Clinical Diabetes Centers of Excellence: A Model for Future Adult Diabetes Care Free

Abstract

Although diabetes research centers are well defined by National Institutes of Health, there is no clear definition for clinical Diabetes Centers of Excellence (DCOEs). There are multiple clinical diabetes centers across the United States, some established with philanthropic funding; however, it is not clear what defines a DCOE from a clinical perspective and what the future will be for these centers. In this Perspective we propose a framework to guide advancement for DCOEs. With the shift toward value-based purchasing and reimbursement and away from fee for service, defining the procedures for broader implementation of DCOEs as a way to improve population health and patient care experience (including quality and satisfaction) and reduce health care costs becomes critically important. It is prudent to implement new financial systems for compensating diabetes care that may not be provided by fiscally constrained private and academic medical centers. We envision that future clinical DCOEs would be composed of a well-defined infrastructure and six domains or pillars serving as the general guiding principles for developing expertise in diabetes care that can be readily demonstrated to stakeholders, including health care providers, patients, payers, and government agencies.

Diabetes is a preeminent public health concern. Approximately 29.1 million people in the United States have diabetes (1), which accounts for 12% of all deaths in this country. Serious diabetes-related complications contribute to mortality and morbidity, with immense associated economic burdens (2). The combined direct and indirect annual health care costs of this disorder are estimated at $245 billion (3). Given the economic and individual burdens associated with diabetes, it is imperative to improve access to care and the manner in which this care is delivered.

Diabetes research centers are well defined by the National Institutes of Health, but there is no clear definition for clinical Diabetes Centers of Excellence (DCOEs). There are multiple clinical diabetes centers across the United States, some established with philanthropic funding; however, it is not clear what defines a DCOE from a clinical perspective and what the future will be for these centers.

Herein we propose a framework to guide advancement for clinical DCOEs. With the shift toward value-based purchasing and reimbursement and away from fee for service, defining the procedures for broader implementation of DCOEs as a way of improving population health, improving patient care experience (including quality and satisfaction), and reducing health care costs becomes critically important. It is prudent to implement new financial systems for compensating diabetes care that may not be provided by fiscally constrained private and academic medical centers.

Three distinct domains contribute to excellence in diabetes care: provision of clinical care by skilled multidisciplinary professional teams guided by clinician-diabetologists experienced in managing complex, high-risk individuals; academic excellence that encompasses teaching, clinical research, and scholarly activity; and patient education, engagement, and satisfaction with a comprehensive care model.

The vision described in this article outlines the essential components of an established DCOE that provides access to the spectrum of state-of-the-art diabetes care.

Vision for DCOEs

A comprehensive model for a clinical DCOE would consist of an infrastructure and six domains or pillars serving as the general guiding principles for developing expertise in diabetes care that can be readily demonstrated to stakeholders, including health care providers, patients, payers, and government agencies.

Infrastructure

First, the definition of a DCOE implies the presence of an appropriate infrastructure to qualify for designation as a “center.” Adequate staffing is an essential component of this infrastructure to provide diabetes self-management education to new and existing patients; provide instruction for administration of injectable medications; engage diabetes-related technologies (e.g., meters, insulin pumps, continuous glucose monitoring); download and analyze glycemic data at the point of care and between visits to guide timely modification of therapy when indicated; discuss diet, exercise, and medication use in relation to patient lifestyles; address management-related phone calls, e-mails, and texts in a timely manner; provide effective professional mental health and social support, including identification and access to community resources; provide professional education to providers at the center and in the community; educate family members and other providers; and sort out insurance issues for medication preauthorizations according to tiers of coverage. A true DCOE cannot function in the absence of such infrastructure.

Six Pillars

Pillar 1: nonexclusive focus on high-risk individuals and an open-door policy

Given the ongoing diabetes epidemic, DCOE will face the number of patients who qualify for care that often exceed capacity because of the national shortage of endocrinologists (4). There are <6500 practicing endocrinologists in the United States, many of whom do not see patients with diabetes. Recent estimates indicate a current shortage of 1500 clinically active adult endocrinologists, a number that is expected to grow (5).

Two potential, preferably complementary pathways can address this problem.

Systematic triage by a nurse experienced in diabetes care can help ensure access for those who would most benefit from receiving care in a DCOE. This includes all patients with type 1 diabetes (T1D) and others with poor glycemic control, impaired hypoglycemia awareness, multiple complications, cystic fibrosis, posttransplant diabetes, atypical forms of diabetes, and complex diagnostic dilemmas. This approach allows a focus on population management and risk stratification before referral.

At the same time, wherever possible an “open door” policy will ensure that patients in need of care are not turned away. To accomplish this task, advanced practice providers such as nurse practitioners, physician assistants, and allied health professionals (clinical pharmacists, registered dieticians, and certified diabetes educators) can be educated and trained to assume a larger collaborative role in the management of patients seeking care at the DCOE.

Pillar 2: communication across the medical neighborhood to guide care

Standardized and clear communication and coordination of patient care is another crucial element of the delivery of effective and comprehensive care for patients seen in a DCOE across the spectrum of disease. Coordinating care through patient-centered medical homes (PCMHs) starts with care contracts that outline expectations, roles, and responsibilities at the time of referral from primary care (6).

Preconsultation exchanges

Preconsultation exchanges address clinical questions that may not require an in-person visit, such as the need for minor medication adjustments. Addressing these questions in a timely manner offsets the need for an extensive in-person visit to the DCOE and allows ongoing management by primary care providers (PCPs). It also reduces waiting times for new patient appointments for those identified as being at highest need. Reimbursement for preconsult exchanges based on a capitated model provides a financial incentive for the time invested in these consults. In areas where certified diabetes educators and specialist physicians are not available, electronic consultations (e-consults) can be used to determine the need for an in-person visit (7, 8).

Several health care systems have been evaluating e-consults or telemedicine as new models of care delivery (9, 10). Although e-consults are being used more frequently in medicine, their role in diabetes management presents challenges. For example, despite possessing knowledge about when and how to initiate insulin (or other injectable) therapy, many PCPs lack resources to for implementation. In other situations, e-consults do not address the poor availability of personnel to manage the preauthorizations and appeals required by many insurance plans for newer diabetes medications. E-consults might also be a unique opportunity to combine expert advice with professional education. A DCOE could assist in overcoming these obstacles.

In general, as telemedicine and other forms of medical technology become better reimbursed and incorporated into care models, expanded opportunities for patient education and managing insurance issues will probably emerge.

Formal consultations and shared management

Some patients need a certain number of in-person visits to a DCOE that address the initiation of injectable therapy, including the use of multiple options or coformulations to advance to basal-bolus insulin or insulin pump therapy, or use of personal or professional continuous glucose monitoring. These patients can often return to their PCP with recommendations for ongoing management once these issues have been addressed. Continuity of care is ensured by having the patient remain with his or her PCP in the PCMH for day-to-day management while maintaining access to the DCOE.

Management by the DCOE can involve shared diabetes management. An example might be a patient who starts insulin at the DCOE, returns to the PCP, and visits the DCOE every 6 to 12 months. Innovative strategies making use of technological advances, including a more fluent and objective electronic medical record correspondence between providers, can allow more efficient management of patients across the spectrum of care, including periods of transition such as from hospital to home (11).

Pillar 3: comprehensive care

An integrated referral network ensures that diabetes care is provided efficiently and effectively by the DCOE. Given that the majority of patients will be referred to DCOE by their PCPs, open and ongoing communication ensures that proper feedback is available to all providers involved in the many aspects of diabetes care. One potentially effective strategy is to schedule monthly collaborative sessions between endocrinologists and collaborating providers where patients who pose specific or more challenging management issues can be discussed.

Availability of the numerous diabetes-related specialties needed for comprehensive diabetes care engages patients and providers alike in establishing screening or early detection and management of diabetes-related complications. This step can be accomplished by colocating specialties that serve as a one-stop shop for patient convenience or by coordinating appointments with collaborating providers on the same day.

Pillar 4: learning health care system: ongoing focus on quality improvement

An integral focus of the DCOE is engagement in clinical research to develop pharmacologic and public health interventions for diabetes. DCOE can use the learning health care system model that links individual and population information in a centralized comprehensive database (12) or registry that allows assessment of relevant clinical process and outcome data and costs. These registries are optimally designed to meet minimum standards to ensure robust access for researchers and other specialists who can assist the center in extracting meaningful clinical metrics and epidemiologic data. Deidentified patient data would allow comparisons of outcomes between DCOEs, fostering research and quality improvement strategies that can extend beyond the United States to international groups.

The DCOE must serve as a beacon of ongoing quality improvement initiatives that help ensure that the most robust and up-to-date care is being provided in an environment that incorporates new information and technologies into clinical practice. The DCOE ideally will implement such programs as the iterative plan-do-check-act process for long-term projects (13), Kaizen events for short-duration improvement projects (14), and Lean Six Sigma (a method that relies on a collaborative team effort to improve performance by systematically removing waste and reducing variation) (15). If interventions are evaluated systematically within a learning health network, effective approaches can be rapidly spread across the health system and beyond through a consortium of DCOEs.

Pillar 5: outcome assessment

To maintain a DCOE, there must be an ongoing effort to preserve high-quality care by producing verifiable results for review and comment by third parties, such as funding organizations or insurance agencies, as well as by patients. The current metrics, such as goal-directed measures of hemoglobin A1c, lipid parameters, and blood pressure, are important but of limited value. Other metrics, such as delay in progression of complications, frequency and severity of hypoglycemia, improvement in cardiovascular morbidity and mortality, and overall longevity and quality of life, are likely to be more important than laboratory measures alone.

Pillar 6: education and dissemination

Dissemination of findings and best practices by the DCOE favorably influences other institutions involved in diabetes care. Local, regional, and national conferences, grand rounds, and small group sessions can promote best practices within and outside an institution. The Pennsylvania Chronic Care Initiative, which supports and trains primary care practices in the PCMH model, and the Extension for Community Healthcare Outcomes project, which provides telementoring of PCPs by diabetologists, are examples of these collaborations (16, 17).

Short “expert courses” that provide expertise on crucial elements of diabetes management can help in disseminating expert diabetes care beyond the confines of a DCOE. Outside formal training programs, DCOEs have the opportunity to work with “itinerant endocrinologist” programs in which specialists from the center visit or establish close relationships with PCPs at the same or other institutions to share expertise and develop mutually beneficial relationships.

Conclusions

DCOEs are an important component of the evolving models of health care delivery that provide cost-conscious, integrated, patient-centered care to patients with diabetes. Optimizing clinical outcomes while assessing cost, efficiency, and redundancy will result in cost-effective care.

The proposed DCOE model with efficient and well-thought-out infrastructure along with six core elements is a realistic approach to providing verifiable and transferable standards of care to large patient populations. This model can serve as a template and comparator for existing and emerging DCOEs in an effort to standardize and create excellent diabetes care.

Abbreviations:

 
• DCOE

  Diabetes Center of Excellence

 
• PCMH

  patient-centered medical home

 
• PCP

  primary care provider

 
• T1D

  type 1 diabetes.

Acknowledgments

Disclosure Summary: The authors have nothing to disclose.

References