The Internal Medicine practice at 999 Silver Lane, Trumbull at a recent process mapping session
Patients with diabetes thrive and have better health outcomes when they have the right interventions in place. NEMG cares for approximately 19,000 patients with diabetes, 21 percent of which have an HbA1c greater than nine.
In January 2019, NEMG launched the interdisciplinary Diabetes Quality Care Pathway Task Force to develop an ambulatory clinical pathway that aligns its Diabetes Clinical Practice Guidelines with office workflows. The short term goal was to reduce the percentage of patients with an A1c greater than nine to less than 19 percent of its respective population. Pathway components included: patient education, blood sugar control and monitoring, blood pressure control with use of ACE/ARB as appropriate, use of statin and aspirin for cardiovascular risk reduction, overall medication adherence, nutrition, diet and exercise counseling and regular follow-up visits and calls.
To gain expertise and insight on performance improvement at scale and promote this standard approach to care across all primary care office sites, NEMG partnered with the Yale Health Clinical Integration Department. Between April and June of this year, several sites served as pilots to test the clinical changes of the pathway and met with great success. Process mapping took place first to determine current state, followed by integration of the pathway into office workflow. The next wave of sites scheduled for implementation include the entire New London region and those on the pathway to PCMH certification.
