Patient-centered care. Coordinated care.
These are two of the many buzzwords heard concerning healthcare. But what do they mean? Or, perhaps the better question: What do they actually look like in practice?
Look no further than the Diabetes Clinics that have occurred the last few months at The Corvallis Clinic’s North Albany Village office. These clinics have provided a team approach to this chronic disease, involving a physician and other diabetes health professionals.
“Physicians often don’t have enough time to spend with patients,” said Dr. Robert Wirth, an internist at North Albany Village, who organized the Diabetes Clinics after reading an article in a medical journal about team-based care for certain chronic diseases. “Sticking with a plan of care for diabetes is hard for patients and their families. Lots of ongoing support is needed, and a team approach provides for this better.”
This slant on diabetes management offers patients with providers committed to evaluating their unique needs.
“Each patient faces different barriers and challenges with their health and diabetes,” said Erin Bartek, RN, who provides additional patient support at the clinics, along with fellow RN Lindsay Rickli and registered dietitian Deborah Bella. “By putting minds together from different backgrounds we can bring forward new ideas to help patients live with their disease and simultaneously offer them guidance and someone to call when they need additional support.”
Bartek, Rickli and Bella are Certified Diabetes Educators (CDE). Bartek and Rickli are registered nurses with Care Coordination and all three are involved with the Diabetes Self-Management Education Program, which has recently been awarded the prestigious American Diabetes Association Education Recognition Certificate.
Continuation of Care
The first of the Diabetes Clinics occurred in July 2015 and have continued every three months. They center on a group of Dr. Wirth’s patients who face particularly hard challenges with the disease, resulting in high Hemoglobin A1C readings, which show a person’s average levels of blood glucose over the preceding three months. The participants first see Dr. Wirth, and then either Bartek or Rickli, before ending the appointment with Bella.
“It is wonderful to be able to take the information and a recommendation that a primary care provider has introduced and really spend the time expanding upon this to ensure that the patient feels comfortable and that all questions have been answered,” Rickli said. “The ‘warm hand-off’ and support on the same day adds comfort to a potentially intimidating scenario, such as beginning a new injectable diabetes medication. We provide a great deal of follow-through and support in this way.”
In addition, the clinics enable the patients to help achieve their overall goals more efficiently with one stop.
“We are able to communicate information on the spot,” Bella said. “If I have blood glucose levels for a patient before my visit, I can spend our time on other aspects of diabetes care. If I know that one of the CDE-RNs focused on medication consistency, I can reinforce that message and add another educational piece that is of interest to the patient.”
The care and support do not cease between clinics. Bartek and Rickli follow up with each patient by phone within two weeks, with some in-person visits as well. Bella sees patients who request additional nutrition information. Alan Schrader, a licensed clinical social worker in Care Coordination, is also available between clinics for help with both stress management and with social issues that impact self-management. “Stress management has been recognized as contributing to lower A1C levels, along with following medication directions, eating appropriately, and exercising,” Schrader said.
In addition, all the patients continue to see Dr. Wirth for their routine visits.
‘Thank you’
One patient who especially appreciates the one-stop clinic is Lois James. “It is great savings in gas and travel time,” said the 69-year-old Lebanon resident.
James is also happy that at the October clinic Bartek correctly showed her how to use Victoza, an injectable diabetes medication prescribed when other oral medications have been unsuccessful in lowering blood glucose levels. At that time, James’ A1C level was elevated at 7.6 percent. According to the American Diabetes Association, normal for people with diabetes is considered below 7 percent. Turns out, she was only giving herself about one-hundredth of the needed dose.
“It’s a multi-step process, and the delivery device can be confusing to use until a patient becomes accustomed to the multiple steps,” Bartek said. “When I met with Lois in October, I asked her to demonstrate to me the multiple steps and one essential step was being missed. Therefore, we were able to work together for her to learn its proper use.” At the most recent clinic in February, James’ A1C was down to 6.2 percent. “That’s incredible,” Bartek said. As a result of her improved A1C, James is able to cut in half the dose of another medication also for blood-glucose lowering that has potentially dangerous side effects.
James reported her energy level is higher now than last July. “I’ve gotten out and walked with my husband and grandchildren,” she said. She has lost 11 pounds and is thinking about water aerobics. “I feel like I can be more active.”
When patient and RN met again during the February visit, James offered a big “thank you” to Bartek. “Thank you,” the RN responded, “I’m just really happy for you.”
A happy patient and a happy provider: Picture perfect patient-centered, coordinated care.
Related story: Diabetes self-management program earns certification
