Program Developed to Help At-Risk Type 2 Diabetes Patients Receive Necessary Care
Date Posted: Tuesday, February 18, 2020
The key to a long and healthy life for people living with type 2 diabetes is maintaining blood glucose within a specified target range. Proper diabetes self-management results in healthy blood sugar levels, thus reducing the risk of developing serious complications from poorly-controlled diabetes. Regular blood glucose testing is extremely important. This includes using a meter or continuous glucose monitor throughout the day and quarterly A1c tests.
Many people receive their diabetes care from a primary care provider (PCP). Experiencing multiple chronic health problems and limited time with PCPs makes receiving comprehensive, guideline-recommended diabetes care a challenge. This new initiative, funded by the inaugural Herman G. Berkman Diabetes Clinical Innovation Fund award, tracked UMass Memorial patients at risk for adverse outcomes due to care gaps. It proactively engaged them to identify their difficulties and “nudge” them towards available services and resources to get them back on track.
The project was a collaboration between UMass Memorial Health Care and UMass Chan Medical School, led by Daniel Amante, PhD, MPH, and Adarsha Bajracharya, MD. A program was developed within the Electronic Health Record (EHR) system to identify people with type 2 diabetes who have not recently visited their PCP, have an A1c greater than 8%, are due for an annual eye, foot, or urine test, or have not received an A1c test within the past six months.
Specially trained outreach specialists contact patients to learn about the challenges and frustrations that hinder their ability to manage diabetes. The program has uncovered a wide range of obstacles that have kept people from receiving necessary care, including transportation issues and the cost of insulin and other medications.
The outreach specialists inform people that the UMass Memorial diabetes clinic offers education on topics such as getting started with healthy eating and physical activity, blood sugar monitoring, problem-solving, and reducing the risk of complications.
This approach has yielded positive results, with more patients now receiving their recommended tests and seeing their providers. Helping people manage diabetes can prevent or reduce the risk of complications, reduce costs, and improve their quality of life.
While the program was designed to improve diabetes care management for at-risk patients, the strategies can be applied to help with other chronic disease management.
Additional Berkman Fund Recipients
Developing a Liver Disease Screening Process in the Adult Diabetes Clinic
Liver disease is strongly associated with type 2 diabetes and obesity. It remains underdiagnosed and undertreated, and many people living with T2D are unaware they have it. This project, led by Endocrinologist Madona Azar, MD, implemented a new process in the UMass Memorial diabetes clinic that uses a screening tool to analyze clinically available data to determine patients' risk of liver fibrosis.
AI Diabetic Retinopathy Screening in Primary Care
This project implemented an artificial intelligence (AI)- based diabetic retinopathy screening program in Family Medicine clinics to detect eye disease and improve comprehensive care for people living with diabetes. Recent studies have identified AI-based algorithms as promising tools for screening and early detection of diabetic retinopathy, helping those at risk. This study, led by optometrist Juan Ding, OD, PhD, tested the diagnostic accuracy of a hand-held AI-assisted camera used by primary care physicians to screen at-risk individuals for retinal changes indicative of diabetic retinopathy.
The GOOD-ER Program
This randomized clinical trial provided continuous glucose monitors (CGM) to people with diabetes who were currently not using one and arrived at the Emergency Room with high or low blood sugar, or other diabetes-related complications. The recently completed study, led by endocrinologist Dr. Mark O’Connor and emergency physician Dr. Laurel O'Connor, analyzes whether CGM successfully prevents people from returning to the ER with diabetes-related issues, compared with the control group who do not wear a device to monitor their blood sugar.
Improving Inpatient Blood Glucose Management
This project aimed to implement a carbohydrate-counting system for hospitalized inpatients with diabetes across the UMass Memorial Health system. Endocrinologist Dr. Leslie Domalik evaluated whether adopting a flexible meal dosing option based on carb counting would improve the outcomes of hospitalized patients with diabetes. By coordinating the timing of blood glucose testing, insulin dosing, and the administration of rapid-acting mealtime insulin, she wanted to ensure carbohydrate counts are listed for all food served to hospitalized patients and to better coordinate insulin delivery with meal delivery.