The Patient-Centered Medical Neighborhood and Diabetes Care

Spatz, Christin; Gabbay, Robert A.

doi:10.2337/diaspect.27.2.131

Cited by 9 publications

(2 citation statements)

References 9 publications

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“…They might also provide guidance about the urgency at which a patient should be referred [15] . Limited availability of timely appointments in specialists' offices is a well-known hurdle to providing care [16] . The practice was able to overcome this hurdle by using the NCM to triage referrals, prioritizing advanced CKD and number of comorbidities.…”

Section: Interventionmentioning

confidence: 99%

Medical Neighborhood Model for the Care of Chronic Kidney Disease Patients

Smith

McNicoll²,

Clark³

et al. 2016

Am J Nephrol

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Background: The patient-centered medical home is a popular model of care, but the patient-centered medical neighborhood (PCMN) is rarely described. We developed a PCMN in an academic practice to improve care for patients with chronic kidney disease (CKD). The purpose of this study is to identify the prevalence of CKD in this practice and describe baseline characteristics, develop an interdisciplinary team-based approach to care and determine cost associated with CKD patients. Methods: Patients with CKD stage 3a with comorbidities through stage 5 were identified. Data collected include demographics, comorbidities and whether patients had a nephrologist. Using a screening tool based on the 2012 Kidney Disease Improving Global Outcomes guidelines, a nurse care manager (NCM) made recommendations about management including indications for referral. A pharmacist reviewed patients' charts and made medication-related recommendations. Blue Cross Blue Shield (BCBS) insurance provided cost data for a subset of patients. Results: A total of 1,255 patients were identified. Half did not have a formal diagnosis of CKD and three-quarters had never seen a nephrologist. Based on the results of the screening tool, the NCM recommended nephrology E-consult or full consult for 85 patients. The subset of BCBS patients had a mean healthcare cost of $1,528.69 per member per month. Conclusions: We implemented a PCMN that allowed for easy identification of a high-risk, high-cost population of CKD patients and optimized their care to reflect guideline-based standards.

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Section: Interventionmentioning

confidence: 99%

Medical Neighborhood Model for the Care of Chronic Kidney Disease Patients

Smith

McNicoll²,

Clark³

et al. 2016

Am J Nephrol

View full text Add to dashboard Cite

show abstract

“…Given this context, optimal care for patients with type 2 diabetes is best delivered in a high-functioning medical “neighborhood” that is anchored by a strong multidisciplinary primary care “home.” The primary care home team is anchored by a generalist physician with expertise in diabetes care and is ideally supported by a nurse educator, pharmacist (with the ability to titrate medications), a social worker with behavioral health expertise, and a high-functioning staff with excellent communication skills. Patient engagement in the practice should be encouraged as well, ideally through the development of a patient advisory council.…”

mentioning

confidence: 99%

Optimizing the Physician Workforce for Care of Patients With Type 2 Diabetes

Pignone

2019

JAMA Cardiol

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The Impact of New Payment Models on Quality of Diabetes Care and Outcomes

McGinley

Gabbay

2016

Curr Diab Rep

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Historic changes in healthcare reimbursement and payment models due to the Affordable Care Act in the United States have the potential to transform how providers care for chronic diseases such as diabetes. Payment experimentation has provided insights into how changing incentives for primary care providers can yield improvements in the triple aim: improving patient experience, improving the health of populations, and reducing costs of healthcare. Much of this has involved leveraging widespread adoption of the patient-centered medical home (PCMH) with diabetes often the focus. While evidence is mounting that the PCMH can improve diabetes outcomes, some PCMH demonstrations have displayed mixed results. One of the first large-scale PCMH demonstrations developed around diabetes was conducted by the Commonwealth of Pennsylvania. Different payment models were employed across a series of staggered regional rollouts that provided a case study for the influence of innovative payment models. These learning laboratories provide insights into the role of reimbursement models and changes in how practice transformation is implemented. Ultimately, evolving payment systems focused on the total cost of care, such as Accountable Care Organizations, hold promise to transform diabetes care and produce significant cost savings through the prevention of complications.

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The Patient-Centered Medical Neighborhood and Diabetes Care

Cited by 9 publications

References 9 publications

Medical Neighborhood Model for the Care of Chronic Kidney Disease Patients

Medical Neighborhood Model for the Care of Chronic Kidney Disease Patients

Optimizing the Physician Workforce for Care of Patients With Type 2 Diabetes

The Impact of New Payment Models on Quality of Diabetes Care and Outcomes

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