Patient team empowered diabetes care in LA

Much of the model I suggest in my Capstone presentation is in use in Los Angeles - including teams of caregivers amplified by teams of local residents in a cascading help-your-neighbor approach.

Here's excerpts from an article Diabetics Need Much More Than a Shot from today's LA Times.

Managing the disease requires constant support and substantial investment, but would pay off in the end for thousands of people.

By Susan Brink
[Los Angleles] Times Staff Writer

May 7, 2007

Diabetes is afflicting more people, at younger and younger ages, sending doctors, insurers and public health officials into a tizzy as the epidemic threatens to overwhelm the healthcare delivery system. The annual cost of healthcare for an adult with diabetes is more than $13,000, and rates of Type 2 have risen sharply in the wake of the upsurge in obesity in this country.

A bold experiment is unfolding in Los Angeles County that may serve as a lesson for the nation as it battles the epidemic.

Experts know that the cost of care could be much lower if patients could take simple measures to control their disease and avoid complications: nerve damage, amputations, heart disease, blindness, even death. But surveys show that many, even those with adequate health insurance, do not get that care, which is costly and labor intensive, demanding daily attention from patients and timely responsiveness from doctors.

Poverty creates additional obstacles, such as finding fresh vegetables or a safe place to exercise. Study after study shows that low-income people have less access to healthcare and a greater risk of getting sick and dying prematurely.

But in an odd twist to the usual healthcare disparity story, more than 1,000 L.A. residents in low-income areas, most of them uninsured or on MediCal, are getting the gold standard of aggressive diabetes management — better, even, than many with insurance who live in ritzy ZIP codes.

The care is taking place at clinics in East L.A. and South L.A., two communities with the highest rates of diabetes in the county, as well as three other outlying clinics. A team of L.A. doctors is participating in the experiment, training nurse practitioners, pharmacists, social workers and community educators to intervene in a way that doctors cannot do.

They're offering frequent patient checkups to monitor the disease, and teaching patients to track blood sugar, get out and take a walk, cut out the doughnuts, all the things they need to do to keep complications at bay.

They are reaching people with uncontrolled disease in some of the county's poorest pockets.

"The county patients [in the program] receive care that is as good, and probably better, as anywhere in the country," says Dr. Mayer B. Davidson, endocrinology professor at Charles Drew Medical Center and UCLA.

There are signs that it's working. Studies so far show that patients in the program have improved blood sugar and have had fewer emergency room visits and hospitalizations.

Local pioneers

The intensive program is a response from local academic and public health experts to the crisis ahead. One of those experts, Dr. Anne Peters, professor at USC's Keck School of Medicine and an endocrinologist who specializes in diabetes, works both sides of the disease's socioeconomic divide.

Peters has a Beverly Hills practice ... But she also has a second job: supervising teams of workers on the same intensive model at five clinics including the Edward Roybal Health Center in East L.A., and the Hubert Humphrey Health Center in South L.A.

Reducing complications is key to protecting patients and controlling costs. It's not rocket science: lose weight, watch your diet, exercise, monitor blood sugar, blood pressure and cholesterol, take your medications, have regular eye and foot exams.

But often, these simple things aren't done.

Doctors needed

Peters' practice is an exception. She's a private practice doctor who spends as much time with her patients as they need. Her practice follows a team model, with a staff of nutritionists, educators, nurses and nurse practitioners to advise and prod patients via face-to-face discussions, phone calls and e-mails.

"I personally believe that anyone can take good care of their diabetes, no matter who they are or what their level of education," she says. "But they need a team, or at least a guide."

So successful has Peters' method been, that six years ago, she launched a pilot program for the county, supervising a team of professionals trained to educate, monitor and, when necessary, nag. The program took off in four other county centers in 2005.

The treatment team members make phone calls, hold classes, help patients change their diets, prescriptions or medication doses. They will even visit patients' homes to keep treatment on track.

Community members who speak the same language and share the same culture and who have successfully controlled their diabetes are recruited to teach classes and help coordinate care for newcomers to diabetes management. The idea is to allow specialist physicians to become consultants to community-savvy teams who offer up a steady drumbeat of medical attention and lifestyle education.

"It makes more sense to reach out to people where they live 24/7, and not think that a visit every three months to a provider is where all the care happens," says Dr. Jeffrey Guterman, medical director of the L.A. County Department of Health Services.

Before being accepted, patients in the county program sign an agreement that they will keep appointments and follow medical instructions. If they fail to comply, they're out. [editor note - it's hard to evaluate the success rate if failures are excluded. The point of my Capstone is to try to figure out what determines the drop-out rate and address that.]

Because funding is limited, patients can stay with the program only 6 to 9 months, but the expectation is that they can learn to control their disease in that time, then go back to a primary care physician. Those county doctors are ready, having been trained in how to manage diabetes patients.

Early studies suggest that the program works. A report in the April 2006 American Journal of Managed Care looked at how a key blood sugar test, called A1c, was controlled in 367 patients in the L.A. County program the year before and the year after they entered the program.

The A1c guideline was met by only 28% of participants when they were under traditional medical care. After a year in the program, 60% of patients met the blood sugar level goal.

[Effective Diabetes Care by a Registered Nurse Following Treatment Algorithms in a Minority Population -

Conclusion: A nurse making clinical decisions based on detailed treatment algorithms did a better job of achieving ADA-recommended process and outcome measures than physicians providing usual care.

(Am J Manag Care. 2006;12:226-232)

A second study published in February in the journal Diabetes Care found that diabetic patients in the program reduced their use of emergency rooms by half and cut down on hospitalizations. Total hospital charges dropped that year for the 331 patients studied to $24,630, from $129,176 the year before.

[ Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population

Mayer B. Davidson, MD¹, Adeela Ansari, MD¹ and Vicki J. Karlan, MPH

Diabetes Care 30:224-227, 2007]



Peters, ... keeps her private practice going only through donations from grateful, wealthy diabetic patients to a foundation she has started.

The health insurance benefits that her Westside patients have cover visits — generally about every three months. They don't cover extra visits to change medications or search out the reason blood sugar has fallen out of control. They don't cover time spent analyzing complex blood glucose printouts, insulin pump data or teaching patients to adjust insulin and drug doses.

Nor do they cover time for long discussions, phone calls, e-mails or the nutritionist, educators and nurses she employs to advise and prod patients....

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susan.brink@latimes.com