The long-term goal of the initial pilot study and the extension of that research in this proposal is the design, implementation and evaluation of a team-oriented, primary care based diabetes disease management model. This model was designed to be practical, effective, population-based, flexible (replicable) and financially viable for community hospitals with regional diabetes centers, given current reimbursement constraints. This project will be accomplished through a partnership between Lehigh Valley Hospital and Health Network and eight primary care practices.
Specific Aim 1 : Implement and evaluate the sustainability of improved diabetes management process performance and improved patient health outcome measures in a primary care setting (4 practices), following an intensive team-based educational intervention. The importance of this aim is to add a third level of intervention (Sustaining Phase) that is minimal in time and cost that can create an ongoing and sustained quality improvement process following the initial two phases of education. This model will use Achievable Benchmarks of Care and Group visits to improve care processes and patient health outcomes in this Sustaining Phase.
Specific Aim 2 : Implement and evaluate a """"""""refined"""""""" model of primary care diabetes management using Achievable Benchmarks of Care to motivate improved physician performance and patient health outcomes in an additional four primary care practices. The implementation and evaluation of the refined Primary Care Physician/Patient Education Project will use a time series analysis (ANOVA and Sheffe post hoc mthods) of the intervention, focusing on the sustainability of the outcomes in the first four practices beyond the first year of program implementation (including the Intensive Education Phase and the Education Reinforcement Phase). Secondly, the refined PCP/PEP model will be initiated and evaluated in four new practices, incorporating Achievable Benchmarks of Care to motivate clinician behavior change. By the end of the two year project, 2nd and 3rd year outcomes in the original practices will shed light on sustainability and costs, and one year outcomes for the new practices will shed light on replicability of the model in a new, and somewhat different set of practices, including one that has a majority of Latino patients.
