Registry, Group Visits, 'Report Card' Help Patients With Diabetes, Says FP

Saria Carter Saccocio, M.D., of Rome, Ga., is enthusiastic about the patient-centered medical home, or PCMH, model of care. And, as associate director of the Floyd Family Medicine Residency in Rome, Ga., which has steadily been incorporating the model, she's seen firsthand how integrating elements of the PCMH into the care of patients with diabetes can greatly improve management of their disease, while realizing significant cost savings.

"We recognize that chronic disease is what is sucking the life out of health care," Carter Saccocio told AAFP News Now. "We are not doing it right. We have a different type of patient than when (physicians) trained 30-40 years ago in the model of episodic care. We need a continuous process and to follow up proactively."

To help address that need for continuity, the residency uses the Diabetes Master Clinician Program (extract), a quality assurance program sponsored by the Florida AFP Foundation that Carter Saccocio characterized as replacing the idea of "patient compliance" with that of "recognizing and overcoming barriers."

She credits family physician Edward Shahady, M.D., of Fernandina Beach, Fla., medical director of the clinician program, as a key mentor who has championed patient empowerment, group visits and registries in diabetes management.

At the heart of the program, she said, is a Web-based diabetes registry that allows the clinic to track such diabetes management indicators as hemoglobin A1c; LDL, HDL and triglyceride levels; and blood pressure readings. This process, in turn, can help reveal the barriers with which the clinic's diabetic patients struggle, both individually and as a group.

For example, the registry can identify patients who haven't had a hemoglobin A1c test in a year and help the health care team determine why they haven't come in for their appointments, such as because of transportation hassles or financial issues.

In addition to providing a broad overview of these health indicators across the clinic's entire panel of patients with diabetes, the registry also records and monitors each patient's progress toward his or her individual goals, such as losing weight and lowering blood pressure, said Carter Saccocio.

"The registry has been a tool to help us practice through population management of care. If we didn't have a tool available, how would we know (the health status of the overall population) except to go chart by chart by chart?" she asked.

A second key component of the Diabetes Master Clinician Program -- group visits -- has been extremely well-received by patients, according to Neeru Chopra, M.D., a third-year resident at the Floyd residency. Each two-hour monthly visit represents a collaboration among patients, physicians, nurses, other midlevel providers and staff during which patients are encouraged to discuss their challenges and successes.

The resources required to make these group visits happen are modest, Saccocio explained: a conference room big enough to accommodate the group, with nearby exam rooms; basic medical equipment, such as stethoscopes, oto- and ophthalmoscopes, scales, and blood pressure cuffs; a dry-erase easel or chalkboard; patient education handouts; and healthy beverages and snacks.

Participants include a nurse, a behavioral counselor, a documenter and an administrator who facilitates discussion of the disease and its complications. Residents and medical students from nearby medical schools, such as Mercer University School of Medicine, the Medical College of Georgia and Morehouse School of Medicine in Atlanta, also contribute, which builds their familiarity with the PCMH model of care, Saccocio said.

During the group visits and other appointments, patients receive the third key element of the program -- their diabetes "report cards." Each report card consists of a printout of information in the registry that describes in layman's terms their personal progress with weight loss, blood pressure, A1cs, LDLs and HDLs.

Carter Saccocio calls the diabetes report card a "golden tool" of the registry that greatly augments patients' self-management of their disease and adherence to medical recommendations.

"If we truly want to put the focus on the patient, shouldn't the patient be carrying the passport? It's their passport to health," she said.

Carter Saccocio described how the patient group improved in one year, using measures from the American Diabetes Association, or ADA. According to the ADA, nationally, 48 percent of patients with diabetes have A1c levels less than 7 percent, 33 percent have LDL levels less than 100, and 33 percent have controlled their blood pressure to less than 130/80.

According to Carter Saccocio, in September 2008, 31 percent and 28 percent respectively of patients with diabetes in the Floyd residency, met the ADA's A1c and blood pressure goals, and 64 percent met the LDL goal. A total of 7 percent met goal on all three indicators.

As of October 2009, she added, 35 percent of the patients met the A1c goal, 42 percent met the blood pressure goal, and a 71 percent met the LDL goal. A total of 11 percent met goal on all three indicators.

Citing actuarial data from the Towers Perrin professional services firm, Carter Saccocio estimated that, cumulatively, these improvements would save the health care system almost $62,000 a year, because good diabetes management leads to fewer complications and hospitalizations.

Goals for the residency clinic in 2010, she noted, include improving patients' exercise rates, increasing annual foot exams and increasing influenza vaccination rates, all of which can be tracked on the registry.