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

摘要

>Introduction: 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.>Methods: A quality-improvement disease-management committee convened for design and implementation of a multidisciplinary DM disease-state-management program, as well as oversight and analysis of the new process. This regional intervention required many members of the health care team to obtain additional education about comprehensive DM care, adopt new work flows, and learn to use tools for evaluating patient care gaps.>Results: Within one year, this regional multidisciplinary intervention resulted in improvements in blood pressure, lipid levels, and glycemic control as indicated by 2009 comprehensive DM-care HEDIS scores.>Discussion: Main contributors to the success of the program included executive support and sponsorship, the leadership of the oversight committee, systematic identification and assignment of patients, the blood-pressure service run by licensed practical nurses, continuous education efforts, dedicated panel-management time, use of a multidisciplinary team, and expanding treatment of the diabetic patient beyond glucose control to include blood pressure and lipid management.