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Patient-Centered Medical Home Reshapes Role of Diabetes Educators

As more practices adopt the patient-centered medical home concept, diabetes educators will become even more integral to delivering effective, compassionate and evidence-based health care.

As the concept of the patient-centered medical home gains support, it is important to more clearly define the diabetes educator’s role in these practices, according to several speakers at American Association of Diabetes Educators (AADE) meeting.

In general, the patient-centered medical home fits into the chronic care model, according to Jan Norman, RD, CDE. The goals are similar in that the chronic care model calls for organization of care, delivery of self-management support, evidence-based medicine and a clinical information system. Likewise, the concepts associated with medical homes include:

  • Engaged leadership.
  • A quality improvement strategy.
  • Patient-centered interactions.
  • Organized, evidence-based care.
  • Continuous and team-based healing relationships.
  • Enhanced access.
  • Population management.
  • Care coordination.

Several of these objectives can be attained through extended hours and increased access, as well as the sharing of information between providers, such as physicians, nurses and physician assistants. Furthermore, training and involving more people who are willing to engage in primary care — not just physicians — are also essential, Norman said during a presentation.

Some physicians, however, question whether any scientific evidence supports the utility and efficacy of the patient-centered medical home. Although there is a lack of standard recording measures, data appear to demonstrate the concept’s effectiveness. At Geisinger Health Systems in Danville, Pa., nine quality measures were tracked and all or none (composite) scoring was applied. One year after implementation of a patient-centered medical home, Geisinger’s composite scores improved from 2.4% to 6.5%. ED visits and inpatient admissions also decreased significantly. Several other sites exhibited similar results, according to Jan Pearson, RN, CDE, of the International Diabetes Center at Park Nicollet in Minnesota. Pearson said expenses may initially escalate because of the potential need to hire more staff or achieve better coordination of care, but significant decreases in ED visits and inpatient admissions reduce costs considerably.

Other speakers also presented examples of the role of diabetes educators in various patient-centered medical homes around the country. Responsibilities range from reaching out to patients in the community to documenting and collecting data. At certain sites, nurses were encouraged to become certified diabetes educators, provide ongoing follow-up via telephone or email or make referrals.

In all patient-centered medical homes, however, diabetes educators were expected to advocate and drive change in the health care system; foster communication between PCPs and patients; and coordinate care. As more practices adopt this concept, diabetes educators will become even more integral to delivering effective, compassionate and evidence-based health care.

Presented at: the American Association of Diabetes Educators Annual Meeting & Exhibition; Aug. 3-6, 2011; Las Vegas.