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HbA1cs improve for most participants
When a case manager at Winchester (MA) Hospital identifies a diabetic patient, she refers him immediately to the hospital’s diabetes center. As much as that case manager is helping, Kathleen Beyerman, RN, CNA, EdD, director of the Community Health Institute, a department within Winchester, says that her group felt there were still a lot of undiagnosed diabetics out there who needed finding.
They initiated an innovative approach to diabetes disease management that has been so successful that it is now being expanded to other chronic diseases. Beyerman is in charge of the Diabetes Casefinder Program and explains why she thinks it is important:
Look to local practices
"We extrapolated national data to our service area and [discovered] that, based on the fact that the American Diabetes Association (ADA) in Alexandria, VA, says half of the diabetics are undiagnosed, we probably had 17,000 undiagnosed diabetics in our service area. How could we find them?" They decided a good way would be to work with local medical offices and help them find their own undiagnosed diabetics.
The staff of Winchester’s diabetes unit consists of a certified diabetes educator (CDE) who serves as the case manager for the unit, an endocrinologist, a dietitian, and two nurses. "Periodically, a case manager may be called into the center to see a patient," says Beyerman, "but that doesn’t happen often because her visit is not reimbursed." It also depends on how fragile the patient is. He could come in here when he is discharged, or the CDE might go to see him in the hospital.
The pilot program involved an RN prevention specialist who reviewed medical records in physicians’ offices to identify people at risk for diabetes. She used agreed-upon guidelines for diabetes and sent notification letters to identified patients, enclosing laboratory slips for appropriate testing. Test results were sent to the physicians’ offices, and the offices notified patients of their results. Patients found to have diabetes were asked to participate in a diabetes education program where teaching is done by CDEs. Teaching content focuses on self-management strategies — a healthy lifestyle, blood glucose self-monitoring, and medication administration and adjustment. The education program also offers support groups, and exercise and weight loss programs.
From nearly 5,500 records reviewed, the pilot program identified 1,500 at-risk patients and 42 newly diagnosed cases. It also turned up 136 patients previously diagnosed with diabetes whose blood sugar was not in control and who had not had an HbA1c (glycosylated hemoglobin) in the previous 12 months. The program generated nearly $350,000 additional revenues in procedures and visits and nearly $300,000 in radiology and lab revenues for the hospital. Within six months:
- 82% of the patients in the education program had improved HbA1c levels.
- 67% showed successful weight loss.
- 72% maintained a successful exercise program.
- 60% complied with blood sugar monitoring.
- 59% complied with their medical regimen.
Winchester, located about 10 miles from Boston, is one of 11 hospitals in Massachusetts whose diabetes education program is accredited by the ADA. Cathy Reardon, CDE at Winchester, says getting accredited "involves lots of paperwork. That was before my time here, but we’re getting ready for reaccreditation now, and we have to collect data for six months on many different criteria such as HbA1c readings before and after education. There’s a lot of tracking involved. Representatives of another facility told me that it took a full-time person close to four months to accomplish ADA accreditation. You absolutely need administrative support to do this."
But it’s worth the effort, she says, because accreditation benefits a hospital. "Once you have the recognition, you’re never questioned about reimbursement. Medicare will only reimburse for diabetes education if it takes place at an ADA-recognized program." Also, once accredited, the ADA puts that hospital on a list for referrals.
Winchester’s center focuses on self-management, Beyerman says, and the most common patient is the senior with Type 2 disease who is struggling with managing his blood sugar. "If a diabetic patient has exacerbations and complications are becoming a problem, he is seen by nurses and the dietitian to see how lifestyle issues are impacting him, but those patients are referred to specialists for care for their renal failure or peripheral vascular problems. The patient totally cared for within the center is one without severe complications."
"Our program for women who develop diabetes during pregnancy is small but very important," says Beyerman. "Women with gestational diabetes pose our biggest challenge." Subsequent to delivery, most new mothers return to normal blood sugar levels, but those women have a 66% risk for developing Type 2 disease during their next pregnancy and a 40% to 60% risk for developing Type 2 disease later in life. "Our goal is to prevent diabetes in those women," she says. Her team works with them on nutrition and exercise. "If they can keep their weight down, they can delay or avoid Type 2 diabetes later in life, either in their next pregnancy or later on." Beyerman also supports the new mothers with breast feeding, since that’s a way to get down to prepregnancy weight.
[Contact Kathleen Beyerman at (781) 756-4713, and Cathy Reardon at (781) 396-6437.]