Mass General Hospital is undergoing a process of redesigning care delivery to increase the value and quality of care.  In the area of diabetes care, the emphasis has been on collaboration across disciplines to support patients on insulin.  To this end, the Diabetes Care Redesign Team called together a multidisciplinary team of stakeholders (including representatives from primary care, nutrition and endocrinology among others) to develop a set of best practices for starting patients on insulin.

A pilot program using this new process was developed and tested at three sites in and around the hospital.  This new process creates a diabetes care team, led by a designated diabetes nurse champion, for each practice.  Physicians work in close partnership with nurses and dietitians, making it easier to stay in touch regarding patient care.  Patients are supported between office visits through frequent follow-up phone calls by their care team and use of the Patient Gateway or iHealthSpace internet health portals.  The pilot program helped improve blood sugar control without increasing side effects. It is has now been expanded to all Mass General primary care practices.

The biggest challenge thus far has been wider implementation of this new care model at a time when the hospital is transitioning into the Patient-Centered Medical Home.  To support efforts at sustainability, twice yearly conferences were established to support teams and promote knowledge sharing.  These conferences also serve as a venue for teams to troubleshoot with peers over problems they have encountered, and review best practices.

Last May, the Diabetes Care Redesign Team was one of several groups to receive the Nathanial Bowditch Prize in recognition of their work improving quality of care while reducing cost.  Receiving the award was a gratifying experience, confirming that hospital administration believes in this new care model.  Funds received with the award are being put toward conferences and training to further support program growth.

The Diabetes Care Redesign team will be participating in the MGH/MGPO Care Redesign Fair next Wednesday, September 4^th.  All are welcome to come and learn more about the ongoing work to improve care delivery across clinical areas.  The fair will be held 9am to 2pm under the Bulfinch Tent.