Traditional or centralized models of diabetes care: The multidisciplinary diabetes team approach

Introduction

Although patients with diabetes may be well managed by primary care physicians, the application of a team approach to the delivery of care enables a range of health care providers to integrate their skills to facilitate improved patient management and outcomes. Centralized diabetes care clinics bring together the expertise of primary care physicians, endocrinologists, registered nurses, nurse practitioners (NPs), physician assistants (PAs), certified diabetes educators (CDEs), dietitians, and/or pharmacists into a multidisciplinary diabetes team (MDT) that operates under a single roof to provide integrated care.

This approach contributes to comprehensive patient management and improved disease outcomes.^1-4 Specialized diabetes care (SDC) centers rely on an MDT structure to provide patients with individualized disease management. The centralized model encourages ongoing communication and interaction between the patient and multiple members of the care team. These SDC centers are typically statewide or regional.

A centralized model of diabetes care

Overview and organizational structure

SDC centers offer medical services for patients with diabetes, based on 4 cornerstones of disease management: medical care; personalized education; nutrition counseling; and lifestyle and exercise coaching. The centralized model involves patients in the management of their diabetes, with the goal of promoting wellness and preventing complications. Specifically, physicians, nurses, and dietitians work with patients to develop personalized treatment plans to prevent and detect diabetes-related complications. At Diabetes America centers, team members include physicians, NPs, PAs, and CDEs. Some SDC centers do not employ pharmacists, while other centralized diabetes clinics have a pharmacist on staff.

Within the MDT structure, the physician, NP, or PA is primarily in charge of monitoring patient health and making pharmacologic decisions; he or she is aware of the full range of available therapeutic options for diabetes management, as well as clinical practice guidelines and emerging evidence. Physicians, in conjunction with the MDT, also provide expert knowledge regarding new management technologies, such as insulin pumps and glucose sensors. Lastly, physicians provide expertise and patient management in other aspects of care, including hypertension and lipid management, and the treatment of diabetes-related complications. NPs and PAs work closely with physicians to coordinate personalized patient treatment plans; these professionals also provide integral support and education to patients who are newly diagnosed with diabetes and/or who are making the transition to insulin therapy (when patients face new lifestyle considerations, including daily glucose monitoring and insulin shots).

In addition to encouraging effective self-management and patient autonomy, SDC patients are provided with comprehensive, ongoing patient education delivered by CDEs. The role of the CDE is to promote positive health behaviors across all areas of diabetes self-management.⁵ The curriculum employed in our centers is consistent with the recommendations of the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA). Patients learn about diabetes pathophysiology and management, circulatory health, medical nutrition therapy, and eye health in individual sessions, group classes, or seminars. The timing and sequence of training and education is predicated on patients’ needs and schedules. Additionally, CDEs are responsible for specific diabetes management tasks; for example, they can discuss treatment issues, medication titration, or dose adjustments, based on patient feedback. A patient’s need for education is evaluated during the clinical part of the visit. For example, when a physician initiates insulin treatment, the CDE would provide all necessary information and training to allow the patient to successfully self-administer insulin.

Dietitians help patients develop personalized nutrition plans, including meal and weight management plans, with the goal of developing targeted lifestyle change programs based on personal preferences. A recent review has confirmed that medical nutrition therapy delivered by registered dietitians is effective and essential in the management of diabetes.⁶ Diabetes America centers offer nutrition education in individual and classroom sessions, and encourage patients, as well as their families and caregivers, to attend. These sessions cover issues such as carbohydrate counting, reading and understanding nutrition labels, healthy portion sizes, meal planning, and weight management. Fitness and nutrition experts educate patients on the basics of healthy lifestyle, and offer tools to help patients reach their goals. In addition, patients are counseled on sick-day management, coping mechanisms for stress, and skin and foot care. The coaching approach is essential to ease patients’ adjustment into lifestyle changes essential for optimal diabetes management.

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.

Business model and profitability

The business model should be adaptable to support changing staffing needs in an SDC network with multiple centers. It is important to provide timely, quality care to patients, but equally important is engaging patients in ongoing care, maintaining a proper rate of patient flow at each clinic every day. Often the model employs a staffing process to match appropriate team members to the number of patients seen at a center, meaning that staff may rotate to different centers depending on need.

For diabetes education services to be covered for reimbursement, the Centers for Medicare and Medicaid Services requires accreditation for all diabetes self-management education and training (DSME/T) programs by the ADA, the AADE, or Indian Health Services. Programs must meet quality standards of the accrediting organization.⁹

Some federally qualified or academic-based diabetes centers are supported entirely by grant and other public resources, and require grant renewals to become sustainable; other centers have a grant-funded component, and a private- funding component. Unlike diabetes clinics that have a nonprofit component, the SDC that we are associated with (Diabetes America) is completely privately funded and receives no grants to cover clinic or care expenses. We are unable to comment with certainty on whether Diabetes America is unique in its funding. Because of our business model, it is fiscally sound to maintain a mix of patients supported by both private and government payers. Self-payers are accepted, but make up only a small percentage of our patient population.

Costs to patients will vary based on the individual patient’s insurance plan. Many employers, and in turn many patients, are unaware of the placement of diabetes care and education within their comprehensive insurance plan. Some plans cover only the physician visit; all other services are applied towards the patient’s deductible. In some cases, patients may incur substantial costs until the deductible has been reached. In recent years, we have seen deductibles increase for all segments of our population, which can be a financial strain for patients. Patients now scrutinize further which medications or diagnostic testing services they will take or reject based on what their insurance will cover. Patients also face the challenge of having to learn how to calculate their co-payment responsibility in advance.

From our knowledge, many employers are evaluating their diabetes care plans and are beginning to recognize education and preventive services as vital parts of diabetes management that should be covered as part of comprehensive care. As a result, we are working with more employers to design and implement full-service plans that include education and supplies (such as blood glucose testing devices and strips) intended to minimize costs over the long term.

Comparisons of multidisciplinary diabetes team care to standard care

A growing body of research supports the benefits of using an MDT for diabetes care. Specifically, available evidence suggests that a physician-led team encompassing nursing staff, diabetes educators, and dietitians to provide intensive diabetes care may significantly improve patient adherence and glycemic control, as well as the quality of care provided.

A randomized, controlled trial evaluated an MDT approach for the management of diabetes and other chronic conditions at a family health network serving more than 1000 patients in Ottawa, Canada.¹⁰ Patients were randomized to receive MDT care or usual physician care. The study measured quality of chronic disease management care based on predetermined performance measures (guideline recommendations) for diabetes, coronary artery disease, chronic heart failure, and chronic obstructive pulmonary disease (primary outcome measure). The study also evaluated quality of preventive care (adherence to the Canadian Task Force on Preventive Health Care recommendations for 6 preventive indicator maneuvers, such as influenza vaccination, eye examination, and hearing examination). The performance measures for diabetes management recommended an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) when appropriate; measuring A1C twice yearly; and giving foot and eye examinations within the past 2 years. After an average of 1.25 years of follow-up, there was significant improvement in the primary outcome measure, with the network’s chronic disease management quality of care improving by 9.2% with MDT care compared with traditional care (P<.001). In addition, the secondary outcome measure of quality of preventive care had also improved, by 16.5%, with MDT care compared with traditional care (P<.001).¹⁰ There were no significant improvements in other secondary outcome measures (eg, glycemic control, hypertension, quality of life, and functional status), but, according to the authors, the clinical team did not concentrate on the 2 specific clinical outcomes (glycemic control and hypertension); instead, they had a more general focus of improving the management of the chronic diseases of individuals in their care. Furthermore, the study may not have had enough power to detect a significant difference in these outcomes. With regard to the lack of improvement in quality of life and functional status measures, inclusion of complex older patients who may be at increased risk of irreversible functional decline might have been a limitation of the study.¹⁰

Two primary care clinics in Israel compared MDT outcomes to standard care in patients with poor glucose control (A1C levels ≥10%); the patients were studied for 6 months.¹¹ One clinic was randomly chosen to provide patients with standard medical care, delivered by physicians and nurses (control group), while another clinic provided patients with an MDT approach that included care from a diabetes specialist, a dietician, and a diabetes nurse educator. At the 6-month follow-up, patients at the intervention clinic had significantly lowered mean A1C levels (–1.8%, P=.00001) and plasma glucose readings (–1.5 mmol/L [~27 mg/dL], P=.003), with no significant changes seen in either measure at the control clinic.¹¹ Patients in the intervention group also had twice the response rate to treatment (defined as a ≥0.5% decrease in A1C at 6-month follow-up) vs the control group (71% vs 35%, respectively). Additionally, patients in the intervention group had a higher rate of follow-up (attendance at 6-month visit) than patients in the control group (82% vs 35%, respectively).

Another study evaluated (over 1 year) a community-based family medicine residency program that implemented MDT care for 105 patients with type 2 diabetes and compared pre- and post-intervention outcomes.¹² Successful disease management was defined as having A1C <7%, low-density lipoprotein (LDL) cholesterol <100 mg/dL, and blood pressure <130/80 mm Hg. At 1 year following program implementation, patients improved in all metabolic and process measures. Additionally, 17.1% of patients achieved successful disease management, defined as meeting all 3 criteria, as compared with 5.7% prior to the intervention.¹² The patients who did not meet all 3 criteria, however, would still benefit from care coordination and targeted intervention to help them manage the disease and achieve goals.

Individual and group diabetes management education approaches are also integral parts of centralized care, and are associated with proven patient benefits. A meta-analysis that included data from 31 randomized, controlled trials evaluating self-management education showed that, at immediate follow-up after the last educator-patient contact, patients who had received self-management education decreased their A1C levels by 0.76% more than patients who did not receive self-management education (95% confidence interval, 0.34–1.18).¹³ Patient outcomes further improved as more time was spent with educators.

Another meta-analysis of 11 studies showed that group-based education for diabetes was related to A1C decreases of 1.4% after 4–6 months of follow-up; these decreases endured at 1 year (0.8%) and 2 years (1.0%) of follow-up (P<.00001 for all 3 time points).¹⁴ Patients who received group-based education also had reduced body weight (1.6 kg; P=.02) and improved diabetes knowledge (P<.00001) at 12–14 months of follow-up, and reduced systolic blood pressure (5 mm Hg; P=.01) at 4–6 months of follow-up. Lastly, about 1 in 5 patients who received group-based education were able to decrease their doses of diabetes-related medications at 12–14 months (P<.00001).¹⁴

Outcomes data from a subset of patients from the Diabetes America clinics showed that after 4 visits, the average patient A1C value was 7.0%. Overall, 59% of patients had A1C values <7.0% and only 9% had A1C values >9.0%. Additionally, 62% of patients had LDL cholesterol values <100 mg/dL, and only 14% had values >130 mg/dL. A total of 64% of patients sustained systolic blood pressure levels <130 mm Hg, and only 14% had values >140 mm Hg. Lastly, 62% of patients sustained diastolic blood pressure levels <80 mm Hg, and only 5% had values >90 mm Hg.¹⁵ All of these outcomes surpass recommended guidelines from the National Committee for Quality Assurance (NCQA) Diabetes Physician Recognition Program (DPRP).¹⁶

Cost-effectiveness analyses from a 3-year study of Diabetes America clinics were performed by Aetna, a health insurance provider. Outcomes and costs were monitored for 4 large, public-sector employers who provided their employees with incentives (co-payment waivers) to use an SDC center (in this case, Diabetes America clinics).¹⁷ Costs were then compared between patients who did and did not use Diabetes America clinics. For the first 2 years of the study, outcomes were similar, but in the third year the SDC patients had average monthly medical costs that were $226 less per member.¹⁷ These cost savings appeared to be due to fewer emergency room visits and shorter hospital stays. Although prescription costs for the clinic patients were on average $40 more per month than for patients not accessing care at these sites, the higher cost was offset by lower medical costs in the long run. Additionally, patients at the Diabetes America centers were more compliant with disease maintenance requirements (such as regular eye exams and blood screenings).

Reasons for success and key challenges

By bringing comprehensive, patient-centered care together in single locations, SDC centers can offer both quality and convenience to patients. The “one-stop” approach is a major benefit for patients who would not otherwise have time to attend separate appointments to have required laboratory work and diagnostic tests, and to see physicians, nutritionists, and CDEs. Furthermore, these health centers accept most insurance plans, with only 1 insurance co-payment for all services rendered, which can provide substantial patient cost-savings compared with noncentralized providers. Many of these clinics are patient-friendly and may provide amenities such as ample parking, free coffee, wireless Internet access, and comfortable waiting rooms.

Financial constraints, which can limit the size of the MDT, are an ongoing challenge of providing care within a centralized model. Patients are taught self-care principles that encourage them to become involved in their own disease management. To achieve goals, team members must have good interpersonal skills, as well as a clear understanding of specific and shared responsibilities. To ensure success, management needs to be proactive in clarifying these responsibilities. Lastly, training provided to the team must be tailored to the clinical environment and community needs (eg, training on cultural sensitivity).

Conclusions

The SDC center model provides highly individualized, quality care to patients. The model is exemplified in the choice not to rely on generalized algorithms for treatment decisions; instead, clinical decision-making takes into account multiple factors about an individual patient. Each provider (physician, NP, or PA) sees a limited number (approximately 15–18) of patients per day, giving providers sufficient time to discuss with them the complexities of diabetes management, as well as the opportunity to individualize therapies. Patient involvement in treatment decisions is solicited, which is especially important when working with patients from diverse ethnic and cultural backgrounds on topics such as individualized approaches to diet. In addition, compared with individual primary care providers, we are early adopters of newer medications and advocate with insurers for full patient coverage. We believe that all of these steps help to ensure successful diabetes management for our patients.

Education is the cornerstone to diabetes care¹⁸; our patients are empowered by the education they receive, and often give positive feedback about the educational aspect of our care centers. Providers at SDC center clinics (physicians, NPs, and PAs) offer diabetes care and education options in a “menu” format for patients, and steer them toward the appropriate treatments, diagnostic tests, and education based on their individual needs. In our centers we take the time to explain to patients the pros and cons of various treatment options, how medications work, and our goals for their overall treatment plan. With an increased understanding of the pathophysiology of diabetes and the mechanisms through which their therapies work, patients can have more say in, and ownership of, their treatment decisions. Because of time constraints, integrative discussions can be difficult for many primary care physicians to accommodate. However, having patient care and education provided at the same clinic helps unite treatment decisions and education goals, enabling patients to increase both their understanding of diabetes management and their own self-efficacy and ability to follow their treatment plan.

It is important for payers and employers to continue to evaluate their goals for diabetes care and ensure that the proper administrative policies are put in place to support diabetes care in a comprehensive manner. Patients respond to incentives to improve care if they can be implemented. With the chronic nature of diabetes and insidious onset of diabetes complications, patient barriers to care must be identified and addressed to continually engage the patient in good diabetes care. We encourage increased collaboration between employers, providers, patients, and payers so that all incentives can be aligned. In particular, it is important that all parties involved understand the nature of, and need for, ongoing diabetes education.

Lastly, SDC centers may provide early intervention to prevent the worsening of diabetes-related conditions and comorbidities that will cost patients and payers more in the long term. Going forward with chronic disease management in the United States, it will be increasingly important to focus on both long- and short-term outcomes if we wish to see both positive and cost-effective results.

Introduction

Although patients with diabetes may be well managed by primary care physicians, the application of a team approach to the delivery of care enables a range of health care providers to integrate their skills to facilitate improved patient management and outcomes. Centralized diabetes care clinics bring together the expertise of primary care physicians, endocrinologists, registered nurses, nurse practitioners (NPs), physician assistants (PAs), certified diabetes educators (CDEs), dietitians, and/or pharmacists into a multidisciplinary diabetes team (MDT) that operates under a single roof to provide integrated care.

This approach contributes to comprehensive patient management and improved disease outcomes.^1-4 Specialized diabetes care (SDC) centers rely on an MDT structure to provide patients with individualized disease management. The centralized model encourages ongoing communication and interaction between the patient and multiple members of the care team. These SDC centers are typically statewide or regional.

A centralized model of diabetes care

Overview and organizational structure

SDC centers offer medical services for patients with diabetes, based on 4 cornerstones of disease management: medical care; personalized education; nutrition counseling; and lifestyle and exercise coaching. The centralized model involves patients in the management of their diabetes, with the goal of promoting wellness and preventing complications. Specifically, physicians, nurses, and dietitians work with patients to develop personalized treatment plans to prevent and detect diabetes-related complications. At Diabetes America centers, team members include physicians, NPs, PAs, and CDEs. Some SDC centers do not employ pharmacists, while other centralized diabetes clinics have a pharmacist on staff.

Within the MDT structure, the physician, NP, or PA is primarily in charge of monitoring patient health and making pharmacologic decisions; he or she is aware of the full range of available therapeutic options for diabetes management, as well as clinical practice guidelines and emerging evidence. Physicians, in conjunction with the MDT, also provide expert knowledge regarding new management technologies, such as insulin pumps and glucose sensors. Lastly, physicians provide expertise and patient management in other aspects of care, including hypertension and lipid management, and the treatment of diabetes-related complications. NPs and PAs work closely with physicians to coordinate personalized patient treatment plans; these professionals also provide integral support and education to patients who are newly diagnosed with diabetes and/or who are making the transition to insulin therapy (when patients face new lifestyle considerations, including daily glucose monitoring and insulin shots).

In addition to encouraging effective self-management and patient autonomy, SDC patients are provided with comprehensive, ongoing patient education delivered by CDEs. The role of the CDE is to promote positive health behaviors across all areas of diabetes self-management.⁵ The curriculum employed in our centers is consistent with the recommendations of the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA). Patients learn about diabetes pathophysiology and management, circulatory health, medical nutrition therapy, and eye health in individual sessions, group classes, or seminars. The timing and sequence of training and education is predicated on patients’ needs and schedules. Additionally, CDEs are responsible for specific diabetes management tasks; for example, they can discuss treatment issues, medication titration, or dose adjustments, based on patient feedback. A patient’s need for education is evaluated during the clinical part of the visit. For example, when a physician initiates insulin treatment, the CDE would provide all necessary information and training to allow the patient to successfully self-administer insulin.

Dietitians help patients develop personalized nutrition plans, including meal and weight management plans, with the goal of developing targeted lifestyle change programs based on personal preferences. A recent review has confirmed that medical nutrition therapy delivered by registered dietitians is effective and essential in the management of diabetes.⁶ Diabetes America centers offer nutrition education in individual and classroom sessions, and encourage patients, as well as their families and caregivers, to attend. These sessions cover issues such as carbohydrate counting, reading and understanding nutrition labels, healthy portion sizes, meal planning, and weight management. Fitness and nutrition experts educate patients on the basics of healthy lifestyle, and offer tools to help patients reach their goals. In addition, patients are counseled on sick-day management, coping mechanisms for stress, and skin and foot care. The coaching approach is essential to ease patients’ adjustment into lifestyle changes essential for optimal diabetes management.

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.

Business model and profitability

The business model should be adaptable to support changing staffing needs in an SDC network with multiple centers. It is important to provide timely, quality care to patients, but equally important is engaging patients in ongoing care, maintaining a proper rate of patient flow at each clinic every day. Often the model employs a staffing process to match appropriate team members to the number of patients seen at a center, meaning that staff may rotate to different centers depending on need.

For diabetes education services to be covered for reimbursement, the Centers for Medicare and Medicaid Services requires accreditation for all diabetes self-management education and training (DSME/T) programs by the ADA, the AADE, or Indian Health Services. Programs must meet quality standards of the accrediting organization.⁹

Some federally qualified or academic-based diabetes centers are supported entirely by grant and other public resources, and require grant renewals to become sustainable; other centers have a grant-funded component, and a private- funding component. Unlike diabetes clinics that have a nonprofit component, the SDC that we are associated with (Diabetes America) is completely privately funded and receives no grants to cover clinic or care expenses. We are unable to comment with certainty on whether Diabetes America is unique in its funding. Because of our business model, it is fiscally sound to maintain a mix of patients supported by both private and government payers. Self-payers are accepted, but make up only a small percentage of our patient population.

Costs to patients will vary based on the individual patient’s insurance plan. Many employers, and in turn many patients, are unaware of the placement of diabetes care and education within their comprehensive insurance plan. Some plans cover only the physician visit; all other services are applied towards the patient’s deductible. In some cases, patients may incur substantial costs until the deductible has been reached. In recent years, we have seen deductibles increase for all segments of our population, which can be a financial strain for patients. Patients now scrutinize further which medications or diagnostic testing services they will take or reject based on what their insurance will cover. Patients also face the challenge of having to learn how to calculate their co-payment responsibility in advance.

From our knowledge, many employers are evaluating their diabetes care plans and are beginning to recognize education and preventive services as vital parts of diabetes management that should be covered as part of comprehensive care. As a result, we are working with more employers to design and implement full-service plans that include education and supplies (such as blood glucose testing devices and strips) intended to minimize costs over the long term.

Comparisons of multidisciplinary diabetes team care to standard care

A growing body of research supports the benefits of using an MDT for diabetes care. Specifically, available evidence suggests that a physician-led team encompassing nursing staff, diabetes educators, and dietitians to provide intensive diabetes care may significantly improve patient adherence and glycemic control, as well as the quality of care provided.

A randomized, controlled trial evaluated an MDT approach for the management of diabetes and other chronic conditions at a family health network serving more than 1000 patients in Ottawa, Canada.¹⁰ Patients were randomized to receive MDT care or usual physician care. The study measured quality of chronic disease management care based on predetermined performance measures (guideline recommendations) for diabetes, coronary artery disease, chronic heart failure, and chronic obstructive pulmonary disease (primary outcome measure). The study also evaluated quality of preventive care (adherence to the Canadian Task Force on Preventive Health Care recommendations for 6 preventive indicator maneuvers, such as influenza vaccination, eye examination, and hearing examination). The performance measures for diabetes management recommended an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) when appropriate; measuring A1C twice yearly; and giving foot and eye examinations within the past 2 years. After an average of 1.25 years of follow-up, there was significant improvement in the primary outcome measure, with the network’s chronic disease management quality of care improving by 9.2% with MDT care compared with traditional care (P<.001). In addition, the secondary outcome measure of quality of preventive care had also improved, by 16.5%, with MDT care compared with traditional care (P<.001).¹⁰ There were no significant improvements in other secondary outcome measures (eg, glycemic control, hypertension, quality of life, and functional status), but, according to the authors, the clinical team did not concentrate on the 2 specific clinical outcomes (glycemic control and hypertension); instead, they had a more general focus of improving the management of the chronic diseases of individuals in their care. Furthermore, the study may not have had enough power to detect a significant difference in these outcomes. With regard to the lack of improvement in quality of life and functional status measures, inclusion of complex older patients who may be at increased risk of irreversible functional decline might have been a limitation of the study.¹⁰

Two primary care clinics in Israel compared MDT outcomes to standard care in patients with poor glucose control (A1C levels ≥10%); the patients were studied for 6 months.¹¹ One clinic was randomly chosen to provide patients with standard medical care, delivered by physicians and nurses (control group), while another clinic provided patients with an MDT approach that included care from a diabetes specialist, a dietician, and a diabetes nurse educator. At the 6-month follow-up, patients at the intervention clinic had significantly lowered mean A1C levels (–1.8%, P=.00001) and plasma glucose readings (–1.5 mmol/L [~27 mg/dL], P=.003), with no significant changes seen in either measure at the control clinic.¹¹ Patients in the intervention group also had twice the response rate to treatment (defined as a ≥0.5% decrease in A1C at 6-month follow-up) vs the control group (71% vs 35%, respectively). Additionally, patients in the intervention group had a higher rate of follow-up (attendance at 6-month visit) than patients in the control group (82% vs 35%, respectively).

Another study evaluated (over 1 year) a community-based family medicine residency program that implemented MDT care for 105 patients with type 2 diabetes and compared pre- and post-intervention outcomes.¹² Successful disease management was defined as having A1C <7%, low-density lipoprotein (LDL) cholesterol <100 mg/dL, and blood pressure <130/80 mm Hg. At 1 year following program implementation, patients improved in all metabolic and process measures. Additionally, 17.1% of patients achieved successful disease management, defined as meeting all 3 criteria, as compared with 5.7% prior to the intervention.¹² The patients who did not meet all 3 criteria, however, would still benefit from care coordination and targeted intervention to help them manage the disease and achieve goals.

Individual and group diabetes management education approaches are also integral parts of centralized care, and are associated with proven patient benefits. A meta-analysis that included data from 31 randomized, controlled trials evaluating self-management education showed that, at immediate follow-up after the last educator-patient contact, patients who had received self-management education decreased their A1C levels by 0.76% more than patients who did not receive self-management education (95% confidence interval, 0.34–1.18).¹³ Patient outcomes further improved as more time was spent with educators.

Another meta-analysis of 11 studies showed that group-based education for diabetes was related to A1C decreases of 1.4% after 4–6 months of follow-up; these decreases endured at 1 year (0.8%) and 2 years (1.0%) of follow-up (P<.00001 for all 3 time points).¹⁴ Patients who received group-based education also had reduced body weight (1.6 kg; P=.02) and improved diabetes knowledge (P<.00001) at 12–14 months of follow-up, and reduced systolic blood pressure (5 mm Hg; P=.01) at 4–6 months of follow-up. Lastly, about 1 in 5 patients who received group-based education were able to decrease their doses of diabetes-related medications at 12–14 months (P<.00001).¹⁴

Outcomes data from a subset of patients from the Diabetes America clinics showed that after 4 visits, the average patient A1C value was 7.0%. Overall, 59% of patients had A1C values <7.0% and only 9% had A1C values >9.0%. Additionally, 62% of patients had LDL cholesterol values <100 mg/dL, and only 14% had values >130 mg/dL. A total of 64% of patients sustained systolic blood pressure levels <130 mm Hg, and only 14% had values >140 mm Hg. Lastly, 62% of patients sustained diastolic blood pressure levels <80 mm Hg, and only 5% had values >90 mm Hg.¹⁵ All of these outcomes surpass recommended guidelines from the National Committee for Quality Assurance (NCQA) Diabetes Physician Recognition Program (DPRP).¹⁶

Cost-effectiveness analyses from a 3-year study of Diabetes America clinics were performed by Aetna, a health insurance provider. Outcomes and costs were monitored for 4 large, public-sector employers who provided their employees with incentives (co-payment waivers) to use an SDC center (in this case, Diabetes America clinics).¹⁷ Costs were then compared between patients who did and did not use Diabetes America clinics. For the first 2 years of the study, outcomes were similar, but in the third year the SDC patients had average monthly medical costs that were $226 less per member.¹⁷ These cost savings appeared to be due to fewer emergency room visits and shorter hospital stays. Although prescription costs for the clinic patients were on average $40 more per month than for patients not accessing care at these sites, the higher cost was offset by lower medical costs in the long run. Additionally, patients at the Diabetes America centers were more compliant with disease maintenance requirements (such as regular eye exams and blood screenings).

Reasons for success and key challenges

By bringing comprehensive, patient-centered care together in single locations, SDC centers can offer both quality and convenience to patients. The “one-stop” approach is a major benefit for patients who would not otherwise have time to attend separate appointments to have required laboratory work and diagnostic tests, and to see physicians, nutritionists, and CDEs. Furthermore, these health centers accept most insurance plans, with only 1 insurance co-payment for all services rendered, which can provide substantial patient cost-savings compared with noncentralized providers. Many of these clinics are patient-friendly and may provide amenities such as ample parking, free coffee, wireless Internet access, and comfortable waiting rooms.

Financial constraints, which can limit the size of the MDT, are an ongoing challenge of providing care within a centralized model. Patients are taught self-care principles that encourage them to become involved in their own disease management. To achieve goals, team members must have good interpersonal skills, as well as a clear understanding of specific and shared responsibilities. To ensure success, management needs to be proactive in clarifying these responsibilities. Lastly, training provided to the team must be tailored to the clinical environment and community needs (eg, training on cultural sensitivity).

Conclusions

The SDC center model provides highly individualized, quality care to patients. The model is exemplified in the choice not to rely on generalized algorithms for treatment decisions; instead, clinical decision-making takes into account multiple factors about an individual patient. Each provider (physician, NP, or PA) sees a limited number (approximately 15–18) of patients per day, giving providers sufficient time to discuss with them the complexities of diabetes management, as well as the opportunity to individualize therapies. Patient involvement in treatment decisions is solicited, which is especially important when working with patients from diverse ethnic and cultural backgrounds on topics such as individualized approaches to diet. In addition, compared with individual primary care providers, we are early adopters of newer medications and advocate with insurers for full patient coverage. We believe that all of these steps help to ensure successful diabetes management for our patients.

Education is the cornerstone to diabetes care¹⁸; our patients are empowered by the education they receive, and often give positive feedback about the educational aspect of our care centers. Providers at SDC center clinics (physicians, NPs, and PAs) offer diabetes care and education options in a “menu” format for patients, and steer them toward the appropriate treatments, diagnostic tests, and education based on their individual needs. In our centers we take the time to explain to patients the pros and cons of various treatment options, how medications work, and our goals for their overall treatment plan. With an increased understanding of the pathophysiology of diabetes and the mechanisms through which their therapies work, patients can have more say in, and ownership of, their treatment decisions. Because of time constraints, integrative discussions can be difficult for many primary care physicians to accommodate. However, having patient care and education provided at the same clinic helps unite treatment decisions and education goals, enabling patients to increase both their understanding of diabetes management and their own self-efficacy and ability to follow their treatment plan.

It is important for payers and employers to continue to evaluate their goals for diabetes care and ensure that the proper administrative policies are put in place to support diabetes care in a comprehensive manner. Patients respond to incentives to improve care if they can be implemented. With the chronic nature of diabetes and insidious onset of diabetes complications, patient barriers to care must be identified and addressed to continually engage the patient in good diabetes care. We encourage increased collaboration between employers, providers, patients, and payers so that all incentives can be aligned. In particular, it is important that all parties involved understand the nature of, and need for, ongoing diabetes education.

Lastly, SDC centers may provide early intervention to prevent the worsening of diabetes-related conditions and comorbidities that will cost patients and payers more in the long term. Going forward with chronic disease management in the United States, it will be increasingly important to focus on both long- and short-term outcomes if we wish to see both positive and cost-effective results.

Introduction

Although patients with diabetes may be well managed by primary care physicians, the application of a team approach to the delivery of care enables a range of health care providers to integrate their skills to facilitate improved patient management and outcomes. Centralized diabetes care clinics bring together the expertise of primary care physicians, endocrinologists, registered nurses, nurse practitioners (NPs), physician assistants (PAs), certified diabetes educators (CDEs), dietitians, and/or pharmacists into a multidisciplinary diabetes team (MDT) that operates under a single roof to provide integrated care.

This approach contributes to comprehensive patient management and improved disease outcomes.^1-4 Specialized diabetes care (SDC) centers rely on an MDT structure to provide patients with individualized disease management. The centralized model encourages ongoing communication and interaction between the patient and multiple members of the care team. These SDC centers are typically statewide or regional.

A centralized model of diabetes care

Overview and organizational structure

SDC centers offer medical services for patients with diabetes, based on 4 cornerstones of disease management: medical care; personalized education; nutrition counseling; and lifestyle and exercise coaching. The centralized model involves patients in the management of their diabetes, with the goal of promoting wellness and preventing complications. Specifically, physicians, nurses, and dietitians work with patients to develop personalized treatment plans to prevent and detect diabetes-related complications. At Diabetes America centers, team members include physicians, NPs, PAs, and CDEs. Some SDC centers do not employ pharmacists, while other centralized diabetes clinics have a pharmacist on staff.

Within the MDT structure, the physician, NP, or PA is primarily in charge of monitoring patient health and making pharmacologic decisions; he or she is aware of the full range of available therapeutic options for diabetes management, as well as clinical practice guidelines and emerging evidence. Physicians, in conjunction with the MDT, also provide expert knowledge regarding new management technologies, such as insulin pumps and glucose sensors. Lastly, physicians provide expertise and patient management in other aspects of care, including hypertension and lipid management, and the treatment of diabetes-related complications. NPs and PAs work closely with physicians to coordinate personalized patient treatment plans; these professionals also provide integral support and education to patients who are newly diagnosed with diabetes and/or who are making the transition to insulin therapy (when patients face new lifestyle considerations, including daily glucose monitoring and insulin shots).

In addition to encouraging effective self-management and patient autonomy, SDC patients are provided with comprehensive, ongoing patient education delivered by CDEs. The role of the CDE is to promote positive health behaviors across all areas of diabetes self-management.⁵ The curriculum employed in our centers is consistent with the recommendations of the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA). Patients learn about diabetes pathophysiology and management, circulatory health, medical nutrition therapy, and eye health in individual sessions, group classes, or seminars. The timing and sequence of training and education is predicated on patients’ needs and schedules. Additionally, CDEs are responsible for specific diabetes management tasks; for example, they can discuss treatment issues, medication titration, or dose adjustments, based on patient feedback. A patient’s need for education is evaluated during the clinical part of the visit. For example, when a physician initiates insulin treatment, the CDE would provide all necessary information and training to allow the patient to successfully self-administer insulin.

Dietitians help patients develop personalized nutrition plans, including meal and weight management plans, with the goal of developing targeted lifestyle change programs based on personal preferences. A recent review has confirmed that medical nutrition therapy delivered by registered dietitians is effective and essential in the management of diabetes.⁶ Diabetes America centers offer nutrition education in individual and classroom sessions, and encourage patients, as well as their families and caregivers, to attend. These sessions cover issues such as carbohydrate counting, reading and understanding nutrition labels, healthy portion sizes, meal planning, and weight management. Fitness and nutrition experts educate patients on the basics of healthy lifestyle, and offer tools to help patients reach their goals. In addition, patients are counseled on sick-day management, coping mechanisms for stress, and skin and foot care. The coaching approach is essential to ease patients’ adjustment into lifestyle changes essential for optimal diabetes management.

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.

Business model and profitability

The business model should be adaptable to support changing staffing needs in an SDC network with multiple centers. It is important to provide timely, quality care to patients, but equally important is engaging patients in ongoing care, maintaining a proper rate of patient flow at each clinic every day. Often the model employs a staffing process to match appropriate team members to the number of patients seen at a center, meaning that staff may rotate to different centers depending on need.

For diabetes education services to be covered for reimbursement, the Centers for Medicare and Medicaid Services requires accreditation for all diabetes self-management education and training (DSME/T) programs by the ADA, the AADE, or Indian Health Services. Programs must meet quality standards of the accrediting organization.⁹

Some federally qualified or academic-based diabetes centers are supported entirely by grant and other public resources, and require grant renewals to become sustainable; other centers have a grant-funded component, and a private- funding component. Unlike diabetes clinics that have a nonprofit component, the SDC that we are associated with (Diabetes America) is completely privately funded and receives no grants to cover clinic or care expenses. We are unable to comment with certainty on whether Diabetes America is unique in its funding. Because of our business model, it is fiscally sound to maintain a mix of patients supported by both private and government payers. Self-payers are accepted, but make up only a small percentage of our patient population.

Costs to patients will vary based on the individual patient’s insurance plan. Many employers, and in turn many patients, are unaware of the placement of diabetes care and education within their comprehensive insurance plan. Some plans cover only the physician visit; all other services are applied towards the patient’s deductible. In some cases, patients may incur substantial costs until the deductible has been reached. In recent years, we have seen deductibles increase for all segments of our population, which can be a financial strain for patients. Patients now scrutinize further which medications or diagnostic testing services they will take or reject based on what their insurance will cover. Patients also face the challenge of having to learn how to calculate their co-payment responsibility in advance.

From our knowledge, many employers are evaluating their diabetes care plans and are beginning to recognize education and preventive services as vital parts of diabetes management that should be covered as part of comprehensive care. As a result, we are working with more employers to design and implement full-service plans that include education and supplies (such as blood glucose testing devices and strips) intended to minimize costs over the long term.

Comparisons of multidisciplinary diabetes team care to standard care

A growing body of research supports the benefits of using an MDT for diabetes care. Specifically, available evidence suggests that a physician-led team encompassing nursing staff, diabetes educators, and dietitians to provide intensive diabetes care may significantly improve patient adherence and glycemic control, as well as the quality of care provided.

A randomized, controlled trial evaluated an MDT approach for the management of diabetes and other chronic conditions at a family health network serving more than 1000 patients in Ottawa, Canada.¹⁰ Patients were randomized to receive MDT care or usual physician care. The study measured quality of chronic disease management care based on predetermined performance measures (guideline recommendations) for diabetes, coronary artery disease, chronic heart failure, and chronic obstructive pulmonary disease (primary outcome measure). The study also evaluated quality of preventive care (adherence to the Canadian Task Force on Preventive Health Care recommendations for 6 preventive indicator maneuvers, such as influenza vaccination, eye examination, and hearing examination). The performance measures for diabetes management recommended an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) when appropriate; measuring A1C twice yearly; and giving foot and eye examinations within the past 2 years. After an average of 1.25 years of follow-up, there was significant improvement in the primary outcome measure, with the network’s chronic disease management quality of care improving by 9.2% with MDT care compared with traditional care (P<.001). In addition, the secondary outcome measure of quality of preventive care had also improved, by 16.5%, with MDT care compared with traditional care (P<.001).¹⁰ There were no significant improvements in other secondary outcome measures (eg, glycemic control, hypertension, quality of life, and functional status), but, according to the authors, the clinical team did not concentrate on the 2 specific clinical outcomes (glycemic control and hypertension); instead, they had a more general focus of improving the management of the chronic diseases of individuals in their care. Furthermore, the study may not have had enough power to detect a significant difference in these outcomes. With regard to the lack of improvement in quality of life and functional status measures, inclusion of complex older patients who may be at increased risk of irreversible functional decline might have been a limitation of the study.¹⁰

Two primary care clinics in Israel compared MDT outcomes to standard care in patients with poor glucose control (A1C levels ≥10%); the patients were studied for 6 months.¹¹ One clinic was randomly chosen to provide patients with standard medical care, delivered by physicians and nurses (control group), while another clinic provided patients with an MDT approach that included care from a diabetes specialist, a dietician, and a diabetes nurse educator. At the 6-month follow-up, patients at the intervention clinic had significantly lowered mean A1C levels (–1.8%, P=.00001) and plasma glucose readings (–1.5 mmol/L [~27 mg/dL], P=.003), with no significant changes seen in either measure at the control clinic.¹¹ Patients in the intervention group also had twice the response rate to treatment (defined as a ≥0.5% decrease in A1C at 6-month follow-up) vs the control group (71% vs 35%, respectively). Additionally, patients in the intervention group had a higher rate of follow-up (attendance at 6-month visit) than patients in the control group (82% vs 35%, respectively).

Another study evaluated (over 1 year) a community-based family medicine residency program that implemented MDT care for 105 patients with type 2 diabetes and compared pre- and post-intervention outcomes.¹² Successful disease management was defined as having A1C <7%, low-density lipoprotein (LDL) cholesterol <100 mg/dL, and blood pressure <130/80 mm Hg. At 1 year following program implementation, patients improved in all metabolic and process measures. Additionally, 17.1% of patients achieved successful disease management, defined as meeting all 3 criteria, as compared with 5.7% prior to the intervention.¹² The patients who did not meet all 3 criteria, however, would still benefit from care coordination and targeted intervention to help them manage the disease and achieve goals.

Individual and group diabetes management education approaches are also integral parts of centralized care, and are associated with proven patient benefits. A meta-analysis that included data from 31 randomized, controlled trials evaluating self-management education showed that, at immediate follow-up after the last educator-patient contact, patients who had received self-management education decreased their A1C levels by 0.76% more than patients who did not receive self-management education (95% confidence interval, 0.34–1.18).¹³ Patient outcomes further improved as more time was spent with educators.

Another meta-analysis of 11 studies showed that group-based education for diabetes was related to A1C decreases of 1.4% after 4–6 months of follow-up; these decreases endured at 1 year (0.8%) and 2 years (1.0%) of follow-up (P<.00001 for all 3 time points).¹⁴ Patients who received group-based education also had reduced body weight (1.6 kg; P=.02) and improved diabetes knowledge (P<.00001) at 12–14 months of follow-up, and reduced systolic blood pressure (5 mm Hg; P=.01) at 4–6 months of follow-up. Lastly, about 1 in 5 patients who received group-based education were able to decrease their doses of diabetes-related medications at 12–14 months (P<.00001).¹⁴

Outcomes data from a subset of patients from the Diabetes America clinics showed that after 4 visits, the average patient A1C value was 7.0%. Overall, 59% of patients had A1C values <7.0% and only 9% had A1C values >9.0%. Additionally, 62% of patients had LDL cholesterol values <100 mg/dL, and only 14% had values >130 mg/dL. A total of 64% of patients sustained systolic blood pressure levels <130 mm Hg, and only 14% had values >140 mm Hg. Lastly, 62% of patients sustained diastolic blood pressure levels <80 mm Hg, and only 5% had values >90 mm Hg.¹⁵ All of these outcomes surpass recommended guidelines from the National Committee for Quality Assurance (NCQA) Diabetes Physician Recognition Program (DPRP).¹⁶

Cost-effectiveness analyses from a 3-year study of Diabetes America clinics were performed by Aetna, a health insurance provider. Outcomes and costs were monitored for 4 large, public-sector employers who provided their employees with incentives (co-payment waivers) to use an SDC center (in this case, Diabetes America clinics).¹⁷ Costs were then compared between patients who did and did not use Diabetes America clinics. For the first 2 years of the study, outcomes were similar, but in the third year the SDC patients had average monthly medical costs that were $226 less per member.¹⁷ These cost savings appeared to be due to fewer emergency room visits and shorter hospital stays. Although prescription costs for the clinic patients were on average $40 more per month than for patients not accessing care at these sites, the higher cost was offset by lower medical costs in the long run. Additionally, patients at the Diabetes America centers were more compliant with disease maintenance requirements (such as regular eye exams and blood screenings).

Reasons for success and key challenges

By bringing comprehensive, patient-centered care together in single locations, SDC centers can offer both quality and convenience to patients. The “one-stop” approach is a major benefit for patients who would not otherwise have time to attend separate appointments to have required laboratory work and diagnostic tests, and to see physicians, nutritionists, and CDEs. Furthermore, these health centers accept most insurance plans, with only 1 insurance co-payment for all services rendered, which can provide substantial patient cost-savings compared with noncentralized providers. Many of these clinics are patient-friendly and may provide amenities such as ample parking, free coffee, wireless Internet access, and comfortable waiting rooms.

Financial constraints, which can limit the size of the MDT, are an ongoing challenge of providing care within a centralized model. Patients are taught self-care principles that encourage them to become involved in their own disease management. To achieve goals, team members must have good interpersonal skills, as well as a clear understanding of specific and shared responsibilities. To ensure success, management needs to be proactive in clarifying these responsibilities. Lastly, training provided to the team must be tailored to the clinical environment and community needs (eg, training on cultural sensitivity).

Conclusions

The SDC center model provides highly individualized, quality care to patients. The model is exemplified in the choice not to rely on generalized algorithms for treatment decisions; instead, clinical decision-making takes into account multiple factors about an individual patient. Each provider (physician, NP, or PA) sees a limited number (approximately 15–18) of patients per day, giving providers sufficient time to discuss with them the complexities of diabetes management, as well as the opportunity to individualize therapies. Patient involvement in treatment decisions is solicited, which is especially important when working with patients from diverse ethnic and cultural backgrounds on topics such as individualized approaches to diet. In addition, compared with individual primary care providers, we are early adopters of newer medications and advocate with insurers for full patient coverage. We believe that all of these steps help to ensure successful diabetes management for our patients.

Education is the cornerstone to diabetes care¹⁸; our patients are empowered by the education they receive, and often give positive feedback about the educational aspect of our care centers. Providers at SDC center clinics (physicians, NPs, and PAs) offer diabetes care and education options in a “menu” format for patients, and steer them toward the appropriate treatments, diagnostic tests, and education based on their individual needs. In our centers we take the time to explain to patients the pros and cons of various treatment options, how medications work, and our goals for their overall treatment plan. With an increased understanding of the pathophysiology of diabetes and the mechanisms through which their therapies work, patients can have more say in, and ownership of, their treatment decisions. Because of time constraints, integrative discussions can be difficult for many primary care physicians to accommodate. However, having patient care and education provided at the same clinic helps unite treatment decisions and education goals, enabling patients to increase both their understanding of diabetes management and their own self-efficacy and ability to follow their treatment plan.

It is important for payers and employers to continue to evaluate their goals for diabetes care and ensure that the proper administrative policies are put in place to support diabetes care in a comprehensive manner. Patients respond to incentives to improve care if they can be implemented. With the chronic nature of diabetes and insidious onset of diabetes complications, patient barriers to care must be identified and addressed to continually engage the patient in good diabetes care. We encourage increased collaboration between employers, providers, patients, and payers so that all incentives can be aligned. In particular, it is important that all parties involved understand the nature of, and need for, ongoing diabetes education.

Lastly, SDC centers may provide early intervention to prevent the worsening of diabetes-related conditions and comorbidities that will cost patients and payers more in the long term. Going forward with chronic disease management in the United States, it will be increasingly important to focus on both long- and short-term outcomes if we wish to see both positive and cost-effective results.