Health care environment
Today’s health care environment is affected by several significant factors, including greater numbers of aging and older people, the development of new technologies, advances in medical treatments, and the tremendous increase in scientific knowledge about health and illness. One result is that more people are living longer with diabetes and its complications. In spite of the growing diabetes population and the high cost of this disease, people with diabetes are often poorly served by the current health care system that is primarily symptom oriented and focused on acute illness. Additionally, payment is heavily weighted toward medical procedures or treatment of late complications of disease, rather than toward the cognitive and time-consuming efforts required for successful primary or secondary disease prevention. Current payment policies need modification to support team care for effective chronic disease management.
Primary care providers
Primary care physicians, physician assistants (PAs), and nurse practitioners (NPs) all play important roles in the delivery of primary care for people with chronic diseases in the United States. Although endocrinologists or other diabetes specialty physicians are involved in caring for many people with diabetes, primary care physicians provide more than 80 percent of diabetes care. In the past, physician shortages in rural or other underserved communities were addressed in part by PAs and NPs. Currently, however, about 33 percent of PAs practice in primary care, 15 percent in rural areas, and 8 percent in federally qualified health centers and community health facilities. The PA profession appears to be moving away from primary care toward specialty training to support specialty physician practices. NPs have traditionally worked in primary care, and a recent national survey reported that the average NP was female (95 percent), 48 years old, in practice for 10.5 years, and a family NP (49 percent) involved in direct patient care. Schools of nursing are increasing training programs for doctoral-level comprehensive care practitioners.
Systems constraints can make it difficult for primary care providers to carry out elements of comprehensive diabetes care, such as to
- identify a practice’s sub-population of patients with diabetes and target those at highest risk for co-morbidities
- conduct ongoing self-management education and behavioral interventions
- provide remote management of glycemia
- promote risk-factor reduction and healthy lifestyles
- provide periodic examinations for early signs of complications.
The challenge is to broaden the delivery of primary care by expanding the health care team to effectively address the various elements of comprehensive diabetes care.
Models for care delivery
The models briefly described on the next page share many similar elements. Each element, however, is a complex undertaking, and the level of guidance available varies in its implementation and evaluation of effectiveness for improving chronic care.
Chronic Care Model
The chronic care model presents six interrelated elements for effective care of chronic diseases
- the health system—culture, organizations, and mechanisms to promote safe, high-quality care
- delivery system design—for clinical care and self-management support, including team care
- decision support—based on evidence and patients’ preferences
- clinical information systems—to organize patient and population data
- self-management support—to enable patients to manage their health and health care
- community involvement—to mobilize patient resources
In 2002, a systematic review included diabetes care programs that featured at least one of four chronic care model elements: delivery system design, decision support, clinical information systems, and self-management support. This review found that 32 of 39 programs improved at least one process measure (e.g., testing A1C) or one outcome measure (e.g., lowering A1C) for patients with diabetes by implementing at least one of the four chronic care model elements. Since the methodological quality of the studies was not uniformly high and the interventions differed among studies, the review authors cautioned about generalizing these findings.
In 2005, a meta-analysis was conducted of randomized and non-randomized controlled trials in chronic disease that addressed one or more elements of the chronic care model. Diabetes was one of the four chronic diseases studied. This analysis found that interventions that incorporated at least one element of the model had consistently beneficial effects on process and outcome measures across the four diseases. Interventions for diabetes led to a 0.3-0.47 percent reduction in A1C but no measurable benefit in quality of life. The elements responsible for these benefits could not be determined from the data.
Medical Home Model
The American Academy of Pediatrics originally used the term “medical home” to describe a partnership approach to providing family-centered, comprehensive health care. The model has since been embraced by the major U.S. primary care organizations, other health care provider groups, private health care purchasers, labor unions, and consumer organizations. This evolving model of care is playing an important part in health care reform.
Also known by other names such as the Advanced Primary Care model, the medical home links multiple points of health delivery by utilizing a team approach with the patient at the center. The model emphasizes prevention, health information technology, coordination of care, and shared decision making among patients and their health care team.
Nurses, diabetes educators, dietitians, pharmacists, podiatrists, eye care providers, dental professionals, and other health care professionals are likely to play important roles in the medical home model by working with primary care providers to collaboratively provide comprehensive diabetes care. Such care includes management of blood glucose, lipids, and blood pressure; weight management; smoking cessation counseling; and diabetes complication care and prevention. Implementation of the medical home model will require modification of current health care provider payment policies to support team care.
Medical home demonstration projects for Medicare beneficiaries are planned for community health centers across the country and for primary care practices in eight states. Medicare may join Medicaid and private insurers to conduct state-based primary care initiatives. These projects will incorporate payment modification for team care and evaluate the effectiveness of the model in improving health care quality and reducing costs. Their findings will help guide future efforts to integrate and disseminate the model’s key components, including payment mechanisms into other settings.
Healthy Learner Model
The Healthy Learner Model extends the Chronic Care Model to include professional school nurses in chronic disease management for students in kindergarten through grade 12. This model enables improved communication and coordination among health care professionals, students with chronic diseases and their families, and school personnel. The goal is to maintain student health in the school setting. Leadership involving communities and school districts is critical to the model as is evaluation of success in maintaining student health. The Healthy Learner Model has been successfully implemented and evaluated in Minneapolis Public Schools and St. Paul Public Schools to improve the health of children with asthma. The model needs further application to diabetes and replication in other school districts.