Project Title:
Partnership IMPACTS Diabetes Outcomes
Project Co-Leads:
Gloria Trujillo, M.D., Duke Department of Community and Family Medicine Kathryn Trotter, MSN, CNM, FNP, Duke University School of Nursing Michele Easterling, MPH, RD, Durham County Health Department Nichole Weedon, MSW, P-LCSW, Durham County Department of Social Services Jacqueline Tatum, MSN, Duke University School of Nursing Katherine Pereira, MSN, FNP, Duke University School of Nursing Viviana Martinez-Bianchi, MD, Duke Department of Community and Family Medicine Frances Mauney, MSN, Duke University School of Nursing
Project Abstract:
Over a period of 10 years (1994 – 2003), North Carolina has seen a 76% percent increase in the prevalence of persons diagnosed with diabetes (4.6% vs. 8.1%). In Durham County 8.2% of the population has been diagnosed with diabetes (≈ 22,000 residents). The innovative model of care developed by this partnership has patient influenced design and flexibility at its core.
This team believes and has data that supports the perspective that patient, family, community, and clinicians must be involved in designing a plan of care that can satisfy the patients’ needs—not the clinician’s or the health system’s needs. The team believes and has evidence to support the perspective that chronic disease management according to evidence-based guidelines and patient satisfaction with care—are not mutually exclusive.
Increasingly, data shows that this approach to chronic illness has better outcomes. By employing this model we expect to affect diabetes outcomes by reducing related co-morbidities, decreasing Emergency Department (ED) utilization, lowering hospital admissions, and thus reducing diabetes-related direct and indirect health care costs in Durham County. This comprehensive initiative will improve the following:
• Increased attendance to clinical care appointments
• Participation with interventions by healthcare support team
• Increased metabolic control (HgbA1c, lipids, blood pressure, weight (BMI))
• Decreased emergency or urgent care visits for routine and complication management of diabetes
• Reduced hospitalization stays including readmission rates
• Increased continuity and utilization of resources
• Improved medication adherence
• Improved rates of retinal screening by patients with diabetes
Diabetes final report [PDF]
