Connie J. Standiford

Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus. Putting evidence into practice.

PurposeTo summarize current knowledge of interventions that should improve the care of patients with type II diabetes mellitus. Interventions lie within the realms of prevention, screening, and treatment, all of which are focused on office practice.MethodsReview of the literature by a multidisciplinary team involved in the care of patients with diabetes, followed by synthesis of the literature into a clinical care guideline. Literature was identified through consultation with experts and a focused MEDLINE search.Main ResultsAn algorithm-based guideline for screening and treatment of the complications of diabetes was developed. The emphasis is on prevention of atherosclerotic disease, and prevention, screening, and early treatment of microvascular disease. Implementation of these practices has the potential to significantly improve quality of life and increase life expectancy in patients with type II diabetes mellitus.

Patient-centered medical home: developing, expanding, and sustaining a role for pharmacists.

PURPOSE The development of a patient-centered medical home (PCMH) health care model and the role of pharmacists in PCMHs at the University of Michigan are described. SUMMARY In 2009, Blue Cross Blue Shield of Michigan (BCBSM) provided financial incentives to physician groups to implement PCMH principles. A partnership was formed among the department of pharmacy, college of pharmacy, and faculty group practice at the University of Michigan Health System (UMHS) to integrate clinical pharmacists into the PCMH model at eight general medicine practices. The rationale was that PCMH pharmacists could assist in managing chronic conditions by substituting or augmenting physician care, help achieve quality indicators, and increase revenue by billing for their services. At the University of Michigan, PCMH pharmacists currently provide direct patient care services at eight general medicine health centers for patients with diabetes, hypertension, hyperlipidemia, and polypharmacy, which are billable using T codes, which are payable to UMHS by most BCBSM plans. In the first year, the number of PCMH pharmacist half-day clinics varied from one to six per health center, and the mean number of patients per half-day clinic ranged from 2.2 to 6. Pharmacists in four PCMHs made more medication changes per visit than the other four, particularly for patients with diabetes. CONCLUSION At the University of Michigan, PCMH pharmacists currently provide direct patient care services at eight general medicine health centers for patients with diabetes, hypertension, hyperlipidemia, and polypharmacy via referral from physicians.

Screening for Psychiatric Illness with a Combined Screening and Diagnostic Instrument

ObjectiveTo determine 1) if the PRIME-MD, a two-step screening and diagnostic instrument for psychiatric disorders, increases diagnosis and intervention when actively implemented in a busy general medicine clinic, and 2) the type of staff support required to achieve sufficient implementation to realize gains in diagnosis and treatment.DesignWe introduced the PRIME-MD into a large general medicine clinic with repeated rotation of four support conditions for implementation: (1) no support, (2) nonclinical staff support (NCSS), (3) nursing staff (RN) support, and (4) a written “Prompt” condition.Setting and PatientsPatients (N=2,263) attending a general medicine clinic at a Veterans Affairs Medical Center.Measurements and Main ResultsOutcome measures were (1) PRIME-MD questionnaire and interview use, (2) overall psychiatric diagnosis, (3) new psychiatric diagnosis, and (4) provider intervention for psychiatric conditions. The NCSS, RN support, and prompt conditions resulted in similar rates of questionnaire use but significantly different rates of structured interview use. The NCSS condition was associated with significant increases in new diagnosis, and the RN support and Prompt condition were associated with significant increases in new diagnosis and intervention compared with no support.ConclusionsNursing staff support resulted in sufficient PRIME-MD implementation to achieve gains in both new diagnosis and provider intervention compared with no support. These gains occurred in a busy primary care clinic with non-selected providers and customary visit lengths. This level of support should be achievable in most clinical settings.

Using a multidisciplinary team and clinical redesign to improve blood pressure control in patients with diabetes.

Objective Optimal blood pressure (BP) control in patients with diabetes poses a challenge in primary care clinics because of the complexity of the disease and competing patient care demands. We used a multidisciplinary team to standardize and improve hypertension care for patients with diabetes by implementing a visual and action-oriented high BP prompt, collaborative practice agreement, medication intensification protocol, and home BP monitoring machine loan program. Design Prospective, pre-/poststudy. Setting General medicine clinic affiliated with a large academic healthcare system. Patients Two hundred sixty-three patients with type 2 diabetes mellitus. Results Hypertension control (ie, BP < 135/80 mm Hg) in patients with diabetes improved from 53.6% to 69.3% (P < .001) after implementing a standardized BP assessment and treatment process. There was also a significant decrease of 4 mm Hg in both the mean systolic and diastolic BPs after the intervention. The improvement in BP control was associated with an increase in the average number of antihypertensive medications from 1.56 to 1.93. Conclusions The use of a process-oriented clinical redesign and a multidisciplinary team approach resulted in improved BP management in patients with diabetes in a primary care setting.

Improving the Provision of Language Services at an Academic Medical Center: Ensuring High-Quality Health Communication for Limited-English-Proficient Patients

Purpose To evaluate and improve the provision of language services at an academic medicine center caring for a diverse population including many limited-English-proficient (LEP) patients. Method The authors performed a prospective observational study between November 2006 and December 2008 evaluating the provision of language services at the University of Michigan Health System. The primary performance measures were (1) screening patients for their preferred language for health care, (2) assessing the proportion of LEP patients receiving language services from a qualified language services provider, and (3) assessing whether there were any disparities in diabetes care for LEP patients compared with English-speaking patients. Results The proportion of patients screened for preferred language increased from 59% to 96% with targeted inventions, such as training staff to capture preferred language for health care and correcting prior inaccurate primary language data entry. The proportion of LEP outpatients with a qualified language services provider increased from 19% to 83% through the use of staff and contract interpreters, over-the-phone interpreting and bilingual providers. There were no systematic differences in diabetes quality performance measures between LEP and English-proficient patients. Conclusions Academic medical centers should measure their provision of language services and compare quality and safety data (e.g., performance measures and adverse events) between LEP and English-speaking patients to identify disparities in care. Leadership support and ongoing training are needed to ensure language-specific services are embedded into clinical care to meet the needs of our diverse patient populations.

Pharmacist leads primary care team to improve diabetes care.

A trend toward interdisciplinary management of diabetes has emerged that includes clinical pharmacists providing care through collaborative practice agreements, allowing pharmacists to alter, add, or delete medication therapies.[1][1]–[3][2] Some practice models include pharmacist-managed diabetes

Effectively implementing FDA medication alerts utilizing patient centered medical home clinical pharmacists

FDA medication alerts can be successfully implemented within patient centered medical home (PCMH) clinics utilizing clinical pharmacists. Targeted selection of high-risk patients from an electronic database allows PCMH pharmacists to prioritize assessments. Trusting relationships between PCMH clinical pharmacists and primary care providers facilitates high response rates to pharmacist recommendations. This health system approach led by PCMH pharmacists provides a framework for proactive responses to FDA safety alerts and medication related quality measure improvement.