medstar health type 2 diabetes pathway to control

Conditions: Type 2 Diabetes Mellitus; Hyperglycemia

Summary: a diabetes institute (mdi), in partnership with key stakeholders-including primary care providers- in a northeastern us regional, mixed-payer healthcare system), seeks to implement an evidence-based, technology-enabled, innovative, and integrated diabetes care management pathway (boot camp) for adult patients with uncontrolled type 2 diabetes (a1c\>/=9%) which will demonstrate improvement in diabetes clinical and health resources utilization outcomes.

* the program is designed to integrate type 2 diabetes specialty services into primary care practices to support pcps and their patients in improving a spectrum of diabetes-related outcomes. * high-risk patients from primary care practices who have uncontrolled type 2 diabetes and meet the target population inclusion and exclusion criteria will be invited to participate in an intensive and concise "boot camp" medication management and education intervention of \~4-8 weeks duration. * the intervention will consist of three key components: (1) intensive, algorithm-based medication management (appendix a), based on continuous review and management of blood sugars; (2) survival skills diabetes self-management education based on knowledge deficits identified on the know diabetes knowledge survey; (3) enhanced patient-provider communication, all provided by endocrinologist supervised allied health professionals (in this instance cdes). * survival skills dsme will focus on nutrition and meal plan basics, blood glucose targets, taking medications as prescribed, hyper- and hypoglycemia recognition and treatment, and when to seek medical help. * the intervention is initiated with one to two face-to-face meetings with the cde, at which the patient's readiness to change is assessed. * these are followed by virtual meetings though a variety of media based on patient preference and health literacy (largely telephone and text messaging). * various technology tools are used to facilitate patient engagement, access and attainment of glycemic targets, including smart meters, virtual meeting platforms, web-based education content and surveys administration via tablets, etc. * near real-time transmission of blood glucose data using a cellular-enabled blood glucose monitoring system sends all glucose results to a web-based dashboard accessed daily by the boot camp educators. * concurrent matched charts of patients receiving standard care at the three medstar locations will serve as a basis of comparison in assessing the impact of mdi on clinical and education outcomes and process of care. * based on patient progress towards improved glycemic control, the patient will 'graduate' from the program and the cde will refer the patient back to their pcp in 8-12 weeks with a full report of medication changes, blood glucose readings and further diabetes management recommendations eg referrals; further dsme, etc.

Eligibility criteria:
inclusion criteria: * diagnosis of type 2 diabetes for \>=1 year * active practice patient * a1c \> 9.0% at their last visit to medical home, ed or hospital admission plus one more high risk factor (ed visit or hospitalization in past 12 mos) * primary care provider willing to have patient enter the program * patient is able and willing to participate in the program and exhibits readiness to change dm self-management * proficient in english exclusion criteria: * known history of dka * no medstar pcp visit within past 12 months * endocrine or diabetes education consult referral order in the past 6 months which resulted in endo visit(s) or dsme visit(s) documented in chart or self-reported by patient during initial screen * active additional medical issues which in the opinion of the care team would preclude concentrating on bg control and/or would predispose to ed visits and/or hospital admits independent of glycemic control, e.g.: severe chf, severe copd; severe mental illness. * resident of skilled nursing facility, nursing home or receiving home health care services. * active cancer in the preceding 3 years excluding nonmalignant basal cell cancer * supraphysiologic doses of glucocorticoids (hydrocortisone \> 30mg/day; prednisone \> 5-6mg daily; dexamethasone \> 2mg daily). * pregnant or anticipates attempting conception in the following year * patient and/or custodial caregiver unwilling and/or unable to participate in program-related activities

Keywords: diabetes care management chronic care model resources utilization hemoglobin a1c hospitalizations emergency room visits cost analysis return on investment