Implementation of an integrated team approach to improve diabetes care by meeting medical and psycho-social needs of an immigrant population

The prevalence of type 2 diabetes mellitus is rapidly growing in populations seen in this Federally Qualified Health Center in Washington DC, which serves an uninsured/underinsured immigrant population, made up of 80% Latino patients with additional distinct populations from Ethiopia and Vietnam. A quality improvement and process design was used to improve the clinical team approach in supporting patients with diabetes self management, as well as the overall health outcomes. Monthly integrated team rotational clinics were held, whereby diabetic patients would meet with all members of the Care Team, including clinician, RN, nutritionist, health promotion educator and case manager. Pre-clinic team meetings were held to coordinate care. Post-clinic meetings were held to debrief and agree on follow-up. Monthly meetings of the care team, supervisors and quality improvement staff discussed progress, addressed barriers and tested changes. Health outcomes included a diabetes bundle – an all or nothing measure – made up of an annual Hemoglobin A1c test, LDL test, Microalbumin test, depression screen and blood pressure screening. Additional measures included annual foot and eye exams, and contact with all members of the team. Results were tracked quarterly and compared to both baseline and patients not attending the rotational clinic. Results: Baseline and quarterly measures will be presented, in addition to qualitative and process data. Conclusion: The rotational clinic design showed itself to be a best practice model for meeting the needs of our diabetic population. Meeting with multiple members of the team reinforced simple educational messages and helped develop self management goals, whilst addressing psycho-social barriers that impede attainment of such goals. The dedicated clinic also allowed for better planning and coordination of patient care through the system of pre and post meetings, without placing undue burdens on already stretched staff capacities.