By Melinda Young

A rural West Virginia pizza shop owner and grandfather found his long work days punctuated with fatigue. He visited his doctor and was diagnosed with diabetes. His A1c (glucose) level was between 11 and 12, twice the optimum level.

“He had multiple people relying on him to be successful,” says Megan Adelman, PharmD, a clinical pharmacy specialist with the department of family medicine and an assistant professor at the West Virginia University (WVU) School of Pharmacy.

The man was referred to WVU School of Medicine’s diabetes team-based program. Within six months, his A1c dropped to below six. “He lost weight and was almost a nondiabetic, and he didn’t have the pain and fatigue he had when diagnosed,” Adelman recalls. (For more information, see related story in this issue.)

Overall, the diabetes care program helped patients lower their A1c levels from an average of 10.25 to an average of 8.7 within three to six months, says Dana E. King, MD, MS, professor and chair of the department of family medicine at WVU Medicine.

Even at 18-month follow-ups, 86% of patients recorded lower A1c levels than they did in the beginning, and one-third of patients registered A1c levels below 8, he adds. “The clinic model was effective in having a positive impact,” King says.

Data about hospitalizations and ED visits are unavailable, he notes. “We need to do this program for several hundred patients to get significant results,” King explains. “After the clinic has been going on for a little longer, we might get longer-term outcomes like hospitalization rates or amputations.”

The team-based diabetes care program started as a quality improvement initiative. Practitioners were concerned about the patients who could not control their diabetes. Through brainstorming, they came up with the team-based approach. A team could determine whether a patient’s issues are related to the medicine, access barriers, mental health issues, or other problems, King says.

“We said it could be any of those things and was probably multifactorial, so we started this Thursday afternoon intensive diabetes clinic for people in our practice,” King says.

The clinic is run through the department of family medicine, corralling all resources within the department, he adds.

The following is how the intensive diabetes clinic works:

• Form a team. The diabetes team includes a resident physician, a pharmacist, a registered dietitian who doubles as a certified diabetes educator, a psychologist, and a nurse care coordinator.

“The team provides multifaceted care,” Adelman says. “I love working with an interdisciplinary team because this is where we get a lot of breakthroughs. Our patients know who we are, and we’re able to motivate them, so they feel empowered about their care, which is so gratifying.”

• Reach out to patients. The nurse care coordinator calls patients two or three days before their visit to remind them to come in for a visit with the team, King says.

“The nurse triages any acute issues that come up,” Adelman says.

• Play assessment musical chairs. Patients see each member of the team, starting with the diabetes educator/dietitian, who finds out how the patient is doing with diet, exercise, and lifestyle.

The psychologist and pharmacist meet separately with the patient. While one professional is meeting with a patient in room A, another person is meeting with a patient in room B, and they rotate for efficiency. For instance, the psychology team might talk with the patient about anxiety and depression, and complete an assessment of the patient’s mental and emotional state, King explains.

“Sometimes, that’s a big focus of the visit, and sometimes it’s about making behavioral changes and working through barriers,” he adds. “Then, the pharmacist comes in and does an assessment of medications and side effects.”

The dietitian might tell the patient, “You need to eat fruits and vegetables every day and not just on the weekend,” King says.

“Patients are there for an hour-long visit, and we’re playing musical chairs with the rooms,” King says. “Then, they come back and huddle with doctors for a few minutes to give them a summary of what they’ve learned.”

Each team member does everything they can to listen to the patient and to identify issues within 15-minute increments, Adelman says. “I talk with patients about medication that is feasible, manageable, and affordable for them,” she says. “We discuss multiple aspects of care in terms of stress,” she adds. “The psychology team member might say the person needs more intensive therapy.”

After hearing the summary, the physician visits the patient to talk about changes the patient can make to improve overall care.

• Provide follow-up. Patients return in a month for a similar visit with each member of the team. Each month, the patient’s A1c is measured, and the plan is adjusted. “It’s the same routine,” King says.

Also, each discipline has a student following and meeting with the patient, he adds. “This is a model that you could do in rural settings,” King says. “Within a whole community, there is a pharmacist and behavioral medicine person, and maybe a diabetes educator.”