Gestational diabetes mellitus: A case study of failure modes and innovation for diabetes prevention among women

Gestational diabetes mellitus (GDM) signals future risk for women.  Sixty percent of women with GDM develop type 2 diabetes within the ten years following delivery . However, health systems routinely fail women as they transition from prenataland postpartum care to primary and preventive care. Our study was designed to elucidate failures in the follow-up  of women with GDM, and to test the feasibility of an  innovation, sustainable under the Affordable Care Act (ACA)-supported Patient-Centered Medical Home (PCMH) models. Methods: We conducted in-depth interviews with GDM patients (N=30) and obstetric and primary care providers (N=24) at an urban academic medical center and community health center.  Based on findings, we created a process map, identified key failure modes along the continuum of care, and populated each with narratives to highlight barriers at the systems-, provider-, and patient-levels.  Our findings informed the design of a patient navigator/motivational interview (PN/MI) intervention to improve postpartum glucose testing and successful transition to primary care.  Results: Key failure modes occur at diagnosis, referral to nutritionists, discharge summaries, postpartum visits, and communication of glucose test results to patients and primary care providers. Patients seek relief from ‘bad sugar’, a debilitating disease in their communities; providers balance reassurance and risk as they counsel patients; and electronic records are insufficient carriers of prenatal information to primary care providers. It is feasible to incorporate PN/MI in prenatal care to prepare women for ongoing self- care and prevention of future chronic illness. Conclusions: PCMH, to be successful for women of reproductive age, must include innovations that bridge prenatal and primary care.