5 Things Hospital Administrators Should Know About Diabetics and Population Management

In Richmond, Va., two large hospital systems – Bon Secours and HCA – have competed keenly over market share for decades, competition that has ultimately benefited patients with innovation and improved services. However, something the two systems agree on is the good work that Cross Over Healthcare Ministry, Virginia's largest free clinic, does in keeping low income, uninsured patients, especially diabetic patients, from relying on the emergency room for primary care. For five years, the two systems have jointly funded salary expense of one of the free clinic's two full-time primary care physicians.

J. Stephen Lindsey, FACHE, chairman of the board at Cross Over Ministry Free Clinic, and a former hospital CEO in Richmond, has a unique view of the partnership. "Much of what is now transpiring in healthcare is focused on population management to keep all of us healthy and out of the hospital," he says. "Bon Secours and HCA are visionary in this regard in their funding of the Cross Over Ministry Free Clinic." According to Mr. Lindsey, the six month results of the most recent 100 patient population being tracked under a federal grant found the average A1c score of the patients has been reduced from above 10 (poor) to 8 or lower (good).

5 steps to keep diabetics out of the hospital

Cross Over Ministry Free Clinic follows a five-step program to keep its diabetic patient population out of the hospital.

1. Grace and truth.
According to Mike Murchie, MD, one of two Cross Over full-time primary care physicians, a diagnosis of diabetes takes a profound mental and spiritual toll on a person's well being. The five stages of grief (denial, anger, bargaining, depression, acceptance) can often be observed in these patients. Additionally, most Cross Over patients already are experiencing social and/or financial upheaval. Many speak very little English and are learning a new culture. All of this requires time and patience from the clinical staff to achieve the best results. Expressions of compassion and grace engender an alliance with the individual, allowing for these expressions to be paired with sober, truthful communication that explains the toll diabetes can have if the individual is noncompliant to the treatment plan.

2. Multidisciplinary. Diabetics suffer from a very well known set of complications that are predictable and will escalate to crises level (inpatient hospital care) if not actively managed. At Cross Over, diabetic patients are actively co-managed by specialists including ophthalmologists, dentists, podiatrists and mental health counselors. They also receive preventative health screenings such as mammograms and colonoscopy (for those over age 50). And any patient with an A1c over 8.5 is assigned to the Diabetes Intensive Care Clinic, which commences with a one hour meeting with a pharmacist for counseling and education.

3. Time intensive. Dan Jannuzzi, MD, Cross Over's medical director for the past 24 years, has seen much change in the care of Type 2 diabetes. According to Dr. Jannuzzi, it takes time to actively manage diabetics to keep them out of the hospital. This means more than the 15-30 minutes of patient time currently allowed under common practice models. This may be the biggest challenge in delivering on the concept of population management. Under current reimbursement systems, physicians must, as small business men and women, see as many patients as possible in a day to pay their practice overhead, staff and earn their income. However, new reimbursement models for primary care physicians under healthcare reform should start rewarding physicians who switch to the population management model. Expanded reimbursement for the non-physician care giver, including pharmacist, nurse practitioner and physician assistant providers, will also be required.

4. Ready access to therapies and technology.
Access to regular A1c testing, as well as the medicines to manage diabetes (pills and insulin) is paramount. The cost of these tests and medicines has traditionally been a barrier to managing uninsured low-income diabetic patients. This in turn feeds into the prevalent cycle of diabetic patients seeking care and management though an emergency room. ER physicians are trained to care for patients who are at imminent risk of dying, not managing chronically ill patients. ER physicians also do not have the time necessary to effectively manage diabetic patients. And finally, an ER is the most expensive point-of-entry into the healthcare system. At-risk diabetic patents are best managed in an outpatient setting, such as free clinics.

5. Continual system improvements. Tracking clinical results is vital to validating and improving the diabetic care model to achieve the results of better outcomes and lower costs. Cross Over has documented results that several compliant patients in their Diabetes Intensive Care Program was able to lower their A1c scores by an average of 2 points into the good range within 120 days. For individuals to achieve this kind of success, radical lifestyle change and regular office visits are required. At the time of diagnosis, a diabetic is informed of the following requirements for success:

  • Diet overhaul, including counting carbs with each meal
  • Exercise five days a week
  • Taking several pills a few times a day; learn to deal with their side effects
  • Injecting insulin (up to four times a day)
  • Finger pricks to test sugar 1-3 times a day
  • Checking their feet for infection daily
  • Physicians visits every three months
  • Eye doctor visit annually

Healthcare practices need to recognize the overwhelming changes required of their patients. They must continually improve their systems so that patients can have access to the entire healthcare team in a way that is "user-friendly." For hospitals, a new era  of population management, will enable administrators to improve their community health in caring for at-risk patients out of the emergency room. Often the best path for hospitals is to support community partners who know and understand the underserved patient.

John W. Mitchell is a long-time hospital manager and administrator and, along with his executive team, was named "Top Leadership Team in HealthCare for Mid-Sized Hospitals" in 2009.

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