The Patient-Centered Medical Neighborhood and Diabetes Care

The health care system is changing, and reimbursements are increasingly being linked to quality measures, performance, and, in some cases, cost. The Affordable Care Act provides a financial incentive to find strategies to achieve its triple aim of improving the health of the population, improving quality and access to care, and controlling the costs of care. This era of health care reform presents an unprecedented opportunity for innovative chronic disease management approaches, particularly for diabetes, a highly costly prevalent disease.Diabetes is increasing in epidemic proportions, affecting 22.3 million Americans. Direct costs of diabetes care are $306 billion annually, or more than one of every five dollars spent on medical care in the United States.1 Despite the high cost of care, few patients meet the evidence-based guidelines for diabetes management. Only an estimated 14% of patients are at goal for A1C, blood pressure, LDL cholesterol, and tobacco use.2The entire health care system is challenged in caring for patients with diabetes, but primary care providers (PCPs) are at the forefront of management, providing > 90% of diabetes management. Increasingly, PCPs have been restructuring their practices into patient-centered medical homes (PCMHs). The PCMH model encourages partnerships between individual patients and their providers through a team-based approach to better coordinate care using population-based registries and combining elements of the Chronic Care Model (CCM).3The PCMH model has shown promising results as a cost-effective strategy to deliver quality care to those with chronic diseases, including diabetes.4,5 The process of transforming a medical practice into a PCMH is now being supported financially by federal initiatives such as the Medicare Advanced Primary Care Practice and Comprehensive Primary Care demonstrations,6 the Bureau of Primary Health Care's call for all federally qualified health centers to become PCMHs, and initiatives of …