Impact of an integrated model of care on potentially preventable hospitalizations for people with Type 2 diabetes mellitus

Abstract

Patients receiving the integrated model of care had a reduction in the number of hospitalizations when the principal diagnosis for admission was a diabetes-related complication. Integrated models of care for people with complex diabetes can reduce hospitalizations and help attempts to curtail increasing demand on finite health services.

Achieving Research Impact Through Co‐creation in Community‐Based Health Services: Literature Review and Case Study

“…The program also required and supported a stream of empirical research, undertaken in parallel with the change effort, on the organizational challenges and patient and staff experience of the new model. Research activities included a development and pilot study of a primary care improvement tool, a qualitative evaluation of a clinical microsystems model in diabetes care, a quantitative study of the evidence‐practice gap in gestational diabetes follow‐up, and the development and evaluation of a community‐based diabetes surveillance and management program …”

“…Within 3 years, the beacon practice was revenue neutral and was partnering with local clinicians to care for complex care patients from the area with better outcomes and high satisfaction at significantly reduced cost. For example, diabetes control in patients served by the beacon practice improved over time; compared to neighboring sites, preventable diabetes‐related hospitalizations halved and metrics of patient satisfaction and empowerment increased …”

Utility of the Hospital Admission Risk Programme diabetes risk calculator in identifying patients with type 2 diabetes at risk of unplanned hospital presentations

“…The HARP tool was developed by the WestBay Alliance and Western HARP Consortium, and is based on the Chronic Condition Risk Calculator. For example, recently, an integrated primary-secondary model of care for the management of T2D that provided multidisciplinary specialist care in general practice was found to reduce potentially preventable diabetes-related hospital presentations to hospital by approximately half 16 and in addition, improved continuity of care 17 and a primary-care-based empowerment programme were also effective. In addition, dedicated services, such as the Victorian HARP, have been implemented that address the risk of hospitalisation in patients with chronic illness, through coordinating access to services and improving patients' capacity for self-care and maintenance of well-being.…”

“…Identifying the drivers of increased risk of unplanned presentation to hospital may lead to targeted education or treatment strategies designed to mitigate risk or referral into specific management pathways to access additional services. For example, recently, an integrated primary-secondary model of care for the management of T2D that provided multidisciplinary specialist care in general practice was found to reduce potentially preventable diabetes-related hospital presentations to hospital by approximately half 16 and in addition, improved continuity of care 17 and a primary-care-based empowerment programme were also effective. 18 Further research on the outcomes of patients with T2D following attendance at services recommended by the HARP tool, to determine their impact on reducing the risk of hospital presentation, would be of significant importance in assessing the utility of the HARP tool in preventing unplanned hospital presentations.…”

Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations

“…Moreover, patients receiving the model of care had fewer potentially preventable hospitalisations when the principal diagnosis for admission was a diabetes-related complication (PPH-D). Specifically, the average number of PPH-D in the usual care group was 0.35 per patient and in the intervention group was 0.19 per patient (crude incidence rate ratio 0.53, 95%CI 0.29, 0.96; p = 0.04) [9]. In this report, we aimed to estimate the cost savings associated with these reduced PPH-D in the integrated model of care.…”