Collaboration is key to beating diabetes
Margarita Persico | 9/23/2009, 5 a.m.
MGH’s Chelsea center has a large number of diabetic patients, and over half are Latinos, said Green. The diabetic coaches, nurses and educators at the program have been identifying at-risk patients since the program started more than three years ago. They serve as liaisons between patients and doctors, and educate Latinos on how to manage their illness.
One unique aspect of the staff at MGH-Chelsea is that many team members are culturally trained health care providers, coaches, health educators and physicians who speak both Spanish and English.
“They’ll call [patients], leave them a [message], explain why it’s important to do it, [or] go out to their house if they can’t reach them,” Dr. Elisha H. Atkins, an internist at MGH-Chelsea said. “This is really evidence of what a team effort can do.”
Health professionals at MGH-Chelsea are searching for high-risk patients through the hospital’s in-house patient navigator database, called Registry Population Management (RPM). The application presents information about groups of patients with diabetes within the MGH system, such as the results of tests that indicate the severity of the disease.
A hemoglobin A1C test, for example, measures the average amount of glucose that has been attached to the patient’s red blood cells during the last three months. An LDL test measures the level of low-density lipoprotein present in the patient; too much can cause heart disease.
The RPM database also tracks how patients’ providers are doing and whether they are meeting patients’ contact goals, according to Dr. Adrian Zai, clinical director of population informatics at MGH, who developed the RPM.
Horta’s job is to track patients like Garcia, whose hemoglobin A1C is 8 and above — below 7 is normal. Besides identifying at-risk patients, the coach says he meets with patients individually to help them overcome problems they may have with diabetes.
Horta said he aims to help them first understand the disease, then set goals to improve their health and cope with the illness.
“I also meet with their providers to give feedback [as] to where the patient is at and what can be put in place to help this patient,” said Horta.
Other organizations are applying the same strategy; according to the American Diabetes Association, health centers that focus on diabetes care often have health care professionals who work as a team. Atkins points to fellow MGH-Chelsea internist Dr. Wynne Armand, who is also using these resources to get at-risk diabetes patients to come in for appointments.
But bringing them in is just part of the mission. Horta and his team also work as liaisons between doctors and patients to find out what barriers they might be facing. They also refer patients to the Diabetes Self-Management Education program, designed to help diabetics assume a greater role in learning how to administer their own care.
“Patients will run out of their pills. Patients will lose their insurance because they lose a job,” Atkins said. “… These resources also check whether their patients eat well and exercise, and also encourage them to live well, take their medicine, and monitor their own sugars.”
In order to help patients, Atkins recommends that physicians establish relationships with certified diabetes educators. He suggests patients go through structured diabetes self-management classes, even if they’ve had diabetes for a decade. These patients will learn to manage their illness and work with their practitioner.
The classes help patients reduce “the gaps they have in their knowledge about diabetes,” said Atkins. “There are a lot of assumptions I had about what they understood.”