Lastly, with an increasing number of diabetes treatment options available, pharmacists are starting to play a larger role in MDTs. Traditionally, pharmacists have helped to oversee drug therapy prescribed by physicians. However, some pharmacists are now taking on additional responsibilities, including initiating or changing patient medications, ordering laboratory tests to monitor drug effects, and counseling patients to assess medication knowledge.7 Pharmacist involvement seems to be beneficial: a systematic review of 21 studies involving pharmacists in diabetes management revealed a significant decrease (0.5% or greater) in glycated hemoglobin (A1C) levels among patients, compared with standard care, in more than half of the studies (13 out of 21) evaluated.8 In addition, overall A1C improvements were greater in interventions in which pharmacists were involved with direct medical management.
Coordination of care
A major strength of MDT centers is that all elements of care coordination are brought together at 1 location. SDC patients typically visit a clinic a minimum of 5 times per year. At each routine visit, patients see a physician, receive counseling from a CDE or dietitian, and are given routine laboratory tests, with results available in real time from point-of-care testing; this permits immediate action and discussion to monitor and advance the treatment plan. In addition to routine testing, we also perform metabolic lab work and fundus eye scans on-site. Physicians, dietitians, and nurses collaborate with patients to create individualized, comprehensive care plans, which are then supported by other staff. In addition, patients can be referred to on-site educational groups or seminars, or individual education as necessary. Our lifestyle instruction and exercise coaching includes around-the-clock access to online education and a forum through which patients can submit questions to providers at any time (to be answered during business hours), as well as a hotline that can be called during or after office hours. The after-hours hotline is managed by CDEs, who are able to triage to other members of the provider team or to emergency care, if needed.
Patient management
During an initial clinic visit, intake is conducted at the general registration office. The registration period includes an evaluation of current diabetes management, an assessment of additional management needs, and on-site lab work. A series of lab tests are performed during the initial intake, the majority of which produce same-day results (in as little as 2–8 minutes for some tests). Patients may also require ancillary testing or care, such as retinal testing or a flu vaccine; these needs would be identified either over the phone or during the initial clinic intake visit. Next, the patient sees a physician, who conducts a thorough medical exam, may identify further necessary ancillary tests, and discusses diabetes management options. Following the physician visit, the patient meets with a CDE for basic education on coping skills, or training on medication administration, which may include basic information or more advanced diabetes topics within the wide scope of diabetes education, depending on the patient’s needs.
All of the linked care occurs at a single visit. The 3 components comprising visits to SDC centers are: intake and screening; a physician examination, including evaluation of needs for disease management; and diabetes education (depending on need). Typically, the patient’s first visit will be used to obtain a comprehensive history and to conduct a thorough evaluation and initial education and care plan, and will usually last about 2 hours. Subsequent visits follow the same model and typically last 1 hour, depending on the patient’s needs. Patient records are managed using electronic medical records, which allow the clinic to easily track each patient’s progress, clinical indications for screening and intervention, and individual and aggregate outcomes. While patients generally receive medical evaluation and care from a physician at their first visit, NPs and PAs in our offices also act as primary providers in our model in order to provide patients with greater flexibility.
The approach to patient care should be highly individualized, which unfortunately sometimes leads to difficulties with payers when it comes to negotiating coverage for the most appropriate medications. Practitioners at SDC centers typically do not follow formulaic algorithms; rather, they approach each patient individually, taking into consideration his or her medical history and current health status to make treatment decisions. Staff time can often be spent contacting payers and completing paperwork to ensure that patients get the care they need. The extra time required for paperwork issues is to be expected when implementing individualized patient care. This tiered medication support and management is a system not frequently available from primary care physicians in private practice.