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Case Study 5: A Collaborative Team Approach to Managing Diabetes in a Clinic Setting

Roger P. Austin, M.S., R.Ph., C.D.E.

Setting

The Henry Ford Health System in Detroit, Michigan, operates four Diabetes Care Centers in outpatient clinic facilities geographically distributed across metropolitan Detroit.

Team members

Registered nurses, nurse practitioners, and clinical pharmacists who are also CDEs, primary care physician “champions,” and specialty care physicians of the Henry Ford Medical Group.

Services

The Diabetes Care Centers’ services require referral from a physician who is part of the closed medical group practice model. Any patient with diagnosed diabetes and an A1C ≥7 percent is eligible for referral. Clinic enrollment is intended for six months and involves frequent interaction with the patient via face-to-face visits, telephone, or email. Services include an initial assessment of the patient’s major concerns about diabetes self-management and associated self-care behaviors (eating patterns, physical activity, medication taking, stress management, problem-solving ability, self-monitoring of blood glucose, and risk-reduction practices). Patients are screened for depression and possible referral for behavioral health counseling. Motivational interviewing methods help patients actively engage in their disease management. Referrals are made as necessary to other Henry Ford Medical Group specialists including cardiology, nephrology, neurology, ophthalmology, and podiatry.

A unique feature of the clinic services is limited, delegated, prescriptive authority to the CDE pharmacist “coaches” who manage and change the patients’ medications using health system-approved treatment algorithms for management of hyperglycemia, dyslipidemia, and hypertension. This allows for rapid-cycle progression of therapy, as required, to help patients achieve therapeutic goals for blood glucose, lipid, and blood pressure. Coaches are authorized to order laboratory tests as necessary to help monitor patients’ responses and to adjust medications.

Communication

All coach/patient encounters are documented in the electronic medical record system. All coach actions and notes require physician approval. Telephone and email contact enhance clinical decision-making.

Insurance coverage

Diabetes care services receive capitated coverage from the health system and certain preferred provider organizations.

Outcomes

Patient satisfaction feedback surveys that are sent to all diabetes center enrollees have been uniformly positive. The clinical study that evaluated the concept for this service showed a clinically significant decrease in A1C levels of nearly 1 percent in the study population (unpublished study).

February 2013​