A patient outreach program between visits improves diabetes care: a pilot study.

Area of Science:

• Internal Medicine
• Public Health
• Healthcare Management

Background:

• Guideline-based diabetes care faces barriers like poor patient engagement and fragmented clinic processes.
• Effective diabetes care coordination is crucial for managing patient health outcomes.
• Existing systems often lack automated support for physicians and organized patient records.

Purpose of the Study:

• To develop and evaluate a patient recall intervention aimed at improving diabetes care coordination.
• To assess the operational feasibility, provider/patient acceptance, and impact on care processes.
• To mitigate barriers hindering guideline-based diabetes management.

Main Methods:

• Patients overdue for visits or tests (hemoglobin A1c, lipid, microalbumin, creatinine, retinal exams) were identified using American Diabetes Association criteria.
• An outreach coordinator contacted patients to schedule recommended services and summarize needed care.
• Patient responsiveness was assessed, and medical charts were reviewed to compare pre- and post-intervention care. Provider satisfaction was also surveyed.

Main Results:

• Over 3 months, 709 patients were overdue for diabetes services.
• The outreach coordinator facilitated visits for 30.1% of overdue patients, with 80.8% completing labs.
• An additional 12.5% self-scheduled visits post-outreach, showing improved service completion and care intensity versus traditional care. Provider feedback was positive.

Conclusions:

• A patient outreach intervention significantly improved the timeliness and intensity of diabetes care in an outpatient setting.
• The pilot program's success in process measures suggests potential for broader implementation.
• Further research focusing on clinical outcomes is warranted to validate the intervention's long-term benefits.