A whole-patient, coordinated approach
By Peter Frederixon, MD
From Minnesota Healthcare News
Health, diabetes affects about 24 million people in the United States alone. Of that number, only 18 million (three out of four) have been diagnosed. Sadly, the risk for death among people with diabetes is twice that of people of
the same age without diabetes.
There are two main types of diabetes. Type 1 diabetes develops when the body’s immune system destroys cells that make insulin to regulate blood glucose. Type 2 diabetes, which accounts for between 90 percent and 95 percent of all cases, is often called adult-onset diabetes. Here, the pancreas gradually loses its ability to produce insulin. Obesity is a great risk factor for type 2 diabetes. Other risk factors include physical inactivity, family history, and age. The risk of type 2 diabetes increases after age 45.
Diabetes is serious, not only because it can disrupt your lifestyle, but also because of the long-term complications it can cause, including heart disease and stroke, high blood pressure, kidney disease, diseases of the nervous system, amputation of feet and legs, dental diseases, and serious eye problems including blindness. Not only can these complications affect your quality of life for many years, but they also put a tremendous strain on the health care system.
Fortunately, diabetes can be controlled for most people by eating healthy meals, losing excess weight, exercising, keeping blood pressure within the normal range, and maintaining healthy cholesterol levels. Some people, however, may also need insulin to control their diabetes. We are fortunate that there are several effective medications on the market today, including faster-acting and longer-lasting insulin, oral diabetic agents, smaller and more convenient blood glucose meters, and implantable insulin pumps that automatically record blood sugar levels and deliver the appropriate amount of insulin.
As reported on the Minnesota Community Measurement Web site (www.mnhealthscores.org), Apple Valley Medical Clinic had the state’s highest percentage of patients receiving optimal diabetes care in 2009. Optimal care was based on patients meeting the following five goals:
- Keeping blood pressure under 130/80
- Lowering LDL or “bad” cholesterol to below 100 mg/dl
- Taking an aspirin every day, for those 40 and older
- Not smoking
- Controlling blood sugar so the A1C level is less than 7 percent
Apple Valley Medical Clinic set the benchmark in the medical group category, with 44 percent of patients in full compliance with all five components. That compared with an average of 19 percent among the 178 medical groups that participated in the program.
Clinic staff worked hard to achieve this distinction. Our “secret” is caring for the whole patient. Two years ago, we began to focus more deliberately on this at-risk patient population. We built a registry of patients with diabetes to enable us to track them better. The program provides our staff with daily reminders on patient status so issues can be addressed immediately.
We put considerable time and effort into both pre-visit and postvisit planning and review of a patient’s charts. We have created a brightly colored card of all five “indicators” so that when physicians see patients with diabetes, this important information is right in front of them. The clinic conducts weekly education classes for patients and is diligent about following up with patients who haven’t been in for awhile.
A medical home pilot
This year, we also began a medical home pilot with Medica for patients with diabetes. A medical home is an approach to care in which health care providers, families, and patients work together to improve the health outcomes of those with chronic or complex health conditions. Health care payers, such as Medica, pay a per-patient care coordination fee to a doctor, clinic, or team of practitioners to manage the care of patients with complex, chronic illnesses, such as diabetes.
This payment is in addition to what a doctor receives for care he or she specifically provides to the patient. The hope is that this coordination of care will increase a patient’s compliance and improve outcomes while decreasing cost. Since most health care spending goes to treat a small percentage of chronic conditions, addressing these conditions aggressively is likely to save money.
Four medical associations—the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association—have developed joint principles to describe a patient-centered medical home. These include an ongoing relationship between a patient and a personal physician trained to provide continuous care. This physician leads a team of individuals who take responsibility for coordinating care for the whole person across all elements of a sometimes-complex health care system.
While today’s health care environment is dependent upon the physician seeing the patient, we are trying to be more creative with different care options. Our goal is to reduce costs for our patients and continue to improve their overall clinical outcomes.
The National Committee for Quality Assurance states that in order to qualify as a patient-centered medical home, a practice has to demonstrate proficiency in several areas, including the use of written standards for patient access and communications, performance measurement and reporting, and active support of patient self-management.
Patient self-management is an important component of controlling diabetes. If you have diabetes, you need to watch your diet and eat healthy foods, such as fruits, vegetables, lean meats, whole grains, and low-fat or skim milk and cheese. Increase foods with fiber and decrease those with fat and salt. If you don’t have a meal plan, ask your doctor to help you create one. Exercise is important to stay at a healthy weight. We all should get 30 to 60 minutes of physical activity most days of the week.
Having diabetes can change your mood. If you feel depressed, ask for help. Learning how to cope with stress, including the stress of having a chronic disease, is an ongoing process, and many people need help achieving a healthy mental state. Other important health tips to remember:
- If you smoke, stop.
- Brush your teeth and floss every day to avoid dental issues.
- Take your medicine even if you are feeling good.
- Check your feet every day for sores that do not heal.
Important research is being conducted around the world to find new and improved treatments for the disease. Some of this involves prevention, early detection, and early intervention. Other research involves islet cell transplantation or immunology and immunogenetics to support risk identification and potential new treatments. Researchers are also exploring new treatments to prevent vascular and cardiac damage. Continuous glucose meters are being enhanced to reduce the need for finger pricks to test blood sugar levels. There even are implantable glucose meters and implantable pumps to make diabetes control almost automatic.
Don’t let diabetes control you. Controlling diabetes is a partnership between you and your physician. Together, we can make your life as comfortable and as normal as possible.
Peter Frederixon, MD, is a family medicine physician at Apple Valley Medical Clinic.