Clinic uses chronic care model to tackle diabetes

Widely viewed as an optimal approach for managing patients with chronic disease, the chronic care model1 (CCM) incorporates several elements into patient care, including decision support, care coordination, linkage with community resources, and mechanisms to promote and support self-management. It’s a tall order to carry out—even for large, integrated healthcare systems—but one group that is successfully tacking the model at the practice level is Seattle-based Polyclinic, a multispecialty group comprised of more than 100 physicians, including 30 focused on primary care.

Beginning with diabetes, the group has implemented CCM-style strategies that have earned it recognition from the National Committee for Quality Assurance (NCQA) and the American Diabetes Association.

And now it is focused on using the same framework to make equally important strides in the care of patients with CVD.

Work begins with a registry

Polyclinic’s work with the CCM began in 2001 as part of the Washington State Collaborative on Diabetes Care, a project that, among other things, served as one of the early proving grounds for the model, explains Claudia Wilson, RN, MSN, Polyclinic’s director of quality. Participating providers in the collaborative, including two physicians from Polyclinic, met regularly to evaluate outcomes and share insight from their respective quality improvement efforts.

But by 2004, Polyclinic moved to greatly expand the effort beyond the pilot stage. “We made a decision corporately and organizationally to bring all of our PCPs into the model,” says Wilson. “It became a cultural imperative, and we had top-down support and direction to do it.”

The effort’s clinical champions first evaluated how they could retool the way they cared for diabetics, especially patients under the care of internal medicine and family practice providers, explains Marc Cordova, MD, Polyclinic’s director of DM.

“Prior to being involved with the collaborative, we had no systematic way of knowing who our diabetic patients were, and how well we were taking care of them,” he says. “So with this model, we were first able to get an idea of who our diabetic patients are, and then develop a way to evaluate the different parameters that reflect what good quality care is for diabetes.”

To accomplish these tasks, administrators took the bold step of creating a new department to develop and maintain a registry of diabetic patients. Without the benefit of an electronic medical record, much of the initial work had to be done manually. However, the Washington State Department of Health eventually made available software designed specifically as a registry tool to the Polyclinic free of charge.

Additionally, Cordova notes that department staff devised a program that enables lab data to be automatically transferred into the registry—a huge, time-saving maneuver.

Extra task proves its value

To keep the registry up-to-date, physicians must complete a form that details the care provided at every encounter with a diabetic patient. “We have dedicated people who are responsible for maintaining the registry, getting the forms to the physicians, and inputting all of the data, such as the dates of things like flu vaccines, eye exams, foot exams, and [other care processes] that we track that are important to the care of diabetes,” says Cordova.

Although the form is an added burden to physicians, it is also designed to draw their attention to any care processes that are overdue or lab values that are out of range. “It is a really a quick way for the doctor to evaluate how well-controlled the patient is,” says Cordova. “Anything that is overdue or [out of range] is underlined in red, and things that will soon be due, but are not yet overdue, are underlined in green, so the colors are part of the form.”

The same staff members who maintain the registry are also responsible for making sure that these forms are on the very top of a patient’s chart whenever that patient is scheduled for an office visit. “What our department tries to do is look through the next day’s schedule and in the morning, provide the forms to the physician to be put on the chart on the day of the visit,” Cordova explains.

Even in cases where the patient comes in for a visit that has not been scheduled at least a day in advance, the department is able to generate and deliver the summary form to the physician in time for the visit, adds Cordova.

Having an extra form to fill out was a hard sell to physicians—at least initially. “I was a little bit opposed to that because I have this real personal connection with patients. I hate to just put checks on a form; it just seemed robotic to me,” says Susan Baumgaertel, MD. “But I think it really has proved its value in [helping us] to be more accurate in providing quality, comprehensive care to our chronic, diabetic patients. So the value outweighs the burden.”

Reports provide transparency

In addition to receiving data about individual diabetic patients, physicians also receive a monthly active summary report that provides them with aggregated information on all of their diabetic patients. “Things that are out of target or overdue are either underlined or in bold numbers so that, again, they can quickly scan which patients are overdue for which tests,” says Cordova.

Physicians also receive graphs that show them where their numbers are with regards to key parameters such as BP control and HbA1c control, and these numbers are measured against benchmark comparisons to their colleagues at Polyclinic, and to NCQA numbers, when they are available.

“Organizationally, we have been very forthcoming about sharing PCP outcomes at regular primary care section meetings, so it is very visible to all the physicians where their counterparts are,” says Marian Sofferin, MPH, Polyclinic’s DM manager. “It provides a little bit of pressure to work harder so that their numbers will improve, and they can be [at the top] as well.”

The motive in revealing these numbers is more about providing transparency than competition, emphasizes Wilson. “We have had some physicians who just didn’t have a sense of where their numbers were, and once the reports were given to them, they got on the bandwagon by themselves and developed individual interventions at their own level on top of whatever we were doing corporately as a quality team.”

Patient-directed care is challenging

The CCM emphasizes the importance of motivating patients to take charge of their own care. To make strides in this regard, Polyclinic hired a certified diabetes educator (CDE) to work with patients one-on-one, establish community forums on an array of diabetes topics, and link physicians and patients with valuable community resources.

Additionally, the CDE put together physician “toolboxes” that contain a list of community resources that they can use as a referral source with patients who may need more specialized education or care, exercise programs, weight management programs, or other assistance.

The physicians have also had to learn to be less didactic and think more in terms of providing patient-centric care, adds Wilson. “To try and develop that kind of relationship with patients is time consuming and it has not been the norm for many doctors,” she says.

Baumgaertel agrees, noting that even recently trained physicians can feel threatened by the idea that the patient is going to direct his or her own care, but she emphasizes that it is the “wave of the future” for chronic care management, and that it is a good thing. “Trying to weave that into the fabric of how we look at diabetic and CVD patients is so much better,” she says. “You have more engaged patients who are so much more willing to work together with you, and you have better outcomes.”

Baumgaertel suggests that establishing goals with patients to work toward does not necessarily have to be time-consuming. “If you don’t have time [to create a written] action plan, it can be something very simple,” she says. “But acknowledging it as an action plan . . . and then coming back to it and following up on it are key because then you get into the habit. And not just you, but the patient also gets involved with the process, and that is where you really have the value.”

Effort produces results

Polyclinic’s efforts have produced clinical improvements. Compared to national best practice standards, test scores on a range of key measures such as LDL cholesterol less than 100, BP less than 130/80, and HbA1c scores under 7 put Polyclinic’s results in the 90th percentile. And the organization is now pushing forward with a similar approach to CVD care.

Cordova acknowledges that implementing the CCM is an expensive proposition, but he is optimistic that the clinic will ultimately be rewarded. “As a large clinic, we have made the commitment financially to do this because we feel it is the right thing, and we are interested in promoting good quality care,” he says. “The physicians feel this is a good investment and we are committed to it. With the pay-for-performance trend, hopefully we will [eventually] be compensated for some of this work.”


1The chronic care model was developed by Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation, is directed by Ed Wagner, MD, MPH, FACP.




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