A Multidisciplinary Quality Improvement Program to Improve Diabetes Care at a Free Clinic

Abstract

Objective: To evaluate the effectiveness of an intensive, multidisciplinary patient-centered approach involving a pharmacist and a dietician in a population of uninsured free clinic patients with diabetes and hypertension.

Methods: A single-center retrospective chart review of a quality improvement project. All patients had diagnoses of diabetes and hypertension and a most recent hemoglobin A1c ≥ 9.0%. Patients met individually with a pharmacist and a dietician during 6 encounters over 12 months. The pharmacist made medication changes, encouraged lifestyle reflections, and helped patients create and track self-management goals. The dietician helped patients plan strategies for diet and exercise. The primary outcome was a change in mean hemoglobin A1c.

Results: Of 30 enrolled patients, 17 completed three months of treatment, and seven completed 12 months. The 17 patients who completed three months of treatment had the following characteristics: mean age 55.5 years; mean hemoglobin A1c 11.5%; 82% were taking two or more antidiabetic medications; 59% were taking two or more antihypertensive medications. Significant reductions in mean hemoglobin A1c values were observed at three months (-3.4%, P<0.0001) and twelve months (-4.0%, P=0.0156). Reductions in systolic blood pressure were also observed at three months (-6 mmHg, P=0.1060) and twelve months (-17 mmHg, P=0.2188).

Conclusions: Large and significant hemoglobin A1c reductions were observed in free clinic patients with diabetes refractory to traditional medical management. Goal-oriented patient empowerment effectively improves a wide range of patient outcomes in the free clinic setting. Other free clinics can implement this collaborative, multidisciplinary model with access to similar personnel.

Keywords: dieticians; free clinic; multidisciplinary care team; patient empowerment; pharmacists; type 2 diabetes; uninsured.

Figure 1. Schedule of Encounters and Procedures

A timeline of study encounters is presented alongside the data gathered and interventions performed at each encounter. All clinic visits involved individual meetings with both a pharmacist and a nutritionist. BMI = Body mass index.

Figure 2. Patient Retention

Of 30 enrollees, 17 remained in the program three months from baseline, and seven remained one year from baseline. Missed appointments were the most common reason for participant non-completion.