Care Management: Assisting the Patient Who is Not at Goal

Nationally, between a third and half of patients with diabetes do not meet targets for glycemic, blood pressure, or cholesterol control.1 Patients may not meet treatment goals for a variety of reasons. What’s important from a primary care perspective is to seek continued engagement with the patient. Population management can serve as a valuable resource for systematically identifying patients who are poorly controlled and bring attention to patterns of control, assuming they come in for routine or somewhat routine visits and have their lab work done. Proactively contacting patients provides the opportunity to encourage patients to schedule a visit with the appropriate clinician to reassess a treatment regimen and identify other factors that may be interfering with or negatively influencing a patient’s ability to meet their treatment goals. Such factors may include changes in income or insurance coverage, increases in diabetes-related distress, depression, other health conditions, or competing demands. Validated assessment tools can help identify and assess changes in these factors, including diabetes-related distress,2 self-efficacy,3 self-care activities,4 and medication-taking behaviors.5 Once identified, the health care team can then work with patients to address the barriers, either directly or through referral to other medical or community resources.

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