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Managing Type 2 Diabetes with Team-Based Care in Oak Forest, IL: A Case Study

Oak Forest Health Center is a community-based medical clinic that delivers healthcare services to residents of Cook County, IL, regardless of their ability to pay for care. In 2016, the clinic had 15,000 primary care visits from 6737 unique patients. Nearly one-quarter of these patients had a diagnosis of type 2 diabetes. It quickly became apparent that the team would need to take steps to effectively manage these complex patients. Specifically, they started using team-based care techniques, such as pre-visit laboratory testing and a daily huddle, to streamline their workflows.

Much of the streamlining took place at points in the workflow that happen well before a patient with diabetes enters the exam room. Pre-visit laboratory testing was implemented, with patients encouraged to visit the lab before their clinic appointments. Reminder calls are made to all patients who have pending lab orders (including for A1C, lipids, and urine microalbumin). Then, one to two days prior to each clinic, the medical assistant (MA) prints the patient schedule for each medical team and notes the A1C value for each patient on the summary sheet used for the huddle. On the day of the clinic, the medical team huddles with the patient schedule and summary sheet to share information and set expectations for each visit. Patients also receive a self-management goal survey to complete when they check in.

During rooming, the MA administers the Ambulatory Health Risk Screen, which includes assessment for depression using the PHQ2/PHQ9, a health literacy screen, and a smoking and social history questionnaire. Patients are also screened for food insecurity, which is prevalent within the clinic's patient population. Next, the patient and the physician review available laboratory test results, home blood glucose test logs and self-management goals. Goals are usually specific and timed, and may include weight loss, decreasing A1C and making lifestyle changes. Other measurable goals are as simple as taking medications regularly over a certain period of time. These are recorded in the electronic health record (EHR) and tracked across visits. Before the visit ends, successes are celebrated with patients and improvements are encouraged.

Patients with a new diabetes diagnosis and those with A1C greater than nine percent are referred for diabetes education as well as care management (CM) visits with a registered nurse (RN). Education takes place in small group classes led by our diabetes educator who is also a licensed dietician. A CM visit with a RN is an invaluable resource for the management of the clinic's patients with diabetes, especially those who are newly diagnosed or have difficulty meeting their A1C goal. The CM visits are interspersed between physician visits, allowing nurses to work at the top of their license and provide patients with additional face-to-face interactions with the RN. The CM visit is a prime opportunity for the patient to exchange and clarify information with the medical team.

Social services are also instrumental for helping patients with additional needs beyond clinical care. Patients with uncontrolled diabetes and comorbid obesity are referred to The Lifestyle Center, where they are taught to read and understand food labels, prepare healthy meals, exercise and make additional healthy choices. Those who have food insufficiency are given vouchers for fresh fruits and vegetables that are delivered by a “fresh truck” to the clinic every couple of months by the Greater Chicago Food Depository, under the Food As Medicine Project (a collaboration between the Cook Count Health & Hospitals System [CCHHS] and the Greater Chicago Food Depository). In addition to the fresh produce from the truck, patients receive recipes for preparing food and are also given information about neighboring food banks.

Ezike Chukwuemeka, MD, attributes the clinic's successes and its ability to better care for patients with diabetes to teamwork and planning ahead. Further stating “Working as a team has definitely improved our care of patients with diabetes, especially those who are having difficulty controlling their blood sugar levels. One case in particular that comes to my mind involves a woman with chronically uncontrolled diabetes who was complaining of having “shakes” when her blood sugar reaches 200 mg/dL. Through CM visits and diabetes education, we were able to successfully bring her diabetes under control, and her A1C under 7 percent. I believe we would not have been successful without a team effort.”

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