As the numbers of patients with diabetes continue to climb, physicians and health policy experts are devoting increasing attention to strategies that can improve care for these patients. One of the strategies frequently mentioned is the Chronic Care Model, developed in 1998 by the MacColl Institute for Healthcare Innovation.
As the numbers of patients with diabetes continue to climb, physicians and health policy experts are devoting increasing attention to strategies that can improve care for these patients. One of the strategies frequently mentioned is the Chronic Care Model, developed in 1998 by the MacColl Institute for Healthcare Innovation.1
Barriers to effective chronic care. There are many barriers to effective chronic disease care. In a previous issue of CONSULTANT,2 about 2 dozen of the most common barriers were identified. Some of the barriers are patient-related, such as a lack of trust in the physician and staff or a lack of understanding of treatment regimens. Many barriers are provider-related, the most significant being lack of time. Another important provider-related barrier, "treatment inertia" (that is, the common tendency of failing to intensify therapy when treatment goals are unmet), is particularly intransigent. Still other barriers to good chronic care are system-related, such as a lack of policies that promote treatment to goal.
Diabetes program establishes Chronic Care Model with 3 main innovations. Just how to overcome these many impediments to good chronic care might seem overwhelming. However, in this issue (see page 331 in print edition), a program in my home state of Florida-the Diabetes Master Clinician Program-is described that manages to surmount many of the barriers to good chronic care. Perhaps most important, it does this with just 3 basic innovations:
• Creation and use of a diabetes registry.
• Implementation of group visits.
• Team approach to care.
Diabetes registry. Use of a registry helps overcome the "lack of time" barrier by expediting the collection of all pertinent information before each visit with a patient with diabetes. In addition, the registry's population monitoring functions, which inform practitioners of how well they are doing at achieving quality goals, are a powerful tool for overcoming clinical inertia.
Group visits. The group visits do much to help overcome patients' lack of understanding of their treatment regimens and goals. They are an invaluable aid in the promotion of self-management. In addition, group visits help to overcome the physician-related lack of time barrier and the patient-related barrier of lack of trust.
Team approach to care. Team care, an essential means of overcoming lack of time and improving patient trust, is facilitated by use of the registry reports and group visits. Members of the office team (nurses and medical assistants) review patient report cards during traditional one-on-one visits. This furthers patients' ability to self-manage their diabetes. Ordering tests earmarked by the population reports and conducting much of the patient education segment of group visits are additional roles for the medical assistant or nurse.
Efficacy and economy. In practices that participate in the Diabetes Master Clinician Program, 19% of patients with diabetes are achieving all 3 of the basic ADA goals (hemoglobin A1c below 7%, blood pressure less than 130/80 mm Hg, and low-density lipoprotein cholesterol level less than 100 mg/dL) at the same time; nationally, only 7% of patients are able to reach all 3 goals at once. Moreover, it is estimated that the program saves more than $1 million annually.
As more clinicians see that substantially improving care for patients with diabetes is not only possible but also cost-effective and realistically attainable, it is our hope that the achievements of the Diabetes Master Clinician Program will be replicated in more and more practices across the country.
Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4.
Shahady EJ. Barriers to care in chronic disease: how to bridge the treatment gap. Consultant. 2006;46:1149-1152.