Online Program

Effectiveness of community based diabetes education in promoting the patient-centered medical home

Tuesday, November 5, 2013

Karen Anthony, MS, CHES, Department of Family & Community Medicine, Christiana Care Health System, Wilmington, DE
Omar Khan, MD, MHS, FAAFP, Primary Care & Community Medicine, Christiana Care Health System, Wilmington, DE
Kathy A. Cannatelli, MS, Department of Family & Community Medicine, Christiana Care Health System, Wilmington, DE
Brian Rahmer, MS, CHES, Department of Family & Community Medicine, Christiana Care Health System, Wilmington, DE
Background The majority of people with diabetes receive their care from their primary care provider (PCP) but many practices are not equipped to meet their needs. One reason is the additional resources required to provide comprehensive diabetes care, which includes diabetes educators at the point of care, as well as education for the office staff and providers. The growing number of diabetics prompted our developing grant funded programs for coordinated care. This was an opportunity to demonstrate the value of a Patient Centered Medical Home (PCMH) model, in which patient care in the office and in the community are seamless and utilize the resources of community health & preventive medicine. Methods We chose two hospital-owned practices and two private practices. Models of care were established within each practice, with some variation based on need and culture. Teams consisting of a Registered Nurse Certified Diabetes Educator (RN-CDE), Registered Dietitian Certified Diabetes Educator (RD-CDE), and a Community Educator were integrated into these practices. This team serves as teachers and coaches engaging patients in the coordination of diabetes management. Our goal was to improve patient compliance with a jointly-developed treatment plan; demonstrate improvements in selected measures; and improve patient and provider satisfaction. Results Early results show improvements in patient compliance; improved diabetes control (A1C); and high provider/patient satisfaction. Conclusion Embedding diabetes education into primary care helped to support a PCMH and improve diabetes care. The model is being assessed for financial sustainability outside a grant-funded model, and this will be discussed in the presentation as well.

Learning Areas:

Chronic disease management and prevention
Implementation of health education strategies, interventions and programs
Program planning

Learning Objectives:
Discuss the impact of diabetes educators embedded in the primary care practice. Describe the elements of a PCMH as applicable to chronic disease such as diabetes. Discuss the role of team-based care in improving patient and provider satisfaction.

Keyword(s): Disease Management, Primary Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I oversee porgrams such as practice based disease management and prevention, employee wellness, and community based healthy lifestyle programs. I also serve as chair of the Healthcare Committee for the Delaware Healthy Eating and Active Living Coalition.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

Back to: 4274.0: Primary care poster session