Diabetes Disease Management at Gotham Hospital
Diabetes disease management at the hospital is overseen by the ‘Clinical Diabetes Center at Gotham’s unit. The unit is a subsidiary of the Care Management Services incorporated into Gotham ACO as one of its branches. The center employs a multidisciplinary approach comprising of teams of endocrinologist, nurses and nutritionist in managing diabetes. ADA guidelines are the standard of practice at the clinic. The Clinical Diabetes Unit works in collaboration with Gotham Diabetes Research Center (DRC). The center employs both clinical and community based approaches in its management techniques. The clinical approach involves: 1) Inpatient management which offers consultation for patients hospitalized at Gotham. Hospitalized patients with diabetes are identified and critical diabetes related information is communicated to the patient’s primary care provider during the duration of admission; 2) Outpatient unit manages patients from ages 18 and older who are referred to the center by their primary care physicians for education and self-management training. The team at this unit offers patients nutritional counseling, insulin pump training and subcutaneous glucose monitoring. The aim of the outpatient is to better help patients keep their sugar level under control through proper nutrition and better use of medication. The team expands on their self-management program through the use of Proactive Managed Information System for Education in Diabetes (PROMISED®). This program strives to improve type 2 diabetes patient outcomes by providing ten hours of education to patients and work in close partnership with patients’ healthcare provider to improve patient clinical outcome (Gotham.org, 2011)
Community- based approach in diabetes management at Gotham targets individuals in the Bronx and Westchester community (Gotham.org, 2011)) through series of programs designed to reach out to the underserved with diabetes. Sometimes services are brought to the people in underserved areas in a non-traditional way in their homes. Depending on specific needs of the diabetes patients in the community, tailor made services can be provided to the patient. Some of the specialized community programs include Diabetes Collaboration in Federally Qualified Health Centers (FQUC); Diabetes in Pregnancy; Obesity Prevention Programs in Adolescent Medicine; Improved Management of Patients with Diabetes on Inpatient and Intensive Care Units; Registered Nurse led Care Management Program for Complex Patients with Diabetes; Health Education Program Focused on Diet; Exercise and Diabetes Prevention and Outreach Program.
With the passage of the healthcare law which encourages hospitals to form ACOs, Gotham hospital integrated its Diabetes Chronic Care Initiative into the Chronic Management Operations (CMO) branch of its ACO (Rosenthal 2010).
The diabetes disease management program at Gotham currently has 9,320 enrolled patients with 63% of the patients from Medicare, 17% from Medicaid and 20% from commercial insurance( Gotham.org,2010) Exhibit 2) .To enlist a patient into the diabetes management program at Gotham, a patient is assessed through comprehensive information collected through a structured assessment tool. A problem list is generated at the completion of the assessment and each patient’s “problem” is linked to one or more intervention management programs. Individualized patient care plans are created based on problems and intervention and periodic patient reassessment evaluations. Diabetes patients are identified through monthly data mining of claims and clinical data (Rosenthal, 2010). Patients are then stratified into risk group based on the severity of conditions- specifically diabetes, co-morbidities and other risk factors. Telephonic and on-site interactions are instituted for high-risk patients. About 20% of patients enrolled in this program in 2009 were members of the high-risk group (Rosenthal 2010). Telemonitoring is also used to monitor a subgroup of the very high-risk diabetes patients. [Isn’t this also an excellent approach for the Medicare population who are not so ambulatory?]
HbA1c and Low Density Lipid (LDL) or “bad cholesterol” levels in the patient’s blood are used to monitor the patient. Recommendations provided by the American Heart Association indicate healthy HbA1c levels range from 4-6% in healthy non-diabetic individuals, and normal LDL levels are below 130 milligrams per deciliter (mg/dl). The aim of Gotham’s’ diabetes management program is to keep HbA1c below 7% in diabetes patients, and to keep LDL below 130mg/dl in low-risk patients and below 100mg/dl in high-risk patients.
