Feasibility and Effectiveness of System Redesign for Diabetes Care Management in Rural Areas

University of North Carolina at Chapel Hill, North Carolina, United States
The Diabetes Educator (Impact Factor: 1.79). 09/2005; 31(5):712-8. DOI: 10.1177/0145721705280830
Source: PubMed


Redesigning the system of care for the management of patients with type 2 diabetes mellitus has not been well studied in rural communities with a significant minority population and limited health care resources. This study assesses the feasibility and potential for cost-effectiveness of restructuring care in rural fee-for-service practices for predominantly minority patients with diabetes mellitus.
This was a feasibility study of implementing case management, group visits, and electronic registry in 5 solo or small group primary care practices in rural North Carolina. The subjects were 314 patients with type 2 diabetes mellitus (mean age = 61 years; 72% African American; 54% female). An advanced practice nurse visited each practice weekly for 12 months, provided intensive diabetes case management, and facilitated a 4-session group visit educational program. An electronic diabetes registry and visit reminder systems were implemented.
There was an improvement in the percentage of patients achieving diabetes management goals and an improvement in productivity and billable encounters. The percentage of patients with a documented self-management goal increased from 0% to 42%, a currently documented lipid panel from 55% to 76%, currently documented aspirin use from 25% to 37%, and currently documented foot examination from 12% to 54%. The average daily encounter rate improved from 20.17 to 31.55 on intervention days.
A redesigned care delivery system that uses case management with structured group visits and an electronic registry can be successfully incorporated into rural primary care practices and appears to significantly improve both care processes and practice productivity.

Download full-text


Available from: Doyle M. Cummings, Mar 11, 2014
  • Source
    • "Assessing human capital needs—It is important to assess human capital needs to implement and maintain health IT interventions in under-resourced settings. Although some of the studies we reviewed commented on the need for nursing staff, case managers, or staff to assist in maintaining health IT interventions, no studies reported the type of staff and number of staff needed to support health IT interventions in under-resourced settings (Bray, Thompson et al., 2005; Chin et al., 2007). Studies in EMR process measurement have noted the importance of a health IT champion, yet this concept still needs testing in underresourced settings and in addressing diabetes (Zandieh et al., 2008). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Differences in rates of diabetes-related lower extremity amputations represent one of the largest and most persistent health disparities found for African Americans and Hispanics compared with Whites in the United States. Since many minority patients receive care in underresourced settings, quality improvement (QI) initiatives in these settings may offer a targeted approach to improve diabetes outcomes in these patient populations. Health information technology (health IT) is widely viewed as an essential component of health care QI and may be useful in decreasing diabetes disparities in underresourced settings. This article reviews the effectiveness of health care interventions using health IT to improve diabetes process of care and intermediate diabetes outcomes in African American and Hispanic patients. Health IT interventions have addressed patient, provider, and system challenges in the provision of diabetes care but require further testing in minority patient populations to evaluate their effectiveness in improving diabetes outcomes and reducing diabetes-related complications.
    Full-text · Article · Oct 2010 · Medical Care Research and Review
  • Source
    • "Care modeled after the CCM includes providing self-management support to patients through goal-setting, follow-up, and links to community resources, as well as providing support to care providers through delivery system redesign, decision support, and clinical information systems (Bodenheimer, Wagner, & Grumbach, 2002a, 2002b; Wagner, 2001a, 2001b; Wagner, Austin, et al., 2001; Wagner et al., 2005; Wagner, Glasgow, et al., 2001). Modeling primary care services after the CCM improves diabetes outcomes (Bray et al., 2005; Bray, Thompson, Wynn, Cummings, & Whetstone, 2005; Siminerio, Piatt, & Zgibor, 2005). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Variability in disease-related outcomes may relate to how patients experience self-management support in clinical settings. The purpose of this study was to identify factors associated with experiences of self-management support during primary care encounters. A cross-sectional survey was conducted of 208 patients seen in a multidisciplinary diabetes program in an academic medicine clinic. Multiple regression analysis was used to test associations between patient-rated experiences of self-management support (Patient Assessment of Chronic Illness Care) and race, gender, insurance status, literacy, duration of diabetes, and intensity of care management. The Patient Assessment of Chronic Illness Care ratings decreased with age (r = -.235, p = .001), were higher for women than for men (3.95 vs. 3.65, t = 2.612, p= .010), and were greater for those with more education (F= 3.927, p = .009) and greater literacy skills (t = 3.839, p< .001). The ratings did not vary between racial (t = -1.108, p = .269) or insurance (F = 1.045, p = .374) groups and were unaffected by the duration of diabetes (r= .052, p = .466) and the intensity of care management (F = 1.028, p = .360). In multivariate models, literacy was the only variable contributing significantly to variation in self-management support ratings. Even when considering the objective intensity of health services delivered, literacy was the sole variable contributing to differences in patient ratings of self-management support. Although conclusions are limited by the cross-sectional nature of this study, the results emphasize the need to consider literacy when developing and communicating treatment plans requiring self-management skills.
    Full-text · Article · Sep 2010 · Nursing research
  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this article is to describe components of organizational support for self-management in primary care and provide illustrations of each of these components from the Diabetes Initiative's Advancing Diabetes Self Management (ADSM) projects. Elements of organizational resources and supports for diabetes self-management in primary care were developed from the experience of the ADSM projects and in collaboration with Diabetes Initiative staff and experts. Eight elements of organizational support for self-management were identified: (1) the establishment of patient care teams, (2) continuity of care, (3) coordination of referrals, (4) documentation of self-management support, (5) ongoing quality improvement, (6) patient input, (7) staff training and education, and (8) integration of self-management into primary care. Establishing a comprehensive system of care for people with diabetes is enabled by an infrastructure of organizational resources and supports for self-management in primary care settings. These components of organizational support provide guidance for integrating diabetes self-management services into primary care settings.
    No preview · Article · Jul 2007 · The Diabetes Educator
Show more