Partners HealthCare is currently undergoing a process of care redesign in several hospital areas and conditions to improve the value of care provided to our patients by increasing the quality of care while decreasing cost. Partners established several goals for Diabetes Care Redesign, including increasing the appropriate use of insulin. Here at Mass General, we used this as an opportunity to develop a population management strategy to start eligible patients on insulin earlier, incorporate behavioral and lifestyle approaches into the diabetes care plan at this important touch point in diabetes care, and minimize the side effects of insulin therapy (hypoglycemia and weight gain). To do this, we convened a multi-disciplinary group of stakeholders, including primary care doctors, endocrinologists, nurse practitioners, nurses, dietitians, psychologists, pharmacists, and others to develop best practices for insulin initiation and titration. Over the past year, the MGH Diabetes Care Redesign Team has been working to implement its innovative new insulin initiation process within several primary care practices. 

Three sites are currently piloting this program: Internal Medicine Associates (IMA), Women’s Health Associates, and MGH Back Bay. In the pilot, a nurse from each practice’s diabetes management team is designated as the Diabetes Champion. Using TopCare Diabetes, an online population management tool, the Champion identifies which patients in the practice are eligible for insulin initiation and titration and reviews the care plan with the primary care provider. The primary care provider, in turn, begins a discussion with the patient about starting insulin. Eligible patients are screened for potential medical or behavioral barriers to success (e.g. depression, lack of motivation, fear of needles). They are then enrolled in a coordinated care process that promotes rapid cycle change, in which the Diabetes Champion uses frequent phone- or visit-based contact to help the patient start and adjust the insulin dose instead of following the usual every 3 month visit pattern.

The entire process lasts several months but reduces the overall time to develop a successful treatment plan. It includes follow up visits with both providers and dietitians, and phone calls by the Diabetes Champion to provide between-visit support. The Diabetes Champion serves as the care manager overseeing every step of the process from the preparation phase, to the insulin start phase, to follow-up after successful insulin initiation. Many of the elements incorporated into this plan were adopted from those already being done informally at many practices. The new process creates a formal standard for providers to learn from best practices and incorporates new elements from other disciplines, specifically nutrition/lifestyle and behavior change, into routine diabetes care. It also meets many chronic disease management criteria required for Patient-Centered Medical Home certification.

At its heart, the Diabetes Care Redesign is all about collaboration; participants from various areas came together to share their knowledge and learn from others’ experience with caring for patients with diabetes.  The project has been led collaboratively by Deborah Wexler, MD of the MGH Diabetes Center and Stephanie Eisenstat, MD (Women’s Health Associates) blending specialist and primary care expertise; Elizabeth Geagan, MHA (Endocrine Division); and Gianna Wilkins, BS (Process Improvement). In particular, the nutrition curriculum was developed by an international expert in diabetes nutrition, Linda Delahanty, MS, RD, LDN working with Lillian Sonnenberg (DSc, RD) Assistant Director, Community Nutrition, and Melanie Pearsall (RD, CDE) of MGH Revere.  Other key contributors to the project include Barbara Chase (APRN, BC, ANP) of MGH Chelsea and Marcy Bergeron (RN, MS, ANP) of the Bulfinch Medical Group, who have spearheaded diabetes population management at their practices for many years; Anne Thorndike, MD of the MGH Division of General Internal Medicine, an expert in behavior change in obesity; and Mira Kautzky MD, a primary care physician in the IMA. We welcome patient participation and feedback in the process; please contact Deborah Wexler, MD if you are interested in learning more.

The Care Redesign process represents a paradigm shift – a fundamental change in how we approach diabetes care. Team-based care requires changes in practice organization, and developing workflow to fit within the Patient-Centered Medical Home model presents its own challenges. But it has been a gratifying experience working with so many people from a range of disciplines, learning from and incorporating their experience and expertise in this effort. It’s our hope that the work we have done with Diabetes Care Redesign will serve as a model for other departments undergoing their own care redesign efforts.