Diabetes pathway slashes length of stay by 26%
Convenient clinic makes difference
The clinical pathway for diabetes at Spohn Memorial Hospital in Corpus Christi, TX, has helped the hospital cut health care costs an average of 68% per patient per year while readmissions dropped 33% and length of stay declined 26%, according to a two-year study of 107 diabetes patients.
The pathway, which was developed and pilot-tested between 1994 and 1996, was implemented right along with the hospital’s overall diabetes program, says Jan Kottke, Spohn’s director of primary care services. "We were seeing hospital visits and severe circulatory problems in diabetic patients that we knew could have been prevented," Kottke says. "The costs were significant for the patients and the hospital. With this program, the patients are better equipped to manage their disease, and they’re healthier as a result."
Based on standards set by the Alexandria, VA-based American Diabetes Association, the path can be customized to meet the needs of each patient, Kottke says. Essentially, each patient is assigned a risk level based on based on his or her level of hemoglobin A1c. "People who are at low risk certainly don’t need to come in with the same frequency as people who are at higher risk," she says. "But a moderate-risk individual is going to be seen on a quarterly basis after their initial assessment and classroom experience."
One obvious key to the success of the program has been the patient education component, which turned the hospital’s standard diabetes education from one week of classes to a year-long relationship between patient and provider. "Most of us have a saturation point for learning," Kottke says. "We’ve stretched that time out, giving patients pieces of information they can handle and then assessing whether they’ve actually learned it."
A multidisciplinary team made up of the primary care physician, the specialist, a pharmacist, a nurse, and a lab technician works on an individual basis with each patient. Patients are seen at least every 90 days and more often if needed. They get frequent lab tests (cholesterol, blood pressure, and blood glucose) and foot checks that are recorded in the computer program that tracks each patient’s care and reported monthly to the physician. "We catch trends before they turn into complications," says Ed Barnwell, chief executive officer of E2M Health Services, the Dallas-based firm that helped design the pilot program.
Because the patients get immediate feedback from their lab results, it’s easier for them to see what they need to change. "We live in a world that consists mostly of waiting lines," Kottke says. "And if we can eliminate delay and allow them to get the information when we have the maximum amount of their attention, that’s very positive. If the numbers are good, the patient gets a sense of accomplishment that reinforces the need to continue good habits. If the numbers aren’t so good, patients know that too. The nurse can tell them that this result is a good example of how a habit like exercise can make a difference in their lives."
Another key to the program’s success was the establishment of a specially designed clinic that provides all necessary services (except for the physician) in one convenient location. Patients get regular lab work-ups including hemoglobin levels, attend group classes, and receive one-on-one counseling at the clinic. In the study, 69% of the patients experienced a reduction in their HbA1c level, averaging a 1.6 point reduction per patient.
"Improving the access to services makes a big difference," says Ed Barnwell, chief executive officer of E2M. "The environment is nonthreatening, and the care is customized." E2M is expanding that concept with other clients in New York to establish clinics in large food stores where patients are likely to shop.
Nurse educators, community pharmacists, and lab technicians participating in the pilot program received extensive training based on established references such as the American Diabetes Association’s core curriculum for diabetes educators. Each clinician had to complete a three-month class including home study, weekly tests, and inservice sessions that covered such topics as patient assessment, communication skills, and use of the computer program that tracks patient care. At the end of the course, team members attended a two-day inservice session and were tested on their knowledge, patient assessment, and injection technique. "We basically teach them how to empower the patient," Barnwell says. "We meld components of traditional patient education with a proactive and progressive style."
The initial enrollment class gives patients and family members a chance to bond with each other and with the care team. Patients in the study were asked at that time to make a commitment to improving their own care for at least one year. Continuous follow-up and individual education sessions with the nurse educator or pharmacist are aimed at making sure patients know how to care for themselves and spot warning signs. Spohn’s existing 24-hour telephone service that allows patients to contact nurses immediately if needed was also available for the patients in the study.
With the director’s advice and support, Kottke and her colleagues sent letters and established contacts with local physicians to let them know the diabetes program was available. They also relied on their close working relationship with the hospital’s residency program to get the word out. Kottke adds that it helped to have the hospital’s medical director as a physician champion.
"Initially, there were some private practitioners who didn’t understand [the program] and thought it was usurping their role," Kottke says. "A lot of effort was made to educate those doctors on a one-to-one basis that our goal was not to usurp their role but to extend their effectiveness and to reinforce what they have been teaching in the office setting."
In addition to Kottke’s efforts, E2M also established an advisory board made up of Corpus Christi physicians who established a consensus on protocols for patient treatment, Barnwell says. "The whole point of this program is to support the physician who doesn’t have the time or the means to track patients this carefully, so we need to make sure the physicians are involved from the beginning," he says. "This is not a cookbook approach. We are reporting information so the physician can make better-informed decisions."
For more information on diabetes disease management, contact:
Jan Kottke, director of primary care services, Spohn Memorial Hospital, 2606 Hospital Blvd., Corpus Christi, TX 78405. Telephone: (512) 902-4196.
Ed Barnwell, CEO, E2M Health Services, 14275 Midway Road, Suite 220, Dallas, TX 75244. Telephone: (972) 687-9052.
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