Open AccessCare Team Integration in Primary Care Improves One-Year Clinical and Financial Outcomes in Diabetes: A Case for Value-Based Care
Author(s) -
Addie L. Fortmann,
Chris Walker,
Kelly Barger,
Maire Robacker,
Robin Morrisey,
Kristine Ortwine,
Ioanna Loupasi,
Ina Lee,
Lou Hogrefe,
Christine Strohmeyer,
Athena PhilisTsimikas
Publication year - 2020
Publication title -
population health management
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.998
H-Index - 40
eISSN - 1942-7905
pISSN - 1942-7891
DOI - 10.1089/pop.2019.0103
Subject(s) - medicine , psychological intervention , health care , medical record , family medicine , coaching , telehealth , glycemic , collaborative care , nursing , chronic care , diabetes mellitus , telemedicine , psychology , primary care , endocrinology , economics , psychotherapist , economic growth
Despite significant treatment advances, diabetes outcomes remain suboptimal and health care costs continue to rise. There are limited data on the feasibility and financial implications of integrating a diabetes-specific care team in the primary care setting (ie, where the majority of diabetes is treated). This pragmatic quality improvement project investigated whether a cardiometabolic care team intervention (CMC-TI) could achieve greater improvements in clinical, behavioral, and cost outcomes compared to usual diabetes care in a large primary care group in Southern California. Over 12 months, n = 236 CMC-TI and n = 239 usual care patients with type 1 or 2 diabetes were identified using the electronic medical record. In the CMC-TI group, a registered nurse (RN)/certified diabetes educator care manager, medical assistant health coach, and RN depression care manager utilized electronic medical record-based risk stratification reports, standardized decision-support tools, live and remote tailored treatments, and coaching to manage care. Results indicated that the CMC-TI group achieved greater improvements in glycemic and lipid control, diabetes self-management behaviors, and emotional distress over 1 year compared with the usual care group (all P < .05). The CMC-TI group also had a significant 12.6% reduction in total health care costs compared to a 51.7% increase in the usual care group during the same period and inclusive of CMC-TI program costs. Patients and providers reported high satisfaction with CMC-TI. These findings highlight that team-based care management interventions that utilize nurses, medical assistant health coaches, and behavioral specialists to support diabetes patients can help primary care practices achieve value-based targets of improved health, cost, and patient experience.