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Before the implementation of a multidisciplinary disease-state-management program in the Kaiser Permanente Ohio Region, the primary care physician (PCP) worked with a registered nurse care manager (RNCM) and a clinical pharmacist with the degree of PharmD to control diabetes mellitus (DM). This occurred through PCP referral when patients required a higher level of care than could be achieved during initial PCP office visits and subsequent follow-up visits. However, not all PCPs consistently initiated referrals, and as patients in need of referral were typically identified through office visits, those without routine appointments were often missed. This practice translated into suboptimal 2008 comprehensive DM care Healthcare Effectiveness Data and Information Set (HEDIS) scores.

Implementation and Methodology of a Multidisciplinary Disease-State-Management Program for Comprehensive Diabetes Care