Care coordination of the diabetic patient in the outpatient setting

Abstract

Diabetes Mellitus is a serious disease that affects about 29.1 million people in the United States and is the seventh leading cause of death. The U.S. spends about one tenth of our healthcare dollars on diabetes and its complications. Uncontrolled diabetes can lead to other serious conditions such as kidney failure and cardiovascular disease. Diabetes is a chronic disease that can be managed by maintaining a steady blood glucose level with the aid of medication, proper diet, and exercise. With proper ongoing diabetic self-management education patients have better control of their diabetes and are more likely to follow best practice treatment recommendations. The local problem at Big Sky Family Medicine is that only 50% of their diabetic patients are in good control with their HbA1C at less than 7%. The microsystem assessment revealed there was no standardized approach to diabetes care and management. A literature review was done to identify best practice for diabetes management. Care that was patient centered, provided care coordination and ongoing diabetic self-management education proved effective. The general aim of this project was to improve the effectiveness of diabetes care at BSFM. A proposed protocol was developed and an ideal process was created as shown in figure 2. Standardized teaching materials are identified along with pre and post testing forms to identify patient knowledge and satisfaction. The evaluation of the protocol will be based primarily on the improvement of the patients HbA1c readings along with BP readings, LDL results, and increase in patient knowledge and satisfaction. The evaluation of the protocol will be based primarily on the improvement of the patients HbA1c readings along with BP readings, LDL results, and increase in patient knowledge and satisfaction. A CNL would be the ideal choice to implement this protocol due to their ability to design, implement and evaluate change along with the ability to coordinate and delegate patient care.