A Publication of WTVP

Innovation is key to entrepreneurship… and to improving healthcare. At UnityPoint Health—Methodist | Proctor, we continue to explore new ways to get people healthier and keep them healthy.

In alignment with the Institute for Healthcare Improvement’s “Triple Aim” approach to healthcare, UnityPoint Clinic has developed a program focused on outpatient diabetes management. The IHI Triple Aim is a framework to improve the patient experience, improve the health of populations and reduce per-capita healthcare costs. Implemented in 2013, the UnityPoint Clinic SCOPE program achieves these objectives by supporting improved diabetes outcomes with guidelines for patient-centered treatment, timely follow-up, hemoglobin A1c (average level of blood gluclose) goals, clinical goals, and patient communication and education.

By following SCOPE guidelines, providers and staff can identify patients who, for one reason or another, have gaps in their care or lack timely follow-ups. A focused education program is then implemented so these individuals can gain a better understanding of their disease, treatment and self-care, such as taking their medication at the right time and following guidelines for nutrition and exercise. During the first 11 months of the SCOPE program, the number of patients with a desired A1c of eight or less increased from 52 percent to 74 percent. At the same time, patients with an A1c above nine (uncontrolled diabetes) decreased from 35 percent to 14.6 percent.

In addition, the SCOPE initiative focuses on timely follow-up for patients who have not had lab work completed within the measurement year, or whose A1c level exceeded the goal. Registered nurses from the Care Coordination Center review the charts for diabetic patients and ensure they receive the timely care they need. Of 114 diabetic patients contacted in February 2014, more than 41 percent were successfully scheduled for recommended appointments and lab work.

Within the clinics, patient care navigators are also focusing on the “sickest of the sick”—the top 10 percent of patients whose chronic conditions result in more frequent hospital visits, higher healthcare costs and decreased quality of life. The care navigator’s role is to identify these higher-risk patients and develop a relationship with them to engage patients in management of their disease. Together, patient, care navigator and the primary care provider set mutual goals. These goals can be as simple as increasing exercise by taking a half-mile walk three times a week or agreeing to take medication as prescribed. Patients also learn to identify the red flags that signal a problem—symptoms of a dangerous spike in blood sugar, for example—and to take action before they end up in the ER. By wrapping resources around these patients to educate and motivate them while removing the barriers to optimal care, patient health has improved and ER visits and hospitalizations have been reduced.

SCOPE, patient care navigators and other innovations are part of a “total care transformation” philosophy at Methodist | Proctor. In the weeks and months to come, you can expect to see the rollout of other innovations designed to provide a better patient experience and improved health at lower costs. Through these breakthrough programs, we are changing the way healthcare is delivered… and building a healthier community. iBi