High-Quality, High-Touch Care Produces Significant Outcomes in Patients With Diabetes

According to collaborative studies from the AAFP's Robert Graham Center and the AAFP National Research Network (AAFP NRN), high-touch health care can work wonders in patients with diabetes.

In back-to-back presentations at the 2012 AAFP Scientific Assembly in Philadelphia, Robert Phillips Jr., M.D., M.S.P.H.; and Wilson Pace, M.D., showed how a for-profit primary care network of 23 practices in San Antonio used the PCMH model and peer mentors to achieve a large percentage of patients with hemoglobin A1c (HbA1c) levels of less than 7 percent.

"From 2000 to 2008, the (WellMed) network was able to go from 81 percent -- which is still really good -- of its diabetic patients with an HbA1c under 7 (percent) to 93 percent of patients," said Phillips, the ABFM vice president for research and policy. "This is fantastic. In fact, it was so fantastic that we didn’t believe it, so we had to study it."

Phillips noted that the Graham Center worked in conjunction with the State Network of Colorado Ambulatory Practices and Partners, an affiliation of practice-based research networks that is itself affiliated with the University of Colorado-Denver, to look at the PCMH model used by the WellMed Medical Group in San Antonio.

WellMed relies heavily on teams with defined roles. Medical assistants do most of the data entry for electronic health records, and health coaches on each team follow up with patients to reinforce the care plans set out by primary care physicians.

In addition, a "complex care" team handles patients with multiple chronic problems, such as those with diabetes and heart failure. "This team manages the most fragile, high-cost patients," Phillips said. "These patients demonstrated through their behavior why they were going to require more services."

Pace, director of the AAFP NRN and a professor in the family medicine department at the University of Colorado-Denver, said the data from the WellMed network was collected in conjunction with LA Net, a practice-based research network in the Department of Family Medicine at the University of Southern California in Alhambra. The data indicate that social determinants of health, such as education, living environment, workplace and friendships, can have a larger impact on health than medical care, especially when isolation is involved. To alleviate this effect, WellMed initiated a peer mentor program.

"Our part in this study focused specifically on those patients with diabetes, and … the drop in HbA1c rates was really amazing," said Pace. "Social isolation can have as powerful an influence on health as smoking in some cases, and that is where peer mentors came into play. Overall, the mentors in this group averaged seven contacts with each of their patients in a seven-month period and showed that they could make a difference in patient outcomes, as well as in diminishing social isolation."

The project recruited and trained more than 50 peer mentors. Via group processes and mentor activities, WellMed was able to create educational and social interactions with more than 500 patients. Because mentors often met with patients at the patients' convenience, in their own environment and without a set limit of contacts, Pace said the network was able to increase patient blood-testing rates and increase the percentage of patients that met or exceeded the HbA1c goal of less than 7 percent.

"(The peer mentors) were able to empower the patients to become owners of their own health and health care," said Pace. "So what happened as a result of that? Well, according to a six-month follow-up, the number of times patients tested their blood sugar each day increased from 4.44 to 5.92 … and if you look at the peer-supported group, their HbA1c (levels) also decreased at a significant rate."

Pace said that the peer mentors, who reportedly saw an improvement in their own diabetes, also began to spread their health message outside of their particular groups at the clinic.

"These people got out there into the community and started talking to people about eating better and exercising," Pace said. "They opened this program up to the entire community, and it really started to produce results.

"At the end of the day, this program brings back some of the revolutionary spirit that was ingrained in family medicine years ago. The WellMed model demonstrates what can be achieved when a clinical organization focuses on improving the health of their patients and not just providing health care."