Bridge Clinic: Spanning the gulf between the emergency department and a medical home for the uninsured

Background: According to the American Diabetes Association 2011 statistics, of the estimated 25.8 million people in the United States with diabetes mellitus (DM), 7 million are currently undiagnosed.

Objective: 1) Decrease the morbidity, mortality, and economic burden secondary to poorly controlled DM and HTN among the uninsured by identifying those persons in the emergency department (ED) 2) Design a grant funded clinic for follow-up and referral to a medical home for those diagnosed with DM and HTN.

Methods: Uninsured patients with risk factors for DM and HTN are identified in the ED. Patients with two or more DM risk factors or a random blood sugar of > 155 receive a bedside HbA1C test which, if > 6.5 are then referred to the Bridge Clinic for repeat HbA1C and glucose tolerance test. Appropriate evidence-based care is then initiated per test results. Patients with a systolic blood pressure > 140 or a diastolic pressure > 90 measured two times without an extreme-causing stressor such as intense pain are also given follow up appointments at the Bridge Clinic. These patients are then placed in a medical home for chronic management. Results: Patients that followed up with the ED run Bridge Clinic and received interventions experienced substantial reductions in blood sugar and/or blood pressure. Newly diagnosed DM patients on oral therapy. Patients with a HgA1c >10 were initiated on low-cost insulin protocol and followed by diabetic specialists until their Hg A1c was < 10. Hypertensive patients were started on antihypertensive medications. All patients were transferred to a medical home for the uninsured within our university health system. During the weeks for the first appointment to the medical home, DM patients were managed at the Bridge Clinic in the interim and hypertensive patients were seen until medication was titrated. A large number of referred patients did not follow up with the Bridge Clinic perhaps due to transportation, time, or other constraints.

Conclusion: Uninsured patients represent a population vulnerable to complications secondary to undiagnosed DM and/or HTN or diagnoses made late in the course of disease progression causing significant stress to their own lives as well as health system. These patients can be identified in the ED (where they often seek primary care) and bridged over via a similar clinic to a definitive medical home.