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Patients with diabetes are at risk for harm events due to poorly designed care processes within the outpatient/ambulatory environment. Additionally, the many different settings that patients navigate during the course of their lives each present challenges and issues that must be carefully considered by patients and caregivers. To optimize primary care delivery and care coordination for increased quality and safety, the patient centered medical home model has been developed. Many of its attributes are listed below.

Key Office-Based Care Processes

  1. Referral tracking and communication optimization
    Patients with diabetes often require the care of multiple different specialty physicians, such as endocrinologists, cardiologists, and nephrologists. Developing clear processes that outline the nature of the required communication elements and responsibilities of both primary and specialty doctors is important. The nature of the relationship and interactions between physicians ideally would occur within the construct of the patient centered medical neighborhood. The ACP outlines the requirements for optimal communication between parties (PDF, 301 KB) and provides additional tools to assist practices in referral tracking.

  2. Test tracking
    Patients with diabetes require regular and ongoing monitoring of a variety of metabolic parameters, such as A1C, lipids, and renal function. Patient safety is at risk when the results of ordered labs are not tracked. Lack of tracking creates situations where health care practices may not be aware that patients did not have labs drawn, or had labs drawn that were not reported to the ordering practice. Advances in health information technology allow for the tracking of labs within electronic medical records. New standards and general guidance on office-based improvement in the arena of test tracking can be found from the American Academy of Family Physicians.

  3. Care coordination
    Poor care coordination can lead to less-than-optimal outcomes as well as patient harm. There are multiple mechanisms and tactics that health care practices can use to improve care coordination, and many of them are reviewed by the Agency for Healthcare Research and Quality.

  4. Medication reconciliation
    Medication reconciliation is the process of reviewing a patient’s medication list as recorded in the medical record, reviewing it with the patient, and correcting it as necessary to make it accurate and complete. Medication reconciliation should ideally be done at every office encounter. This requirement is a Joint Commission National Patient Safety Goal. The Joint Commission's National Patient Safety Goals are presented by type of practice and location. Failure to perform an adequate medication reconciliation can lead to harm through medication errors.

  5. Let the Evidence Guide You

    Learn more about interventions to help patients play a more effective role in their own health care.

    Coulter A. Patient engagement–What works? (PDF, 97.7 KB). J Ambulatory Care Manage. 2012;35(2):80-9.

  6. Medication management
    Patients with diabetes are often on complex medication regimens. Multiple applications exist that allow health care professionals to scan medication lists for drug-drug interactions, drug-health issue interactions, and drug-lab value concerns. More comprehensive solutions that optimize medication regimens for efficacy and safety have been developed and involve office-based pharmacists as key members of the health care team. Increasingly, technology is playing a role in medication management.1

  7. Patient-centered care and engagement
    Patients who are not engaged in their health care are more likely to suffer adverse events. Patients who are motivated to take ownership and control of their care are more likely to have desirable outcomes.

References

1. Brummel A, Lustig A, Westrich K, et al. Best practices: Improving patient outcomes and costs in an ACO through comprehensive medication therapy management. J Manag Care Spec Pharm. 2014;20(12):1152-8.

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