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Leveraging virtual care options for diabetes management patients

Insight Article - September 26, 2022

Patient Access

Population Health

Patient Care Technology

Jill Berger-Fiffy MS, MHA, FACPE
Robert Weinstein MD
Nationwide staffing shortages are impacting healthcare intensely, from physicians and nurses to medical assistants (MAs) and administrative staff. With roughly 11% of Americans diagnosed with diabetes and millions more who are undiagnosed1 or pre-diabetic, the need for endocrinologists will only continue to increase to ensure successful diabetic patient care; however, a study published by Mayo Clinic suggests that the national supply of endocrinologists has been lower than demand and a widely progressive gap will continue.2

Signature Medical Group (SMG), a multispecialty physician group consisting of more than 150 physicians practicing in 18 ambulatory locations throughout southeastern Massachusetts, faced a similar shortage. As part of the medical group’s mission to provide healthcare access to individuals in a socioeconomically diverse and underserved area, SMG cares for a patient population with a higher propensity for diabetes.

Diabetes affects millions of Americans at an increasing rate: 
  • More than 34 million people in the United States live with diabetes, or about 10.5% of the entire population. 
  • About 7.3 million people living with diabetes have not yet been diagnosed and may be unaware of their condition.
  • Almost 90 million adults in the United States have prediabetes (abnormal blood glucose that is not high enough to make the diagnosis).
  • Each year, 1.5 million Americans are diagnosed with diabetes.
  • Racial and ethnic groups in the United States (including American Indian/Alaska Native, Hispanic, Black and Asian adults) are impacted at higher rates than white adults.
  • Nearly 27% of people over the age of 65 have diabetes.3

Creative virtual care solutions during a staffing shortage

A care gap within the diabetic patient population occurred due to internal staffing shortages within SMG’s endocrinology department. While physician recruiting took place, a short-term solution was implemented for continuity of care by an interim endocrinologist and employed nurse practitioner. When this 90-day coverage plan expired, diabetic patients were referred to their primary care physicians (PCPs) for follow-up care. This contributed to rising panel sizes and a lack of specialized expertise in diabetes care, medication, and insulin management within the primary care network. These gaps required additional internal support by pharmacy and nursing resources.

A dyad structure was used to engage the team, which included the chief of primary care, the chief of specialty care and the interim service line director. Leadership was focused on finding a quality solution, reducing network leakage, maintaining excellent care for patients and including clinical information in the EHR. This leadership group considered leveraging other temporary solutions, including:
  • Hiring another locum tenens professional while recruiting. Signature Medical Group considered hiring another locum tenens healthcare professional for diabetes care and endocrine management of disorders, while simultaneously exploring recruitment of employed providers.
    • Outcome: A locum would be a short-term approach, while recruitment was recognized as a longer-term strategy. Recruitment for employed providers was in process for two endocrinology nurse practitioners (NPs), one certified diabetes educator and two physicians. 
  • Referring patients to an affiliated tertiary hospital. Another strategy considered to meet demand was referring complex Type 1 and Type 2 diabetic patients to an affiliated tertiary hospital in Boston, including those under treatment with insulin pumps who were willing and able to travel to Boston.
    • Outcome: This option was activated as an external choice but within the defined network affiliation. It was found that many patients did not want to travel to Boston and preferred care in their own community. 
  • Referring patients to a community-based affiliate hospital. Since many patients prefer not to travel far from their community, SMG considered referring patients to a community-based affiliate hospital that could provide nutrition counseling for a variety of endocrine disorders. 
    • Outcome: SMG could refer to its local partners, but access was a concern since they were busy as well.
  • Referring patients to a tertiary affiliate. For gestational diabetes patients, a maternal fetal medicine service at Signature Healthcare Brockton Hospital would accommodate these patients and was already working within the health system.
    • Outcome: Gestational diabetic patients were referred to this program.
  • Collaborating with virtual health partners. Another alternative was developing a relationship with a virtual health partner who could provide care to diabetic patients.
    • Outcome: The team considered this outsourced option after several meetings and demonstrations with the providers and hospital leaders. A virtual care option made sense while rebuilding the internal service.
 
Although some of these solutions helped a subset of patients and filled in staffing and patient care gaps, SMG realized it needed a more consistent and collaborative solution.

Virtual care: The right fit, the right time

During the transition to these alternative short-term solutions, many patients couldn’t wait — they had complex cases and comorbidities that required frequent insulin adjustments or devices that required close monitoring.

Many patients required the full spectrum of treatment, including communication, education and self-management skill-building to modify unhealthy lifestyle behaviors. To improve outcomes, patients must be empowered to change their diet, maintain an exercise program, and manage their stress. This often requires the support of a qualified healthcare professional.

With the rapid advancement and increased familiarity with virtual care options in recent years, patients can receive immediate feedback to inquiries, information on medication prescriptions, and coaching while enjoying the convenience of virtual appointments.

The leadership team explored several virtual service vendors and discovered a solution to bring diabetic care to patients quickly, conveniently and easily. This third-party option allowed collaboration between primary care, specialty care and OB/GYNs so they could increase the speed of patient care while rebuilding internal service.

Stability Health offered a tech-enabled hybrid care model combining digital technology with human connection for patients with complex diabetes. Patients were assigned a virtual human health coach to provide support and education. The goal of motivating patients to engage in self-management, modify unhealthy living habits, and adhere to treatment was critical to the success of this program. Coaching included access to certified diabetes care and education specialists (CDCES) for intensive diabetes education individualized to a patient’s needs.

Stability Health’s diabetes platform contains a proprietary rules engine that embeds the American Diabetes Association Standards of Care with standards of practice for diabetes and nutrition education and behavior change. The Stability Health care team can capture a holistic view of a patient’s history and experience with their diabetes; collate data from devices that monitor glucose, weight, and blood pressure; and create individualized care plans. 

All care plans are shared with patients’ clinical care teams to coincide with appointments so that recommendations can be acted on at the point of care. The Stability Health diabetes team constantly monitors to proactively provide outreach to patients when needed and alert a patient’s clinical care team when there is a need for therapeutic modifications.

Working with Stability Health enabled SMG PCPs to care for patients with complex diabetes more effectively and allowed the physicians more time to focus on other quality metrics for their patient population.  

The additional benefit of appointment reminders helped reduce no-show rates as a secondary key performance indicator (KPI). Patients were also prompted via the service with potential topics that may be brought up by their clinician during the appointment. 

To ensure a smooth working relationship while providing the care patients needed, SMG and Stability Health:
  • Developed an agreement and contract to solidify the relationship and partnership details.
  • Held staff orientation meetings for training and transparency. The partners scheduled frequent touch-base meetings where the teams worked together to develop:
    • A marketing document for patients who were referred from the office
    • Front-end workflows to include scheduling, registration, referrals and charting
    • Clinical service protocols, which were considered best practices
    • A response timeline, in which it was agreed Stability Health would contact all patients to set up the intake and schedule an assessment.
      • It was agreed patients would be encouraged to use the medical group ancillaries to keep each patient’s medical chart complete.
  • Targeted and prioritized patients to ensure appropriate care and patient outcomes.
    • This model supported PCPs and OB/GYN providers by helping define the best treatment plan for patients, offering support and advice regarding medication options as well as assessment and treatment plans for patients under joint care. The program also included dietary management and medication education, and the practice was able to use its nurse educator and pharmacist for internal education and insulin starts.
 
PCPs were able to continue care with patients in person and through telehealth, using the information they learned; this included medication adjustments and ordering of tests.

The virtual care solution was being used simultaneously with the medical group’s ongoing recruitment activities, so patients and providers were better supported while SMG worked toward onboarding an endocrinologist.

Results: Successful 0utcomes for patients and staff

Figure 1. Average A1c for patients who reduced A1c - Initial: 10.2%25, Most recent: 8.2%25
After deploying the virtual solution for diabetic patients in September 2021, SMG referred 240 patients to Stability Health. Of those:
  • 151 patients successfully completed the initial assessment and had an initial care plan created.
  • 78% of these patients quickly reduced their A1c, with an average reduction of 2.0 points.
  • 61% of these patients have lost weight while engaged with Stability Health, and the average weight loss for those patients was nine pounds, which represents a clinically significant 4% average weight loss.
  • 55% of patients reduced low-density lipoprotein (LDL) and reached the goal of LDL below 100.
 
Perhaps the most dramatic example is a 67-year-old man who had diabetes for seven years. His diabetes was not well-managed; his PCP started insulin, which the patient wasn’t using consistently. His A1c test was 15.8% (target is less than 7%) when he began the program. Over the following five months, he made changes to his diet, and he learned that he could sustain eating fewer carbohydrates to help improve his blood sugar. He also began to understand and manage his insulin regimen, and Stability Health worked with his PCP at SMG to optimize his insulin dose. At his last visit with his PCP, his A1c test was 6.9%, and he remarked that he had never seen his home sugar readings as well controlled as they are now. 
Figure 2. Average weight for patients who reduced weight
As SMG rebuilds its endocrinology department, the partnership with Stability Health enabled the leadership team to look at how diabetes care is deployed in the organization from a different perspective.
Average LDL for patients who reduced LDL

They found that by working together, efficiently supporting patients and clinicians in the space between visits is possible using a technology platform that automates and enhances trusted relationships and allows for more efficient use of scarce specialty resources. Overall, it has been a win-win for patients.

Notes:

  1. Centers for Disease Control and Prevention. “National Diabetes Statistics Report.” U.S. Department of Health & Human Services. Available from: bit.ly/3QUXb25.
  2. Rizza R, Vigersky R, Rodbard H, Ladenson P, Young W, Surks M, Kahn R, Hogan P. “A model to determine workforce needs for endocrinologists in the United States until 2020.” ASJC Diabetes Care. 2003 May 1; 26 (5): 1545-1552.
  3. CDC.

About the Authors

Jill Berger-Fiffy
Jill Berger-Fiffy MS, MHA, FACPE
Senior Advisor Impact Advisors

Jill Berger-Fiffy serves as interim service line director for Signature Health and as senior advisor at Impact Advisors. Reach her at jill.berger-fiffy@impact-advisors.com


Robert Weinstein
Robert Weinstein MD
Family Physician and Chief of Primary Care Signature Medical Group Brockton, Mass.
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