout the day using a meter or continuous glucose monitor, and quarterly A1c tests.
Many people receive their diabetes care from a primary care provider (PCP). Experiencing multiple chronic health problems and limited time with PCPs makes receiving comprehensive, guideline-recommended diabetes care a challenge. This new initiative is tracking UMass Memorial patients who are at-risk for negative outcomes due to gaps in care, and proactively engage them to identify their difficulties and “nudge” them towards available services and resources to get them back on track.
The project is a collaboration between UMass Memorial Health Care and UMass Chan Medical School, led by Daniel J. Amante PhD, MPH and Adarsha Bajracharya, MD. A program was developed within the Electronic Health Record (EHR) system to identify people with type 2 diabetes who have not recently visited their PCP, have an A1c greater than 8%, are due for an annual eye, foot or urine test, or have not had an A1c test within the past six months.
They are contacted personally by specially trained outreach specialists who are learning about the challenges and frustrations getting in the way of people properly managing their diabetes.
“Many find it helpful and are thankful to have us contact them,” said Anna Lu, one of the clinical research assistants making the phone calls. “They appreciate our help scheduling the many appointments that people living with diabetes need. Especially those who don’t have a well-established relationship with their PCP.”
The program has uncovered a wide range of obstacles that have kept people from receiving necessary care including transportation issues and the cost of insulin and other medications.
The outreach specialists let people know that the UMass Diabetes Center of Excellence offers diabetes education to help with everything from getting started with healthy eating and physical activity to blood sugar monitoring, problem-solving, healthy coping and reducing risk of complications.
This approach has seen positive results as more patients are now getting their recommended tests and seeing their providers. Helping people manage diabetes can prevent or reduce the risk of complications, reduce cost, and improve their quality of life.
While the goal of this program is to improve diabetes care management for at-risk patients, the strategies can be applied to help with other chronic disease management in the future.