Medical center helping diabetes patients

February 28, 2010
Courier Express Tri-County Sunday

Pennsylvania has started a Chronic Care Initiative that will enable patients to be more actively involved in managing their ailments and health care providers to more efficiently counsel and refer patients. This article describes the initiative and specifically how a Western Pennsylvania medical center is implementing it.

The Reynoldsville Medical Center was chosen to be one of 36 medical practices throughout the state to participate in the Pennsylvania Chronic Care Initiative. The program uses a computer registry to identify patients at risk for complications from diabetes; it then reminds patients and staff of needed care and provides feedback to the offices about patient care. Numerous studies show a gap between evidence based recommendations for care and the outcomes for patients, according to the Penn State Diabetes Center. Doctors concur that gathering all the patient data can be difficult, so using information technology could alleviate at risk patients slipping between the cracks.

To initiate this program, the staff members at Reynoldsville Medical Center reviewed 1,500 charts, identifying 300 patients with diabetes. From there, each patient’s lab results and other care information were uploaded into the registry. At each visit, the staff is prompted by a computer generated check list to look into important data related to diabetes assuring the most updated standard of care. From this information, a monthly report is generated back to the state office to assess progress and areas that could use improvement.

The staff helps patients to set personal goals to work on between appointments; every three to six months there are 22 measures for the patient to achieve. Also, a group visitation for patients to support each other is a program in the works. Research has shown outcomes are better when patients take responsibility for their own health rather than relying on their doctor to do the work for them.

The team approach has yielded improvement in results and is changing healthcare delivery systems for the better. Pennsylvania is part of a pilot program for the United States. If this program continues to succeed, it will be generalized to management of other diseases such as asthma, coronary artery disease and congestive heart failure.