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The Master Plan to Bring Diabetes under Control
There’s a new wave in community medicine that is driven by a rise in the number of people with diabetes and the escalating costs of their care.
From coast to coast, this increase has caught as much media attention as the threat of avian flu. Associated Press reported “About 2 million U.S. children ages 12 to 19 have a pre-diabetic condition linked to obesity and inactivity that puts them at risk for full-blown diabetes.” UCLA’s Health Policy Brief reports that “Nearly 1.7 million California adults age 18 and over (6.6%) have been diagnosed with diabetes, up from 1.5 million in 2001.
RFHC is especially concerned because there is a higher incidence of diabetes in the population groups that we serve. In fact, it is the leading chronic disease with 517 patients diagnosed as diabetic in 2005.
Who’s in Control
To improve the quality of chronic care, RFHC is participating in a federally sponsored Health Disparities Collaborative that is piloting a new approach—a chronic care model that is being adopted by many in the medical community.
As the Physician Champion on RFHC’s Health Disparities Chronic Care team, Dr. Jaime Chavarria says, “Not much happens if you just tell a patient you need to exercise and watch your diet. The new approach in chronic disease care is to make the patient an equal partner on the team and empower them to take charge of their health and medical decisions. It is in partnering with the patients and listening to them that we can understand what challenges they face in improving diet or getting into a routine of exercise. We have to help them break down the barriers.”
To adopt this model of care is a learning process that involves the entire team in reinforcing and helping the patient to attain their goals. The HDC team meets monthly to evaluate the effect on care and ways to improve. Any team member can initiate an improvement process that then tested and adopted if it works. “We don’t have it down quite yet, but we’re evolving, and more staff members are participating in improving patient care.”
RFHC can gauge chronic care outcomes by generating reports from PECS, a disease registry that tracks standard disease measurements. “It gives us a much more accurate picture of how well our diabetic population is doing.” These measures are also compared with other clinics nationwide also participating in similar programs. Palo Alto Medical Foundation is providing their technical expertise in quality improvement and population management.
But in the end, in this model of care, it is the patients who make the improvements happen.
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Controlling Diabetes