The SJRRHN has been operating as the lead administrative agency for a successful five-county diabetes management program since its inception in 2006. Despite limited Low Income Pool (LIP) funding from Florida’s Medicaid Reform initiative, the program has demonstrated significant cost savings and return on investment, and it considered one of the state’s potential best-practice models.
The program incorporates a team-based, patient centered approach, with all of the components of the HRSA-recommended Chronic Care Model including the integration and coordination of community resources, support for disease self-management, an effective delivery system design, decision support for health care providers, and the utilization of clinical information systems.
Self-management Tools
In 2003, a web-based electronic disease registry was developed as part of the Diabetes Master Clinician Program to ensure ongoing, outcome-based quality improvement. This electronic disease registry is now part of the clinical information system supporting the program; it contains the records or more than 17,000 diabetic patients from more than 70 medical practices across Florida. The system provides population-management tools for physicians as well as individual report cards for patients, helping them manage their disease by tracking a variety of relevant health indicators, including Hba1c, blood pressure, blood cholesterol, BMI, micro-albumin, smoking and tobacco use, annual foot and eye exams, recommended immunizations, and disease self-management education.
Metrics Prove Success
The program’s quality-assurance data shows that among enrolled clinets, the avergae HbA1c is reduced by 5% within 6-8 months of program enrollment. Additionally, LDL blood cholesterol is reduced by 8% from an avergae baseline of 110 to 101 (goal is less than 100). Clients enrolled for longer periods of time have achieved even more significant outcome improvements. Of the program’s enrolled client population in September 2009, at least 15% had achieved the ADA-recommended goals for HbA1c, blood pressure, and LDL indicators. Nationally, only 7% of diabetic patients have achieved all three of tese recommended goals.
While we currently have the resources and capacity to serve only 260 clients, we will continue our efforts to expand and enhance the program, working toward increased capacity to serve a larger client base and capabilities that result in improved patient outcomes.