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Success Story: Decrease Patients With Poorly Controlled Diabetes By One-Third

Based on an American Medical Association news article published March 8, 2019 and an interview with Kim Huntington-Alfano, DO, Midwestern University Multispecialty Clinic (MUMC), Downers Grove, IL.

Learn how a small family practice posted a one-third decrease—from 31% to 20.5%—in the total number of patients with poorly controlled diabetes(defined as HgbA1C≥9).

What Was the Problem?

The practice wanted to establish a clinical action plan to help their patients better manage diabetes and other chronic conditions.

Developing the Intervention

The family practice within the Midwestern University Multispecialty Clinic (MUMC) was enrolled in the Transforming Clinical Practices Initiative (TCPI) when they sought extra support from STEPS Forward consultants. The consultants visited the Downers Grove, Illinois, office in early 2018, said Kim Huntington-Alfano, DO, a family physician. She practices full-time alongside a part-time physician colleague, a part-time clinical pharmacist, and office staff in a multispecialty building offering dentistry, physical therapy, optometry, and other services.

A few weeks after the visit, the consultants reported back “with their observations and recommendations for changes we might be able to make in order to improve the workflows, the efficiency and, by extension, the quality of the care we're given,” said Dr Huntington-Alfano.

Figure 1. Three Ways to Establish a Better Clinical Action Plan

Including the whole team

One team member took on the role of chronic care coordinator, which included development of a pre-visit planning sheet for patients with diabetes. A formal process for tracking and performing outreach to those patients was also put into place. When the final TCPI numbers were tallied, the practice identified 39 patients with diabetes.

A fourth-year medical student then created a patient education folder for patients newly diagnosed with diabetes and as warranted, to those who were previously diagnosed. The materials were designed to motivate patients to become engaged with appropriate self-management of their condition.

Completing education for practice efficiency

Dr Huntington-Alfano and her team were provided with suggestions from the more than 50 STEPS Forward modules that would help the practice achieve its TCPI improvement goals.

“We pulled out the pieces of various modules that were really applicable to the situation we were currently in,” said Dr Huntington-Alfano.

Pre-visit planning was “one of the big modules that I relied on that just helped our day to day functioning in general,” she said, adding that it played an important role in the diabetes clinical action plan.

Elements of STEPS Forward approaches were used for other initiatives at the practice as well, such as opioid control. The program was successful.

Updating technology

Looking forward, the practice is deeply engaged with upgrading its electronic health records. Their goal is to add functionality to track, treat, and engage with patients.

“The implementation of these practice transformation strategies enhanced the effectiveness and efficiency of workflows for addressing patient care gaps—a big change from the early days of the still-growing practice when just getting through the day was the goal,” said Dr Huntington-Alfano.


In less than a year, the two-physician office created a large improvement in diabetes control by focusing on workflow efficiency teamwork and technology.

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Article Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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