Program directs stable diabetes patients from endocrinology back to primary care

One academic health system developed a program to “graduate” patients out of endocrinology visits for their diabetes. Criteria included HbA1c level less than 8.0%, blood pressure less than 140/90 mm Hg, no tobacco use, and use of statins and aspirin if needed.

Applying lean manufacturing principles allowed one health system to free up specialty diabetes care visits for more first-time referrals by moving stable patients back to primary care, a study found.

Researchers at a single academically affiliated health system had a months-long backlog of first referrals for specialty care, and only 8% of endocrine visits were for new patients. They applied lean methodology quality improvement to encourage the care team to identify patients who could have been cared for by primary care, introduce them to the concept, and apply shared decision-making to move their care. Results were published Aug. 29 by the Journal of General Internal Medicine.

The researchers identified criteria for eligible patients, including HbA1c level less than 8.0%, blood pressure less than 140/90 mm Hg, no tobacco use, and use of statins and aspirin if needed. A “graduation button” was added for clinicians to identify appropriate patients in the checkout section of the electronic health record. An agreement with the primary care network defined expectations and care transition needs for returning patients to primary care.

In the specialty clinic waiting room, digital products introduced the graduation concept to patients. New patients had to identify their primary care clinicians as a requirement for scheduling, and follow-up patients were asked to do so as well. Specialists set goal-directed expectations for all patients, anticipating their return to primary care once they met graduation goals. Graduation-eligible patients were listed on a whiteboard to alert staff for previsit planning huddles. Medical assistants alerted eligible patients that they were ready to graduate during the rooming process or in other previsit communications.

Endocrinologists would then engage in shared decision-making with patients about the transition. Medical assistants presented patients with a graduation certificate and a visit summary with graduation information. Nurses handed patients off to coordinate care and to schedule the next appointment. A letter to the primary care clinicians included final instructions, and patients were provided with a year of diabetes medication refills.

Seventeen percent of eligible patients with optimally controlled diabetes (58 of 341) graduated by six months. Reasons for not graduating included change in diabetes medication or dose (26%), comorbid endocrine conditions (19%), increase in HbA1c level (16%), patient refusal/not ready yet (10%), one- or two-year follow-up with another doctor (5%), recent hospitalization (1%), no show (2%), and other (4%) (including no primary care clinician, pregnancy, insulin pump, complex patient, or transplant).

The study authors noted that they weren't actually able to show improvement in access for new specialty patients, due to the pandemic, or assess patient and clinician satisfaction or the number of patients who returned to specialty care after graduation.

Despite these limitations, the authors wrote, “The innovation and feasibility of opening [specialty care] access through the use of a team-based graduation program to transfer stable diabetes patients back to their home clinic was demonstrated. This innovation has the potential to support health system triage of new patients to limited access specialty care.”