Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities

Abstract

Purpose of review Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment. Recent findings Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multi-disciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. Summary As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.

Advancing Pharmacist Collaborative Care within Academic Health Systems

“…However, this approach is largely retrospective and dependent on the frequency of outcome trending. EHR disease registries are used to capture, manage and provide access to condition-specific information for a specified group of patients to support organized clinical care [14,15]. Registries enable point of care integration with clinical practice guidelines, outreach to patients between visits to address care gaps and periodic evaluation of aggregate data and performance to manage a population [16].…”

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial

“…A third factor is that in modern health care systems, diabetes management is increasingly conducted by a team of health care providers that may include diabetes educators, pharmacists, nurses, and care managers. 32 Focusing solely on primary care visits, while clearly a foundation of care, may not have taken full advantage of the opportunity to help patients in their interactions with other care team members. Moreover, the patient was given the opportunity to identify both diabetesrelated and diabetes-unrelated priorities.…”

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes—2018

“…Optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated health care professionals working in an environment where patientcentered high-quality care is a priority (7,13,14). While many diabetes processes of care have improved nationally in the past decade, the overall quality of care for patients with diabetes remains suboptimal (15).…”