Cutting-Edge Care for Patients with Diabetes

Health care professionals interested in improving outcomes for patients who have diabetes may find an article published in the September issue of Current Diabetes Report interesting. Written by members of the Kaiser Permanente clinical team, it speaks to the values of multidisciplinary care. At Kaiser, teams include—and give cutting edge authority—to pharmacists.

The southern California Kaiser program, called the KPSC Complete Care program, optimizes care coordination. The program serves approximately 390,000 patients diagnosed with diabetes.

KPSC’s multidisciplinary teams include physicians, physician assistants, pharmacists, registered nurse practitioners, registered nurse (RN) care managers, office-based RNs, licensed vocations nurses, health educators, and others as needed. These teams address the patient’s complete needs, and do so with consideration of the patient’s native language and cultural needs.

Team members follow an evidence-based algorithm that has several goals:

• Allow for patients to self-titrate medications safely and efficiently.
• Create a treatment sequence or pathway for clinicians to guide medication treatment decisions.
• Provide the underpinning for automated systems.

The authors review the purpose of a formulary—to help providers select appropriate pharmacologic options—and discuss how their organization considers safety, efficacy, and patient preference along with quality of care and cost. The system incorporates formulary recommendations into its electronic medical record, but it also allows override. Cost is only a driving factor if several options deliver identical clinical outcomes.

Kaiser also invites patients to participate in an online Personal Action Plan (oPAP). Patients use the oPAP to report current status and make adjustments to their medications. They can also communicate with their teams using e-mail or text.

Kaiser’s population of patients who have diabetes is growing, but their resources are not growing at the same rate, according to the study researchers. For this reason, they continue to pursue cost-effective ways to serve patients efficiently. At this time, they are developing wireless remote glucose monitoring programs pursuant to a successful pilot program. The program is also using predictive analysis to intervene early.

Reference

Martin JP, Aboubechara N. Process-Based Treatment of Diabetes in Kaiser Permanente Southern California: How to Make Diabetes Care "Complete". Curr Diab Rep. 2017 Sep;17(9):79. doi: 10.1007/s11892-017-0897-9.