Roughly 26 million Americans have diabetes and the number is expected to soar in the coming years, reaching nearly half of all Americans by 2020. Diabetes is responsible for $116 billion in direct medical costs annually. In this yearlong series, H&HN will examine the impact the diabetes epidemic is having on the delivery system and how hospitals are responding. Articles will appear every other month in the magazine; look for additional multimedia content in H&HN Daily.

Framing the Issue:

  • Hospitals are adopting population health strategies to manage chronic conditions, including diabetes.
  • The move is prompted in part by the shift to value-based reimbursement and the effort to improve the health of patient populations across the care continuum.
  • Treating diabetes well will reduce its many complications, such as heart disease, stroke, and eye, kidney and nerve disease.
  • According to the latest data, just 19 percent of patients met the three so-called ABCs of diabetes as recommended by the American Diabetes Association.

Undoubtedly quixotic" is how David M. Harlan, M.D., describes his diabetes center's mission to help not just the 30,000 diabetics in the UMass Memorial Health Care system but all of the estimated 60,000 diabetics in the region.

"One of our mottoes is 'eyes-to-toes care with a heart,' " says Harlan, co-director of the UMass Diabetes Center of Excellence in Worcester. "We say 'eyes to toes' because of the impact diabetes has on people. It's still the leading cause of adult blindness and adult amputations, and we want to avoid both."

The center offers one-stop care for about 6,000 patients with type 1 and type 2 diabetes, primarily those with the most complicated disease. The remaining 24,000 UMass diabetic patients, typically those with uncomplicated type 2 diabetes, are cared for by another practitioner, usually a primary care physician.

Harlan describes himself as a child of the '60s, and the center's effort to reach patients outside the system reflects that era's ethos. UMass Memorial farms out endocrinologists to five other hospitals, some outside the system, on a regular basis to provide diabetes care, says Harlan, who is also chief of the diabetes division for UMass.

"We tell each one of our providers, 'If you go out there and you're Elliott Joslin to every patient you see, for that you get a C,' " he says, referring to the turn-of-the-century U.S. diabetes pioneer. "The only way you can get an A is by establishing connections with the doctors and the [diabetes] educators in that area and helping them to build a system so they can help all the patients, too."

The center charges the hospitals just enough not to lose money, Harlan says. "We never start with 'What's the business model to make this work?' We always start with 'If we wanted to build the perfect system, how would we do it?' Then we say, 'How do we get there without going bankrupt in the process?' "

The effort is part of the UMass shift toward population health management of diabetes.

Hospitals nationwide are adopting population health strategies as a way to manage chronic diseases, such as diabetes, notes Stephen A. Martin, executive director of the American Hospital Association's Association for Community Health Improvement. The increased prevalence of chronic conditions, the shift to value-based reimbursement, and the Affordable Care Act are spurring hospitals to try to improve the health of their patient populations across the care continuum. How far along they are in the transition varies widely and depends largely on hospitals' resources and their role and relationships in their communities, Martin says.

When it comes to population management of diabetes specifically, hospitals' progress likewise ranges across the board. Programs at the hospitals that are pushing the envelope all emphasize five major factors: patient outcomes, strategic use of health information technology, a team approach, collaboration with primary care physicians and patient engagement.

New quality standards

About 26 million Americans have diabetes. Treatment of the disease has changed dramatically since federal approval of the now front-line type 2 diabetes drug Metformin in 1995.

"Until about 10 years ago, the way we treated diabetes was damage control," says Christopher Sorli, M.D., chair of the Diabetes, Metabolism and Endocrinology Center at the Billings (Mont.) Clinic. "It was an inevitably progressive disease and, despite the limited tools we had available, people got worse and their insulin supplies failed, [and] they became harder to manage."

Diabetes complications are many. Among them are heart disease, stroke, and eye, kidney and nerve disease. Earlier quality measures were centered on screening for complications; so providers focused on whether the patient had an annual foot exam, kidney function test and eye exam.

The discovery of the link between blood glucose control and reduced diabetes complication risk — and an explosion of new drug therapies — have changed the way the disease is treated. "We're no longer talking about damage control," Sorli says. "The medicines allow us to modify the disease process." In short, good diabetes management can stop the disease from progressing and prevent its complications.

As treatment changes, so must the quality measures. The American Diabetes Association's care standards recommend medication approaches and intervals for screening for complications. They also recommend tests and target outcomes designed to gauge whether the patient's diabetes and its associated cardiovascular risks are under control. These goals are known as the ABCs of diabetes — A1C (blood sugar), blood pressure and cholesterol levels.

Measures that track whether providers are screening for complications are still necessary, Sorli says. However, just following those process measures "means you've missed the opportunity to do preventive medicine." In 2012, the Billings Clinic instituted a bundle of seven diabetes process and outcomes measures, including its version of the ABC goals. During the year, the percentage of patients receiving the entire bundle rose from 21 to 24 percent.

Nationwide, providers have made progress in managing diabetes, but much work remains, according to a federal study that analyzed national survey data. Just 19 percent of diabetics met the three ABC goals in the most recent reporting period, 2007–2010. That figure is up from 2 percent in the 1988–1994 reporting period. The study was published Feb. 15 in Diabetes Care.

At the Billings Clinic, the Diabetes Management Center increasingly is focused not just on preventing diabetes complications but on preventing the disease itself. The idea is to have primary care physicians refer patients with such diabetes risk factors as prediabetic blood sugar levels, obesity and high blood pressure, to the center for intervention to stop the onset of diabetes.

Attracting patients hasn't been a problem. "We get 17 new consults a day, and it's the patients we want — those who are in the preventive category," Sorli says.

The center has made inroads in the Native American community, where the epidemic is more severe. "In a couple of the Native American populations, we now get the 18- to 25-year-olds who come in and say, 'I want what my neighbor got' because they've lost 20 percent of their body weight and their blood sugars are normal," Sorli says.

This shift necessitates figuring out a way to measure prevention efforts, Sorli says. "What we really want to start tracking is whether we are screening people who are prediabetic. Are we doing the right things, the behavior modifications?"

To improve care on a population basis, leading-edge providers are beginning to use health information technology to direct their efforts and measure their success. The first step is to cull data from electronic health records or another source to identify the diabetic patient population and assess any gaps in care.

UMass developed a patient registry to create a picture of its diabetic population and its performance on a number of measures, including whether diabetics received the flu vaccine, and the timing and results for A1C, cholesterol, blood pressure and kidney function tests.

Some UMass physician practices tap into the registry to identify their patients who are doing the most poorly so they can focus attention on them, but this isn't yet done systemwide. A long-term goal is to use the data to show practices how they stack up compared with others in diabetes management, Harlan says.

Coastal Medical, a Rhode Island medical group, has been transforming its diabetes care approach in the past few years to make it more proactive, says Yul Ejnes, M.D., an internist at the practice's Cranston office. The group, a certified primary care medical home, is using its electronic health records not only to keep tabs on annual preventive screenings, but also to track such metrics as patients' A1C, blood pressure and cholesterol levels.

"One of the big conceptual changes is uncoupling what we do from the [traditional] patient visit," Enjes says. "Before, if the patient didn't visit, nothing would happen. Now with the EHR, we've been able to run reports to identify patients who are doing poorly." Doctors can use the information to modify drug therapy between visits. Patients doing poorly are referred to a nurse case manager, who helps them to lose weight or change their diet.

The Billings Clinic is working on using its diabetes registry as a tool to target resources. The idea is to "pull up our database and say, for example, 'We want all the patients who are early in the disease, they're on one drug, their A1C is less than 8.5, they have hypertension,' and then we can focus our efforts," Sorli explains.

The clinic, a regional center serving patients in Montana, Wyoming and the western Dakotas, uses its EHR and telemedicine to manage rural patients' diabetes. The clinic has outreach centers in several locations where a nurse or diabetes educator can download the patient's glucose meter, and the patient can have a telemedicine visit with a Billings endocrinologist who is accessing the EHR.

Team approach is a must

Given the complexity of the disease and the shortage of endocrinologists, a team approach to diabetes management is essential. At comprehensive diabetes centers, teams typically include endocrinologists, nurse practitioners, nurses, pharmacists, certified diabetes educators and nutritionists. They include or have close relationships with specialists who treat the disease's complications.

The programs make strategic use of mid-level providers, especially to manage care between physician visits. At UMass, a nurse practitioner looks through data from patient-uploaded glucose meters to determine who is in poor glycemic control, Harlan says. "If all of their blood sugars are high or if there are lows, she calls and intervenes right then," he says. "The idea is to prevent an emergency department visit or hospital admission because nobody knew the patient was doing poorly."

At Coastal Medical, the team approach takes pressure off the primary care physicians, says Ejnes. The nurse managers handle diabetes education and, between visits, work with high-risk patients and discuss possible medication adjustments with physicians.

Tying these teams together is the EHR. At the Howard University Hospital Diabetes Treatment Center in Washington, D.C., the EHR not only provides patient information, it also serves as a communication tool. It lets physicians and staff easily see each other's schedules and patient notes, and plan care coordination, says Gail Nunlee-Bland, M.D., the center's director.

Electronic records are particularly useful because diabetes center patients often see more than one provider on the same day. "We're finally getting to a point where the integration and the technology are becoming a very valuable clinical tool," Sorli says. "If a patient drives from 300 miles away, I see that patient in initial consult. Then they go to the eye doctor and their foot doctor, and my note is available about what we did. It's a huge benefit for the patient and the referring doctor."

The shortage of endocrinologists and population health management's emphasis on primary care makes primary care physicians key to diabetes management efforts.

UMass began rolling out MyCareTeam, a diabetes management software platform, to the system's primary care physician practices in July 2012. The product, integrated with the Allscripts EHR, allows patients to regularly transmit their blood glucose readings directly from their glucose meters — along with blood pressure, weight, vital signs, caloric intake and exercise — to a database through the Internet. It presents patients and their care teams with data in an organized way that allows them to see blood glucose control patterns.

"What [PCPs] hated was patients' coming in and handing their meters to the doctor or the nurse and saying, 'My sugars are all in there,' " Harlan says. "They'd have to scroll up and down, and you just can't see patterns that way."

At the Billings Clinic, referring primary care physicians, both employed and independent, get monthly reports on how well they're managing their diabetic patient populations. It's broken down into red light/green light depending on whether the practice has met certain metrics.

Sorli conducts grand rounds lectures, which are broadcast to remote sites, to help primary care doctors keep up-to-date on the latest drug therapies and treatment guidelines. "The system allows me to see the patient, and then that patient goes back to his or her primary care doctor who is going to handle the bulk of [the care]," Sorli says. "I want that primary care doctor handling those in a preventive, latest-greatest fashion, not doing damage control and letting the disease progress."

Primary care disease management and the diabetes center's education and healthy behavior programs should reduce specialist visits and save money by preventing costly complications.

The patient's obligation

"All of these efforts will fail unless patients buy into this," Harlan says.

Involving patients in managing their diabetes is a major MyCareTeam goal. "The nice thing about MyCareTeam is that it color-codes the blood sugar number," says Kimberley Johnson, R.N., UMass certified diabetes educator. "Blue means they're below their ideal target, green if it's their target, and red if it's above their target. It's very easy for patients to identify patterns in their blood sugar just by the color."

More than 4,600 UMass patients are enrolled in MyCareTeam, which the system began to roll out in June 2011. A patient engagement team is working to boost that number and plans to set up kiosks at the hospital where patients can learn about the tool and how to upload their glucose meters.

At Howard University Hospital, the Diabetes Treatment Center is engaging patients through a personal health record, NoMoreClipboard. The portable, patient-controlled PHR launched at Howard in 2009, gives patients access to their clinical information in a user-friendly format via computer or smartphone. It's integrated with the hospital's EHR, so patient lab results, problem lists, progress notes and medications automatically flow into the PHR.

Since the program began, patients' A1C levels dropped from an average of 8.9 percent to 7.7 percent, says Nunlee-Bland.

Hospitals also are taking advantage of outside resources to enhance patient engagement. Wishard Health Services, an Indianapolis safety net system, has received a Richard M. Fairbanks Foundation grant since 2006 to offer free wellness coaching to patients. Because HealthyMe is targeted to patients who are obese or overweight with cardiovascular risk factors, many participants are diabetic. The four wellness coaches focus on weight loss and healthy eating, says Lisa Pastotnik, manager of HealthyMe.

HealthyMe has an online Facebook support group, in-person support groups, exercise classes, cooking demonstrations and regular open weigh-ins. The clinic's dietitians offer monthly diabetes management programs.

The payment paradox

Hospitals walk a fine line between delivery reform and payment reform. By and large, payment is still based on the fee-for-service model, but good diabetes management results in fewer visits and, thus, less income.

"We will go out of business unless the switch is flipped that says from now on we will pay you based on how your patient population does, as opposed to how often you see them," Harlan says.

"The tricky thing is the transition," Harlan says. "So, we've got a foot in the boat and a foot on the dock. Everybody knows the boat is leaving at some point, and the question is: When do you jump onto the boat?"

Geri Aston is an H&HN contributing editor.

Executive Corner

Transform quality measurement

New drug therapies have changed diabetes from an inevitably progressive disease with inescapable complications to a condition that can be controlled with disease management. As a result, hospitals should assess care quality not only by using process measures, such as whether patients get tests at the right intervals, but also by utilizing outcomes measures, such as whether patients' blood sugar levels meet the desired target.

Maximize information technology

Electronic diabetes registries that cull information from electronic health records help to identify the patient population and any gaps in care so disease management resources can be appropriately targeted. EHRs can uncouple care from the patient visit to find patients who are doing poorly and intervene between appointments. They are instrumental in communication and coordination among care team members.

The team approach

Diabetes is a complicated disease managed through medication, blood sugar checks and patient lifestyle changes, so it requires a team approach that involves endocrinologists, primary care physicians, mid-level providers, diabetes educators and dieticians. The short supply of endocrinologists means disease management efforts should make strategic use of mid-level providers and involve and assist primary care physicians.

Engage patients

No matter how sophisticated the disease management program, it won't succeed without patient buy-in. Beyond patient education and behavior modification classes, hospitals are using personal health records, patient-friendly diabetes management software, and in-person and online support groups to engage patients.