There is a widening quality of care gap in diabetes mellitus (DM) management that sees
Black and Hispanic patients with much higher rates of DM complications and
hospitalizations compared to their white counterparts. Primary Care is the frontline for
DM prevention and management; however, Primary Care Clinics, including Internal Medicine
resident continuity clinics, struggle to improve DM metrics. The lack of resources, such
as time and personnel, is a significant limiting factor in strategies that would allow
these clinics to optimize care. As a result, the current DM management model was created,
in which Primary Care providers refer patients with elevated hemoglobin A1c (HbA1c) to
subspecialty care. This process is inefficient, overwhelms subspecialty practices, and
most importantly does not address the social determinants of health that often make it
difficult for patients to get their DM under control.
This traditional model also comes with a potential institutional financial cost. There is
a perception that reducing upfront costs of care can make a system more economically
viable; yet this can have devastating results for a system and for its patients on the
back end. For example, HbA1c is a Merit-based Incentive Payment System Clinical Quality
Measure if a patient population is not supported in their efforts for DM control, this
can translate to monetary loss annually for the Emory Healthcare System. In addition,
there are also potential losses to the system related to long-term morbidity and
mortality risks of elevated HbA1c over time.
Studies have shown that a multi-disciplinary approach including physician, dietitian, DM
education, psychotherapy, and social work services functioning concurrently and
cooperatively has the potential to positively change the current paradigm. Given the
vital role Primary Care plays in the management of all aspects of patient care, including
physical and psychosocial well-being, this care delivery model is optimally designed to
have the most impact and success in the Primary Care Clinic setting. The research team
proposes to embed a multi-disciplinary diabetes-focused clinic within Primary Care in the
Emory Healthcare System where this approach would create a central location for all the
patients' DM needs, provide efficient care that helps patients address social and
economic barriers, and engage the care team through between-clinic touchpoints to
motivate patients to take agency over their health. This also provides a venue to
implement modern technologies for DM management, such as continuous glucose monitoring
(CGM). Despite its proven efficacy in DM management, CGM remains an understudied
intervention in Primary Care, especially in patient populations that would otherwise have
difficulty accessing specialty care. Researchers anticipate that these changes will
enable improved adherence to follow-up visits and treatment.
In addition to the benefits of streamlined patient care, this model also offers the
opportunity to enhance Internal Medicine residency education. Investigators intend to
develop a hybrid clinical/educational curriculum for residents that capitalizes on and
models appropriate resource utilization through an integrated care model and provides
early exposure to multi-disciplinary care and CGM.