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A guest post from Joan K Bardsley, MBA, RN, CDE, FAADE, Assistant Vice President of Nursing and Research Integration at the MedStar Health Research Institute.
Those of us who work in the area of diabetes know the challenges of diabetes care. Keeping overall blood glucose levels within a target range, as measured by a test called A1c, can help to prevent complications and enhance overall well being. The goal of most people with diabetes is to keep the A1C <7%. Yet, we know that less than 53% of US adults with diabetes have A1C <7% and more than 15% have an A1C >9%.
Diabetes Self Management Education and Support (DMSES) have been shown to effectively help with management of diabetes, yet fewer than 7% of those with newly diagnosed type 2 diabetes with private insurance participate in DSMES within 12 months of their diagnosis. Only 8.14% of Medicare beneficiaries with newly diagnosed diabetes use DSMES services at least once within 6 months of diagnosis.
There is also evidence that failure to initiate or intensify therapy despite suboptimal glucose control is common and that there is a lack of timely advancement of the diabetes medication regimen.
So with this sub-optimal diabetes care environment in mind, what can be done to change the outcomes of patients with type 2 diabetes?
The MedStar Diabetes Institute Team, lead by Michelle Magee, MD and supported by Gretchen Youssef, MS, RD, CDE, and Carine Nassar, MS, RD, CDE, developed the MedStar Diabetes Boot Camp to tackle this problem within the MedStar Health system. They reported on the program design and outcomes at a dedicated symposium session at the American Diabetes Association’s 78th Scientific Sessions (2018) in Orlando, Florida on June 22, 2018. To say this was well received by the audience would be an understatement!
The symposium session audience at ADA showed great interest in this program and attendees lined up at the microphones to congratulate the speakers on the presentation and ask pertinent questions about implementation, system support, and future plans. MedStar Health and MHRI were well represented as being at the forefront of translating diabetes research into successful direct patient care.
How does it work?
The Boot Camp is a 13-week program that targets high risk, high-cost patients (A1C of >/9, ED or hospitalization with uncontrolled diabetes) who are cared for within our system. These patients are referred to the Boot Camp through a 1-click order in our EMR.
The program starts with of 2 in-person initial visits with a Boot Camp Certified Diabetes Educator (CDE) to establish a relationship for patient engagement, complete assessment, and provide education on the use of a smart blood glucose meter which automatically sends data to the Boot Camp dashboard. The patients receive survival skills education as well as medication management during those visits, with the program’s Nurse Practitioners (NP) signing off on medication changes. The patients then graduates to virtual visits via a communication hub where NP CDEs monitor uploaded blood glucose numbers, make medication changes and adjustments, and provide additional education as needed. At the end of the Boot Camp, patients are referred to their PCP with a detailed letter indicating current BG average and A1C, current diabetes medications and need for additional referrals if any (such as to podiatry or eye clinic).
Is it making a difference? The numbers speak for themselves!
To date, a total of 366 patients have completed the boot camp with an end of intervention A1c available. When compared to matched controls, the boot camp participants showed a 3-month A1c drop of 3.06% vs a 1.44% for the controls. In addition, the overall risk for acute care utilization decreased by 51%, the risk for inpatient admissions decreased by 77% and the risk for ED visits decreased by 38%.
The patients are followed after they complete the Boot Camp to see if improvements in glycemic and utilization outcomes are sustained over time. Early results show that while a majority of patients retain most of the improved outcomes, some backslide and need additional intervention. Therefore, sustaining strategies are being tested. Based on these positive results, MedStar Health has tasked Dr. Magee and her team with expanding the Boot Camp to additional locations throughout the system.