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Redesigning Care Delivery in Fee-for-Service Practices

Redesigning Care Delivery in Fee-for-Service Practices East Carolina Health/Bertie All-County Health Services
Eastern North Carolina
Diabetes
African American

Project


Redesign the way diabetes care is delivered in a rural primary care practice.

Based on the Chronic Care Model, primary care practices are redesigned to include a “circuit rider” staffing method, in which a certified diabetes educator nurse, a dietitian and a certified diabetes educator pharmacist rotate to clinics and partner with providers during patient visits as care managers. In this way, patients receive their education and behavior-centered coaching by a trained non-physician. In addition to staffing changes, an electronic health record disease registry system with physician decision support reminders is created.

At the point-of-care, patients receive: four-part American Diabetes Association education materials, self-management support, culturally relevant educational tools, and community-based follow-up and support services. This project is a collaborative effort involving: small rural hospitals, rural community health center practices, a regional medical school, and a pharmacy school program at a historically Black university.

Rationale


This intervention is directed at multiple components of the health care system including patients, providers, and the care team structure. Multi-component interventions have been shown to improve chronic disease outcomes for minority patients.

The circuit rider method of delivering skilled diabetes care is uniquely suited for medically underserved rural communities and those with disparate outcomes because it allows multiple practices to share the high costs and recruitment challenges of providing access to skilled diabetes care clinicians. It maximizes the efficiency of such a staff member because single clinic locations may not have a sufficient diabetic population to support a full-time staff member. Finally, circuit rider methodology requires scheduling provider and coaching visits on the same day (when the care manager is available). Clustering patients with a similar diagnosis together, this encourages staff to prepare diabetes specific educational tools and decision making protocols.

Summary Results


Certified diabetes educators (nurses and pharmacists) and a dietician rotated among rural clinics to partner with providers. This intervention is a financially viable means to bring specialists into clinics that would normally not be able to afford such services. Intervention patients experienced statistically significant decreases in HbA1c levels (0.72 absolute percentage point decrease vs 0.29 percentage point decrease for the control).  Providers reported that the intervention increased visit quality for patients.

Publications


Use of Integrated Care Delivery to Improve the Quality of Diabetes Management Among African Americans
North Carolina Medical Journal. 2011 Sep-Oct;72(5):390-2.
Full Article (
subscription may be required)

Improved Outcomes in Diabetes Care for Rural African Americans
Annals of Family Medicine. 2013 Mar-April; 11(2):145-150.
Full Article (
subscription may be required)

Additional Resources

Principal Investigators

  • Paul Bray, MA, LMFT (University Health Systems-Bertie Memorial Hospital)
  • Doyle M. "Skip" Cummings, PharmD, FCP, FCCP (Brody School of Medicine, East Carolina University)