Uncontrolled diabetes may lead to blindness, kidney failure, heart disease, stroke, and loss of toes, feet or legs. The risk of death for adults with diabetes is 50 percent higher than for adults without it. That’s why Altru Health System chose to create a system-wide diabetes quality goal aligned with Minnesota Community Measurement (MNCM).
Ensuring we are meeting this target is not only critical for our health system. It enriches our patients’ lives.
A national leader in the development of high-value, patient-reported outcome measures, MNCM’s focus areas include management of diabetes and cardiovascular care. These measures are used by Altru to improve our patients’ health, experience, cost and quality of care. Patient-reported outcomes allow Altru to measure quality through our patients’ eyes.
Making Progress
Great work has been happening throughout our region.
Let’s take diabetes for example. In January 2015, our optimal diabetes score was 26 percent. By November 2015, we increased our score to 41 percent.
Factors that contributed to this success included:
- Primary care providers developed standard guidelines for patient visit frequency and medication management.
- We encourage all patients to schedule regular visits with a designated primary care provider to coordinate their care.
- We encourage our patients with diabetes to visit with a dietitian and nurse educator when diagnosed, and as needed thereafter.
Health Coaches
Altru’s primary care clinics all have health coaches, or registered nurses who regularly follow up with patients. Health coaches provide additional support, including scheduling follow-up visits and medication management. Our goal is to keep patients out of the hospital and safely managing their diabetes at home. Social workers are also available to assist patients with their social needs.
Altru’s Diabetes Center has supported our primary care providers in managing the care of these patients. We developed a MyHealth flow-sheet that allows patients to easily upload their blood glucose readings for online review by their care team.
We’ve opened up barriers for patients to easily access the care they need, when they need it. We’ve done this by following up with patients who fail to show up for their appointments, streamlining our referral process and offering group classes for patients with type 2 diabetes.
By the end of 2015, our results were all above target, including diabetes at 46 percent, hypertension at 83 percent and vascular disease at 59 percent.
Practicing evidence-based medicine leads to healthier patients. By adopting the standards, all providers follow the same guidelines to ensure patients are managed appropriately and consistently.
Patients need to have an active role in their healthcare. Care planning is interactive with the physician, care team and patient. The improvement experienced in 2015 is because the patient is engaged and taking an active role in managing their care.
