Implementation of a Diabetes Risk Reduction Program in a Community Health Center

Objectives: The purpose of this project was to target at-risk patients with diabetes at a community health center in North Carolina in order to decrease their risk for future complications. The project was part of the Health Resources and Services Administration’s Patient Safety and Clinical Pharmacy Services Collaborative. An intensive interdisciplinary team-based model was utilized, focusing on the identified individualized needs of each patient. The objective of this intensive health management model was to embed the concept of regular contact in the patient’s routine in order to reinforce diabetic education and sustain the patient’s engagement in his or her own care.

Methods: The population of focus was those patients with Type II diabetes whose last HgbA1c was > 9% and who had not been seen at the center for six months or more.  The initial telephonic patient contact was conducted by the case manager who provided education and scheduled a patient visit to the center. Patient encounter at the center included clinical pharmacy time to conduct medication therapy management, medication adherence counseling, and insulin titration.

Results: Data were collected from September 2010 through August 2011. Thirty patients from one physician’s panel were identified for inclusion in this care model. The percentage of patients with HgbA1c > 9% went from 100% in October to 59.4% in August, demonstrating a 40% decrease in patients with severely uncontrolled diabetes.

Conclusion: The improved outcomes evidenced through the use of an intensive interdisciplinary care management model, including clinical pharmacy services for high-risk patients with diabetes in this community health caner, has been sustained and has the potential for individualized spread to the other five centers within the system. These results indicate the significance of clinical pharmacy services in the management of those who are at high risk for complications as a result of having diabetes.