Effectiveness of community based diabetes education in promoting the patient-centered medical home

Background The majority of people with diabetes receive their care from their primary care provider (PCP) but many practices are not equipped to meet their needs. One reason is the additional resources required to provide comprehensive diabetes care, which includes diabetes educators at the point of care, as well as education for the office staff and providers. The growing number of diabetics prompted our developing grant funded programs for coordinated care. This was an opportunity to demonstrate the value of a Patient Centered Medical Home (PCMH) model, in which patient care in the office and in the community are seamless and utilize the resources of community health & preventive medicine. Methods We chose two hospital-owned practices and two private practices. Models of care were established within each practice, with some variation based on need and culture. Teams consisting of a Registered Nurse Certified Diabetes Educator (RN-CDE), Registered Dietitian Certified Diabetes Educator (RD-CDE), and a Community Educator were integrated into these practices. This team serves as teachers and coaches engaging patients in the coordination of diabetes management. Our goal was to improve patient compliance with a jointly-developed treatment plan; demonstrate improvements in selected measures; and improve patient and provider satisfaction. Results Early results show improvements in patient compliance; improved diabetes control (A1C); and high provider/patient satisfaction. Conclusion Embedding diabetes education into primary care helped to support a PCMH and improve diabetes care. The model is being assessed for financial sustainability outside a grant-funded model, and this will be discussed in the presentation as well.