The traditional model of medical care involves the physician as the driving force in the delivery of heath care services; the patient’s role is mainly to comply. However, this paternalistic model is now being challenged. The health care industry is learning that patients’ involvement and empowerment are essential to improving their overall health, and patients are demanding more say in their care. Medical practices are being retooled to accommodate patients who are seeking more autonomy, who have greater access to medical information via the Internet, and who desire to play a greater role in the decision-making process for the management of their medical problems.
Type 2 diabetes mellitus is a perfect example of a chronic disease where patient-physician partnering can significantly affect outcomes. The management of type 2 diabetes requires consistent attention on the part of the primary care physician and the patient to ensure optimal disease control and risk reduction.
Recently, our practice implemented a diabetes management system that allowed us to partner with our patients toward the goal of improving outcomes. It involved three steps:
Step 1: Identify patients who have type 2 diabetes. To manage diabetes effectively, you first need to know which patients have the disease and will require follow-up. To do this, we extracted data from our billing system for all patients visiting the office in the past year. We then reviewed the list to identify patients with type 2 diabetes that we were actively managing. Patients identified as receiving primary diabetic care from a specialist outside of our office or as being no longer active in our practice were dropped from the list. We arrived at a list of 73 patients.
As an alternative, practices may be able to identify their diabetes population by searching their computer system for all patients with a diabetes-related ICD-9 code or prescription.
Step 2: Involve the office staff and patient care team. Early on, we formed a physician-led team to develop a Patient-Physician Partnership Agreement (
) and to define the patient care goals, based on evidenced-based guidelines (see the recommended reading list). Involving the staff at the outset increased their investment in the project and their understanding of the disease process.
Step 3: Involve patients. As patients presented for routine care, we introduced the Patient-Physician Partnership Agreement, completed it with them and established it as part of their chart. The purpose of the Patient-Physician Partnership Agreement was to educate the patient on the importance of disease management and to help the patient establish short- and long-term disease-related goals. Physicians could also use the agreement to reinforce goals at follow-up visits and to help patients develop action plans.
At the end of the three-month introduction period, we contacted all patients who had not been seen and asked them to make an appointment for a diabetes check-up.
After five months, 74 percent (54/73) of eligible patients were participating in the Patient-Physician Partnership Agreement, and 76 percent (16/21) of patients seen in the initial three months had already attended their quarterly follow-up visit. This was particularly encouraging because our office uses an open-access appointment system in which we do not routinely schedule patients in advance but rather see patients on the day they call for an appointment. This shifts much of the responsibility for initiating follow-up care from the physician to the patient.
Of the 73 eligible patients, 19 patients did not enroll in the Physician-Patient Partnership Agreement. Of these, seven had not been seen for management of their diabetes or for any other illness in the office setting within the time period of our study. Twelve of the patients had been seen for acute problems, but we simply failed to initiate the Patient-Physician Partnership Agreement at those visits. Both groups are obvious targets for further follow-up.
For the enrolled patients who had obtained their three-month follow-up visit, nearly a third of their defined goals were met specifically because of an action plan generated as a result of the Patient-Physician Partnership Agreement. Our study population was small, but we view the results as positive first steps for our patients.
American Diabetes Association. Clinical Practice Recommendations 2002. Diabetes Care. 2002;25(suppl 1).
Parchman ML, Pugh JA, Noel PH, Larme AC. Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes. Med Care. 2002;40(2):137-144.
Coordinated performance measurement for the management of adult diabetes. A consensus statement from the American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance; April 2001.
Health care guideline: Management of type 2 diabetes mellitus. Institute for Clinical Systems Improvement Quality Assurance Committee Recommendations for the management of Type 2 Diabetes; 2001.
Diabetes. Clinical Evidence. June 2000;3:258-275.
Our office and clinical staff also benefitted from this process by gaining an improved understanding of type 2 diabetes and the most effective approach for managing this disease. The project enabled our practice to identify a group of patients with a chronic disease who we believed would experience improved outcomes as a result of focused, cooperative care. We now encourage patients to participate actively in the management of their disease and to set healthy goals for themselves, and we are reminded to stay patient-focused as we manage their diseases.