Poorly controlled diabetes and co-morbidities represent a significant service and fiscal burden to the health care system. Data from 2003-2004 NHANES showed that approximately 40% of patients on oral agents alone were not on HbA1c target. The primary care nurse provider is central to CHC’s planned care, patient-centered model, assuming responsibility for primary prevention (vaccines and immunizations, health education), delegated nurse visits (Coumadin management, hypertension follow up), health education, triage and quality control. This is a two year trial for high risk patients with diabetes, using direct nursing support, group visits, panel management, and peer support.
This project hopes to deliver more, better and more coordinated care to a cohort of poorly controlled diabetics. The demonstration will position the Diabetes e-Co-System™ to satisfy key requisites for a successful Medical Home functioning as part of a future Accountable Care Organization. In addition, selected short-term clinical indicators associated with the preservation of end-organ function and reduction of cardiovascular risk will be improved, including HbA1c, LDL cholesterol, blood pressure, and renal function tests.